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Biomedical subjects

S M Fakhry

Publications and source records attributed to S M Fakhry.

35 records · Page 2Linked to original sources
PubMed1994

Effect of inhalation injury, burn size, and age on mortality: a study of 1447 consecutive burn patients.

The relative impact of inhalation injury, burn size, and age on overall outcome following burn injury was examined in 1447 consecutive burn patients over a five and a half year period. The overall mortality for all patients was 9.5% (138 of 1447). The presence of inhalation injury, increasing burn size, and advancing age were all associated with an increased mortality (p < 0.01). The incidence of inhalation injury was 19.6% (284 of 1447) and correlated with increasing percent total body surface area (%TBSA) burn (r = 0.41, p < 0.01) and advancing age (r = 0.15, p < 0.01). The overall mortality for patients with inhalation injury was 31% (88 of 284) compared with 4.3% (50 of 1163) for those without inhalation injury. Using multivariate analysis inhalation injury was found to be an important variable in determining outcome, but the most important factor in predicting mortality was %TBSA burn (accuracy = 92.8%) or a combination of %TBSA burn and patient age (accuracy = 93.0%). Adding inhalation injury only slightly improved the ability to predict mortality (accuracy = 93.3%). The presence of inhalation injury is significantly associated with mortality after thermal injury but adds little to the prediction of mortality using %TBSA and age alone.

Adolescent↗
PubMed1994

Report on the clinical workstation and clinical data repository utilization at UNC Hospitals.

On December 1, 1993, we implemented version 2.1 of the Clinical Workstation-Clinical Data Repository application in the Ambulatory Care Center. This version of the workstation allowed access of laboratory data from the clinical data repository that had been populated by a real-time HL7 interface between the Clinical Data Repository and the Laboratory Information System. This implementation completed a major part of the Clinical Workstation project. Also in December, we implemented a security system that records the date and time, user logon code, clinical workstation functions used, and the patient medical record number on whom data were displayed. In addition to the security function, this system has proven to be a valuable tool in evaluating the utilization of the clinical workstation and is the source of the data presented in this paper.

Clinical Laboratory Information Systems↗
PubMed1994

Incidence, management, and outcome of femoral shaft fracture: a statewide population-based analysis of 2805 adult patients in a rural state.

UNLABELLED: Early surgical management of femoral shaft fracture (FSF) is considered the standard but patients are still treated nonsurgically. The purpose of this study was to analyze the results of management of FSF in a large population based data base. METHODS: Data were obtained from a statewide hospital discharge data base for 1989-1992. Adults having a FSF were stratified by ISS (ISS < 15 vs. ISS > or = 15) and management (nonsurgical, surgery within 1 day, surgery at 2-4 days, or surgery at > 4 days). Mortality rates and mean length of hospital stay were compared among groups. RESULTS: 2805 patients had FSFs: 69% were managed surgically and 31% nonsurgically. Mortality was higher for nonsurgical therapy in both ISS groups. In the surgically treated groups, length of hospitalization increased as delay to surgery increased. In patients with an ISS > or = 15, repair at 2-4 days was associated with the lowest mortality and shortest hospitalization, while a trend to higher mortality and longer hospitalization was noted with repair within 1 day. CONCLUSION: 31% of patients were treated nonsurgically with higher associated mortality. These results support "early" surgical fixation, which can shorten hospital stay without increasing mortality regardless of overall injury severity. The trend toward higher mortality in severely injured patients operated on within 1 day of admission suggests that this group warrants further study and individualized management.

Adolescent↗
PubMed1993

An analysis of the association of trauma centers with per capita hospitalizations and death rates from injury.

