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PubMed1976

Inflammatory carcinoma of the breast: A correlation of clinical, radiologic and pathogic findings.

In a study of 75 patients with inflammatory carcinoma of the breast seen at Emory University Clinic over a 38 year period, the average longevity from the time of diagnosis was 22 months and the 5-year survival 5.6%. The results of treatment were poor with all methods used, although supervoltage therapy improved local control, and when followed by mastectomy, gave the longest average local control and survival. The designation of inflammatory carcinoma as primary and secondary is often not applicable and should be dropped. Instead, the terms inflammatory carcinoma and recurrent inflammatory carcinoma seem more appropriate. It is suggested that in a number of patients fulfilling certain criteria, surgery should be contemplated and all others treated by non-surgical means. The diagnosis of inflammatory cancer is still primarily clinical. However, radiologic and pathology examination are invaluable to confirming the clinical impression and occasionally suggest the diagnosis before inflammatory signs appear.

Adult↗
PubMed1977

Concomitant aortic valve replacement and myocardial revascularization.

Twenty-six consecutive patients underwent combined aortic valve replacement and myocardial revascularization at the Emory University Affiliated Hospitals between May, 1973 and March, 1976. Acute myocardial infarction resulted in two operative deaths (8%). There have been four late deaths, all Class IV preoperative. The age range was 37 to 79 years with an average age of 60. Preoperatively all patients were Class IV or late Class III. Twenty-three patients had symptoms of angina pectoris; congestive heart failure was evident in 56%. Postoperatively, 70% are now Class 1 or II. Single coronary bypass was performed in 16 patients, double in 6, and triple in three. Double bypass plus mitral valve replacement was required in two with aneurysmectomy in one. The rate of intraoperative infarction was 27% for the series but only 7% in the last year. The methods of intraoperative myocardial preservation and the technical approach for the operative procedures were variable. Results with each method are correlated, and currently preferred techniques are presented and discussed. Best results were obtained in patients who presented early in their symptomatic course with isolated proximal coronary lesions and good renoff vessels. Excellent results could be achieved despite advanced age of patients, requirement for multiple bypass grafts, and correction of other associated cardiac lesions. Poorest results were obtained when long-standing ventricular failure was combined with poor vessels distal to coronary stenoses.

Adult↗
PubMed1979

What role should the intra-aortic balloon have in cardiac surgery.

Intra-aortic balloon pumping (IABP) to assist the failing circulation has become widely applied and accepted since its introduction in 1968. The elective, preoperative use of IABP for patients undergoing cardiac surgery has now become the controversy. The purposes of this report are to examine our experience with IABP and to determine its appropriate role in high-risk patients. IABP was utilized in 75 of 2333 (3.2%) adult cardiac surgical patients at Emory University Hospital from January 1976 through June 1978. IABP was required for refractory shock following cardiopulmonary bypass (CB) in 53 patients, for preoperative cardiogenic shock after acute myocardial infarction (CSMI) in nine and was electively placed prior to CB in 13. Sixty-two patients (81%) were able to separate from CB with IABP and pharmacologic support and were assisted 24-432 hours (median 64 hours). Fifty-five (73%) were weaned from IABP. Fifty (67%) are hospital survivors; late deaths have occurred in six patients (8%). Hemodynamic effect of IABP was demonstrated by comparison of pumping 1:1 to 1:8 mode in five balloon-dependent patients after CB. IABP was found to decrease systolic blood pressure, left ventricular filling pressure and peripheral resistance (p < .05). It increased diastolic and mean blood pressure, cardiac index and the endocardial viability ratio (p < .05). The post-CB use of IABP resulted in highest salvage when utilized to support failing hearts that required surgery despite recent preoperative infarction or when intraoperative ischemic injury had occurred. Poorest results were in patients with extensive chronic myocardial damage. Except in the case of preoperative cardiogenic shock, it was impossible to establish statistically reliable criteria for patients in whom elective preoperative insertion was found to be necessary. Careful surgical and anesthesia management with good monitoring can be used instead of preoperative IABP in the majority of (if not all) hemodynamically stable patients regardless of risk classification.

Adult↗
PubMed1980

Infected median sternotomy wound. Successful treatment by muscle flaps.