OBJECTIVE: This study used population-based data bases to assess the association of trauma centers with per capita county hospitalization and trauma death rates in the State of North Carolina. SUMMARY BACKGROUND DATA: The current study extended previous work using two North Carolina data bases to assess the association of the presence of a trauma center with per capita county trauma death rates. METHODS: Data on per capita county trauma hospitalizations and deaths were obtained from the state hospital discharge data base and the North Carolina Medical Examiner's data base. Bivariate and multivariate analysis techniques were used. The dependent variables of interest were prehospital, hospital, and total trauma death rates and hospitalization rates for injury. RESULTS: Bivariate analysis identified a number of factors associated with per capita county hospitalizations and trauma death rates. These included the per cent unemployment, racial distribution, county alcohol tax receipts, and advanced life support certified emergency medical services providers. The per capita trauma death rates were significantly lower in counties with trauma centers compared with those without trauma centers (4.0 +/- 0.5 and 5.0 +/- 1.1 deaths per 10,000 population, p = 0.0001, respectively). The per capita hospitalizations for trauma were also lower in counties with trauma centers. Multivariate modeling showed that the presence of a trauma center and advanced life support providers were the best predictors of decreased per capita county trauma death rates. CONCLUSIONS: The study showed that the presence of a trauma center and advanced life support training were the two medical system factors that were the best predictors of the per capita county prehospital and total trauma death rates. These findings are consistent with the hypothesis that trauma centers are associated with a decrease in trauma death rates.

Adolescent↗
PubMed1991

A comparison of intensive care unit care of surgical patients in teaching and nonteaching hospitals.

Three hundred forty-eight teaching (TH) and 282 nonteaching (NTH) hospitals were surveyed to determine how intensive care unit (ICU) care is delivered to surgical patients and current views on surgical critical care. Teaching hospitals were more likely than NTHs to have a separate surgical ICU (92% versus 37%), a dedicated ICU service/physician (37% versus 7%), and a surgeon as director of the ICU (67% versus 29%). All THs and 33% of NTHs provided 24 hour in-house coverage for the ICU. A majority of respondents preferred a surgeon as ICU director (TH, 85%; NTH, 67%) and felt that critical care was an essential part of surgery (THs, 87%; NTHs, 74%). Most (THs, 58%; NTHs, 56%) thought that a cooperative effort between the primary service and an ICU service provided better patient care, but only 37% of THs and 22% of NTHs provided care with such a system. Many (THs, 45%; NTHs, 33%) thought that surgeons are willingly relinquishing ICU care. Surgeons continue to desire responsibility for their patients in the ICU and most prefer ICU service involvement provided by surgeons. This discrepancy between what is practiced and what is desired, along with proposed changes in reimbursement for surgery and the recent definition of critical care as an essential part of surgery, may stimulate greater involvement of surgeons in critical care.

Attitude of Health Personnel↗
PubMed1991

Acute Physiology and Chronic Health Evaluation (APACHE II) score and outcome in the surgical intensive care unit: an analysis of multiple intervention and outcome variables in 1,238 patients.

OBJECTIVE: To assess the statistical association of the Acute Physiology and Chronic Health Evaluation (APACHE II) score with multiple intervention and outcome variables in surgical ICU patients. DESIGN: Continuous data collection on every patient admitted to the surgical ICU for a 21-month period. MATERIALS AND METHODS: For every admitted patient in the surgical ICU, APACHE II scores were calculated and the relationship between APACHE II score as an independent predictor of outcome was assessed with multiple outcome variables selected for study. The outcome and intervention variables tested included: treatment intervention measures such as days on ventilator; days with an arterial catheter, central venous catheter, triple lumen catheter, pulmonary artery catheter; days receiving total parenteral nutrition; days receiving tube feedings; number of transducers per days in the ICU; number of infusion pumps per ICU days, days in the hospital, number of complete blood counts; number of electrolyte determinations; number of blood gases; number of units of blood transfused; ICU and hospital mortality rates in the presence of complications, including: respiratory distress syndrome, renal failure, congestive heart failure, coma, requirement of cardiopulmonary resuscitation, and others. RESULTS: The APACHE II score was statistically associated with each intervention and outcome variable tested. Unfortunately, the associations, although consistent, were weak with r2 values ranging from .03 to a maximum of .22 for Pearson's correlation coefficients. CONCLUSION: The APACHE II score was statistically associated with all the variables examined in our surgical patients, but its predictive power for the individual surgical patient was limited. These findings suggest that the score may be useful for retrospective analyses of large cohorts of patients but should not be used as a triage tool or as a predictor of outcome for the individual patient. Triage decisions should continue to be based on the best available clinical judgment.

Adult↗
PubMed1991

Observations and current operative management of congenital lumbar hernias during infancy.

Congenital hernias in the lumbar region are very uncommon. Approximately 10 per cent of all lumbar hernias are congenital and the vast majority are unilateral. We report our experience with seven congenital lumbar hernias in six infants treated during a five year period. All patients presented in the first year of life with abnormal protrusions in the lumbar region. In addition to the lumbar hernia, major associated malformations, including caudal regression anomalies, diaphragmatic hernia, ureteropelvic junction obstruction, cloacal exstrophy and lipomeningocele, were observed in 66 per cent of the infants and were consistent with lumbocostovertebral syndrome. In five patients, unilateral defects were repaired primarily. One patient with bilateral lumbar hernia underwent staged repair. The larger right-sided defect was repaired using a polytetrafluoroethylene prosthesis. At a second operation two months later, the small left-sided hernia was closed primarily. All patients have done well without recurrence with a follow-up period ranging from four to 48 months. Early repair of congenital lumbar hernias in infants after correction of other life-threatening conditions is advocated. Unlike the acquired variety, congenital lumbar hernia may include a more extensive deficiency of the entire lateral abdominal wall extending to the rectus sheath and inguinal ligament and satisfactory closure of the defect without prosthetic material may be difficult or impossible.

Female↗
PubMed1990

Cost-effective use of microcomputers for quality assurance and resource utilization in the surgical intensive care unit.

Need for organ system support, severity of illness, and the risk of life-threatening complications are major factors in determining the need for ICU care and directly affect ICU costs. Using a microcomputer and a relational database program, an ICU database was developed to study ICU utilization. The following information was collected for each ICU patient on admission, then daily, and on ICU discharge: demographic data, procedures, monitors used, laboratory tests, complications, outcome, and Acute Physiology and Chronic Health Evaluation (APACHE II) score as a measure of acuity. In our study, this information was used as a first step in an attempt to define categories of patients who might benefit most from intensive care and those who would not. From September 1, 1987 to March 1, 1989, 1,062 patients were admitted to the surgical ICU (SICU). Otorhinolaryngology (ENT) patients with major head and neck resections, routinely admitted to the SICU, were compared with those from other surgical services. The ENT patients had the lowest mean admission APACHE II (6.8 +/- 0.4 vs. 11.4 +/- 0.3), lowest mean daily APACHE II (7.8 +/- 0.4 vs. 13.2 +/- 0.1), lowest percent of ventilated patients (7.6% vs. 39.4%) and ventilator days (18.9% vs. 64.6%), and had the least monitoring by central venous catheters (20.9% vs. 57.1%) or pulmonary artery catheters (0.9% vs. 29.8%) (p less than .0001 for all of above). They also had the shortest mean ICU stay (1.2 +/- 0.1 vs. 3.3 +/- 0.2 days, p less than .05). The only complication in 105 ENT patients was one uncomplicated myocardial infarction.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1990

ABGs and arterial lines: the relationship to unnecessarily drawn arterial blood gas samples.

Arterial blood gas measurements (ABGs) are the most common tests ordered in an ICU. ABG utilization in a surgical ICU over a 1-year period (September 1, 1987-October 31, 1988) was evaluated to identify factors that might help reduce overutilization. A total of 842 admissions comprising 2,381 patient days were reviewed. ABGs were the most commonly ordered test (mean of 4.8/patient/day). Patients with arterial lines (A-lines) had more ABGs drawn than those who did not regardless of the value of PaO2 (p less than 0.01), PaCO2 (p less than 0.01 except for PaCO2 greater than 55), APACHE II score (p less than 0.01), use of ventilators (p less than 0.01), pulse oximeters (p less than 0.01), or a combination of the last two (p less than 0.01). Multivariate analysis demonstrated that the presence of an A-line was the most powerful predictor of the number of ABGs drawn per patient (p less than 0.0001) independent of all other measures of the patient's clinical status such as the use of ventilators, oximeters, and values of PaO2, PaCO2, or the APACHE II score. This suggests that ABGs are being drawn unnecessarily simply because of the presence of an A-line. To reduce the number of ABGs drawn, a policy for specific indications for placement of A-lines and ABG analysis should be adopted.

Blood Gas Analysis↗
PubMed1989

Critical care education in general surgery residencies.