The purpose of this paper is to present the experience at Emory University Hospital with the infected median sternotomy wound and to offer a treatment plan for those patients recalcitrant to the usual therapy of debridement and closed catheter irrigation with antimicrobial agents. When standard treatment fails, we proceed not only with the necessary thorough debridement to convert the wound to a relatively clean one but also concomitant closure by pectoralis major muscle flaps to completely obliterate dead space. Transposition flaps of rectus abdominus muscle or omentum are used when necessary to complete the closure. In the initial phase of this study, there were 3,239 patients who underwent open heart procedures through a median sternotomy approach in the years 1975 through 1978. In the 50 patients who had wound infections (1.54%), there were nine deaths. Three were thought to be unrelated to the sternal wound infection, four patients ruptured the ventricle or aorta, two patients died of generalized sepsis. Of these 50 patients, 22 responded to simple drainage; 28 had involvement of the mediastinum (0.86%). Of the 28 patients, 25 had debridement and closed mediastinal irrigation by catheter. Fourteen of these 25 did not respond. In these failing patients, 12 were treated by further debridement and closure by muscle flaps. Nine of these 12 were rescued. In the past nine months, an additional 1,052 patients had an open heart procedure. Of these, 11 had a median sternotomy infection. There have been no deaths in this latter group of patients, most of whom were treated by the muscle flap procedure. In addition to the improvement in mortality, morbidity has been reduced substantially. This procedure provides for a rational approach that we have found to permit salvage of a high percentage of patients who failed conventional closed irrigation techniques.

Anti-Bacterial Agents↗
PubMed1980

Dacron interposition shunts for portal hypertension. An analysis of morbidity correlates.

Analysis of 79 Dacron interposition shunts performed at Emory University from 1971 to 1977 identified a number of preoperative characteristics that correlate with short-term and long-term morbidity. Initial hospital mortality was related to the degree of elevation of the bilirubin and serum glutamic oxaloacetic transaminase (SGOT), to the presence of encephalopathy and to the urgency of the shunt procedure. Cumulative survival correlated best with the preoperative SGOT and bilirubin values, but other variables, including the Child's classification, preoperative encephalopathy, serum albumin, and the age of the patient at the time of operation, also exhibited significant associations. The hospital mortality of 13% and cumulative mortality of 48% in this series are in substantial agreement with similar reports in the literature. This experience differs widely from that described by most authors, however, in two other important respects: 1) significant hepatic encephalopathy has been observed in 45% of these hospital survivors, and 2) almost one-quarter of these patients have experienced spontaneous shunt closure. Thus, major shunt related complications have occurred in 70% of the patients to date. This incidence of undesirable consequences raises a serious question concerning the continued use of the Dacron interposition shunt for elective portal decompression.

Adult↗
PubMed1981

Reoperation for primary hyperparathyroidism.

Between 1960 and April, 1980, 302 patients were explored for primary hyperparathyroidism at Emory University Hospital. Seventeen of these 302 patients had undergone initial surgical exploration elsewhere, and were referred for persistent hypercalcemia. Of the 285 patients who were operated on at our institution, 14 subsequently had persistent hypercalcemia, and two had recurrent hypercalcemia. Twenty-eight of these 33 patients had had re-exploration, and 23 (82%) are now normocalcemic. Twenty-eight abnormal glands were found; 22 (79%) were retrievable via the neck and six (21%) required sternotomy. Of those glands removed via the neck, nine were in a near normal location and 13 in a subnormal or abnormal location. The causes of initial surgical failures were abnormally located glands, in ten patients, insufficient explorations of the neck in eight patients, hyperfunctioning parathyroid remnants in three patients, inadequate plans for hyperplasia in two patients, and carcinoma in one patient. In 57% of our patients who underwent successful re-exploration, the glands were correctly localized before operation by angiographic examination or selective venous sampling for parathormone. Thorough exploration and obtainment of biopsy specimens of all parathyroid glands are recommended in order to keep initial failures to a minimum. If reoperation is required, localization using CT scan, angiography and selective venous sampling are recommended.

Adenoma↗
PubMed1982

Ten years portal hypertensive surgery at Emory. Results and new perspectives.

Five hundred four Shunt procedures have been done at Emory University Hospitals between 1971 and 1981 to decompress bleeding esophageal varices. This paper reviews how far the experiences of a prospective randomized study (55 patients) of distal splenorenal shunts against total shunts is supported by the nonrandomized experience (449 patients), and outlines our current methods of management dictated by this experience. The overall operative mortality for 348 selective shunts is 4.1% and for 156 nonselective shunts, 14.1%. The five-year survival following Selective shunt is 59%, and following nonselective shunt is 49%: more than half the selective shunt patients are alive, in contrast to the median survival of 44.5 months for patients having nonselective shunts. Following Selective shunt, the survival in nonalcoholic patients is significantly better than the median survival of alcoholic patients of 57 months. Encephalopathy, reported at three years after surgery in the randomized patients was significantly (p < 0.001) lower after selective shunt (12%) compared to nonselective shunt (52%): in the same population at seven years, all patients with patent nonselective shunts have clinical or subclinical encephalopathy, but only 30% of the selective shunt patients have subclinical encephalopathy. Shunt patency, immediately after surgery, is 93% following selective shunt, with only two documented late thromboses: nine of nine patients, at a mean of seven years, retain patency in the randomized study. Shunt occlusion increases with time after interposition nonselective shunts: seven of 13 are occluded at a mean follow-up of seven years in the randomized study. Portal venous perfusion is retained in 93% of patients seven to ten days after selective shunt, but in no patient with a patent nonselective shunt. Late portal perfusion is maintained in nine of the eleven patients in the randomized group studied at a mean of seven years after selective shunt. Restoration of portal perfusion has led to clearing of encephalopathy and improvement in hepatic function in six patients. The following conclusions are made: (1) selective shunts can be done with low operative mortality, and long-term patency with excellent control of bleeding; (2) hepatic portal venous perfusion has been maintained after selective shunt for ten years, and this is vital for preventing encephalopathy and maintaining hepatic function; (3) long-term survival after selective shunt is better than any reported series for nonselective shunt; and (4) selective shunts are the operative procedure of choice for variceal decompression and nonselective shunts should rarely be performed for elective decompression.