Surgical critical care (SCC) was recently identified as an essential component of general surgery by the American Board of Surgery (ABS). Previous studies have found limited attention to critical care education in general surgery programs. This survey was developed to determine the changes in critical care education, following the emphasis by the ABS. The survey determined the format for SCC education, the time and resources committed, and the views of the program directors toward SCC. Program directors of all 296 approved general surgery residencies were surveyed, with a 79% response. Most program directors (91%) agree that SCC is an essential component of general surgery, and 72% believe a separate intensive care unit (ICU) rotation should be used in SCC education. Education in SCC was provided by a separate ICU service in 110 (47%) of the programs. The remaining 53% used care of patients in the ICU during traditional services as their educational experience. The average ICU rotation for surgery residents was 9 weeks and usually occurred in the second year of training. In 97% of the 110 programs with an ICU service, lectures and conferences were conducted regularly. Seventeen programs sponsored critical care fellowships, and 25 additional programs were considering them. Ninety percent of surgical ICU services had faculty that consisted exclusively of surgeons or surgeons and other specialists. Only 53% of surgeons attending on an ICU service had a reduction in their other responsibilities. Despite overwhelming agreement that critical care is an essential component of general surgery, less than half of the training programs have an ICU service to coordinate resident education in SCC. If surgeons are to continue to provide total care to their patients, there needs to be increased commitment to SCC education.

Critical Care↗
PubMed1988

Cervical vessel injury after blunt trauma.

Blunt trauma accounts for 3% to 10% of cervical vessel injuries. Death and severe neurologic impairment have been reported in more than 80% of blunt carotid injuries. In our recent experience, 10 patients sustained 18 blunt cervical arterial injuries: two internal carotid artery (ICA) dissections, three ICA transections with pseudoaneurysm, five ICA thromboses, two vertebral artery dissections, one vertebral artery transection with pseudoaneurysm, one vertebral artery thrombosis, one minimal vertebral artery injury, and three caroticocavernous fistulas. A delay of more than 12 hours in making the diagnosis occurred in seven of the 10 patients. The mental status was initially normal in seven patients. The subsequent development of focal neurologic findings incongruent with CT scanning of the head prompted four-vessel angiography. Treatment was individualized and included supportive management, intravenous heparin, ligation, extracranial-intracranial bypass, and radiologic embolization. We have developed an angiographic classification that may aid management. Early angiography in patients with neurologic findings incongruent with head CT scan or in whom a normal sensorium and hemiparesis are present may permit improved outcomes. We advocate direct operative repair for accessible lesions of recent onset. For surgically inaccessible lesions, those with delayed presentation or in some cases with a fixed neurologic deficit, intravenous heparin can be started and follow-up angiography, head CT scanning, and the patient's clinical status determine further therapy.

Adult↗
PubMed1987

Cholecystectomy in morbidly obese patients.

Indications for performing cholecystectomy simultaneously with a gastric bariatric operation remain controversial. The extremes are to always perform cholecystectomy or to perform cholecystectomy only when there are palpable stones or the gallbladder is grossly diseased. Since 1975, 136 cholecystectomies have been performed simultaneously in 724 patients who had a gastric bariatric operation. Cholecystectomy had been performed before the bariatric operation in 120 and was required later in 18 patients. The clinical records, anesthesia, pathology, and operative reports provide the data for this study. Simultaneous cholecystectomy was done through the vertical midline incision used for gastric bariatric operation. No patients had the gallbladder bed closed or were drained. Operative cholangiogram were not performed because this procedure would have been difficult and significantly prolonged because of the obesity. No patients have developed postoperative choledocholithiasis. One patient developed a complication related to cholecystectomy, a common bile duct stricture. The length of the operation and the postoperative hospitalization with and without simultaneous cholecystectomy were compared. The results of intraoperative ultrasound studies performed upon these patients are described and discussed. It is concluded that cholecystectomy should be performed simultaneously with all gastric bariatric operations when there is gross or echogenic evidence of gallbladder disease. Cholecystectomy does not significantly prolong or complicate the gastric bariatric operation.

Adult↗
PubMed1986

Pseudotumor of the supraclavicular fossa.

Minor musculoskeletal variants of the upper thoracic spine or of the ribs can cause effacement of the supraclavicular fossa, simulating a mass ("pseudotumor"). These variants may occur singly or in combination, and include unilateral prominence or asymmetry of the first rib, unilateral prominence or asymmetry of a cervical rib, and mild upper thoracic scoliosis causing prominence of the first rib on one side. The detection of variants by physical examination or more easily by review of the chest x-ray film may in selected instances obviate the need for costly diagnostic procedures and unnecessary biopsies. We call attention to this condition and describe our experience with four patients.

Aged↗
PubMed1985

Complications requiring operative intervention after gastric bariatric surgery.

In a series of 565 morbidly obese patients having one of five gastric bariatric procedures done at North Carolina Memorial Hospital between May 1975 and December 1982, 55 patients had 58 complications requiring reoperation. These complications included a leak from the stomach or anastomosis, stomal obstruction, and subphrenic abscess. Weight loss after vertical banded gastroplasty appears to be comparable to that following gastric bypass with Roux-en-Y gastrojejunostomy. The complication rate of vertical banded gastroplasty is the lowest of the gastric obstructive operations we have done.

Bile Reflux↗
PubMedDate not supplied

The utility of traditional prehospital interventions in maintaining thermostasis.

OBJECTIVE: Hypothermia can have a negative effect on the metabolic and hemostatic functions of patients with traumatic injuries. Multiple methods of rewarming are currently used in the prehospital arena, but little objective evidence for their effectiveness in this setting exists. The purpose of this study was to assess the relative effectiveness of traditional prehospital measures in maintaining thermostasis in trauma patients. METHODS: Participating helicopter and ground ambulance ALS units were prospectively randomized to provide either routine care only (passive or no warming) or routine care (passive warming) in conjunction with active warming (either reflective blankets, hot pack rewarming, or warmed IV fluids). A total of 174 trauma code patients, aged >14 years, who met inclusion criteria were prospectively enrolled by prehospital providers. Patients who received a non-assigned intervention or who had incomplete temperature data were dropped from the analysis. A total of 134 patients were included in the final analysis. RESULTS: Patients who received hot pack rewarming showed a mean increase in body temperature during transport (+1.36 degrees F/0.74 degrees C), while all other groups (no intervention, passive rewarming, reflective blankets, warmed IV fluids, warmed IV fluid plus reflective blanket) showed a mean decrease in temperature during transport [-0.34 to -0.61 degrees F (-0.2 to -0.4 degrees C); p<0.01]. In addition, the hot pack group was consistent, with every patient who received hot pack warming showing an increase in body temperature during transport, while in all other groups there were patients who had both increases and decreases in temperature. The intervention groups did not differ significantly on exposure to precipitation, transport unit temperature, total prehospital time, initial vital signs, amount of fluid administered, Injury Severity Score, or Glasgow Coma Score. CONCLUSIONS: Most traditional methods of maintaining trauma patient temperature during prehospital transport appear to be inadequate. Aggressive use of hot packs, a simple, inexpensive intervention to maintain thermostasis, deserves further study as a potential basic intervention for trauma patients.

Adolescent↗
PubMedDate not supplied

Regional and institutional variation in burn care.

In reviewing the literature on burn therapy and observing clinical burn care, we noted differences among institutions and individual experts in several areas. To study variation in burn care, we surveyed the 140 burn centers listed by the American Burn Association to determine how burn care is currently administered in the United States and Canada. Responses were obtained from 83 hospitals (60%). The survey addressed resuscitation, operative and nonoperative wound care, medications, antimicrobial agents, and pain control. The major influence on care appeared to be the experience of the director (considered "very influential" in 85%) compared with the literature ("very influential" in 12%) and habit/what works for us ("very influential" in 48%). The Parkland formula was used "always" or "often" by 78%, and the Brooke formula "never" by 81% of respondents. Lactated Ringer's solution was the most popular initial fluid, and most (78%) respondents changed fluids after 24 hours. However, the fluids used in the second 24 hours varied equally among several choices. The use of colloids also varied without a set pattern. Furosemide (Lasix) and nonsteroidal antiinflammatory drugs were used "rarely" or "never" by 67% of centers in the acute stage. H2 blockers were used for gastritis prophylaxis "always" or "often" in 60% (vs 53% for antacids and 20% for sucralfate [Carafate]). Tube feedings were started on day 1 after burn injury "always" by less than 30% of centers. Total parenteral nutrition was not commonly used. Most centers use of silver sulfadiazine on the body and hands, but facial topical antimicrobial therapy varied.(ABSTRACT TRUNCATED AT 250 WORDS)

Anti-Bacterial Agents↗