Analysis of Variance↗
PubMed1982

Concomitant carotid and coronary artery reconstruction.

Data are presented on 68 patients who underwent concomitant carotid endarterectomy (CE) and coronary artery bypass surgery (CAB) at Emory University Hospital from January 1974 to February 1981. This group is then compared with a randomly selected, matched population without known carotid disease who underwent CAB alone. Asymptomatic bruit was the reason for investigation in 40 patients (59%); another 23 patients (34%) experienced transient cerebral ischemic attacks (TIAs); and five patients (7%) had TIA and prior stroke. Carotid stenoses (>75% luminal narrowing) were demonstrated as follows: isolated left, 24 patients; isolated right, 27 patients; and bilateral lesions, 16 patients. One patient had innominate artery stenosis. Associated total occlusion of one or both vertebral arteries was demonstrated in six patients. Ninety-seven per cent of patients had disabling angina pectoris prior to operation; the angina was unstable in 57%, 15% had congestive heart failure, and 54% had had at least one prior myocardial infarction (MI). Single-vessel coronary disease was present in 12.5% of patients, double in 37.5%, triple in 41.1%, and left main stenosis in 9%; 43% of patients had abnormal ventricular contractility. CE was performed on 67 patients (36 left and 31 right); aortocarotid bypass was performed on one. The CE procedures were performed immediately prior to the sternotomy for CAB under the same anesthesia. CAB consisted of single bypass in eight patients (11.8%); double in 16 patients (23.5%); triple in 22 patients (32.4%); and quadruple or more in 22 patients (32.4%) (mean = 2.9 grafts per patient). There was no hospital mortality. Perioperative MI occurred in 2.0% and stroke with residual deficit in 1.3%. Cumulative survival is 98.5% at two years. Sixty-three patients (92%) reported improvement or elimination of anginal symptoms after operation. Rehospitalization for stroke was necessary in 3.7% patients. Postoperative activity levels are; self-care only, 3.9%; normal daily activity only, 17.6%; moderate exercise capability, 45%; and vigorous exercise capability, 33%. Comparison was made with a group of 84 randomly selected patients who underwent CAB alone during the same time interval. Data revealed no significant difference between the groups regarding sex, angina subset, ventricular function, coronary anatomy, vessels grafted, perioperative stroke or MI, mortality, or postoperative activity capability. Older age (59.8 vs. 55.6, p < 0.01) and less complete coronary revascularization possible (66 vs. 84%, p < 0.05) in the CECAB group were the only significant differences. Carotid stenosis co-existing in patients requiring CAB should be concomitantly corrected with the same risk and results expected from CAB alone.

Aged↗
PubMed1982

The omentum: its use as a free vascularized graft for reconstruction of the head and neck.

The experience at Emory University Affiliated Hospitals with transplantation of the greater omentum as a free revascularized graft in 18 patients is presented. In each instance, there was realization of the therapeutic objective, either 1) the amelioration of congenital or acquired somatic deformity (14 patients) or 2) the control of infection (4 patients). Because the omentum is a syncytium of blood vessels and a variable amount of fat within redundant leaves of peritoneal membrane laden with macrophages, it is a tissue that serves admirably its extended role as an extracelomic free transplant. The greater omentum has been used for this purpose in five patients with hemifacial atrophy (Romberg's disease); three patients with hemifacial microsomia (first and second branchial arch syndrome); two patients with extensive losses of the maxilla, palate, and face due to a shotgun blast; two patients with atrophy and facial growth arrest due to x-irradiation; and two patients with deformity of the jaw and neck following tumor resection. In three additional patients, the omentum was used to obliterate the dead space after debridement of an infected open frontal sinus following failure of conventional therapy. In one instance, a revascularized free graft of omentum was used to salvage a patient with an exposed irradiated carotid artery graft and skin flap failure following radical neck dissection. In these 18 patients, there were no intra-abdominal complications consequent to harvest of the omentum. In one patient afflicted with hemifacial atrophy, there was spotty necrosis of the overlying attenuated facial skin flap and limited fat necrosis. In the follow-up period of four months to seven years, there has been no instance of late resorption. The method is reliable and has considerable promise in reconstructive surgery.

Face↗
PubMed1984

Clinical, hemodynamic, and operative descriptors affecting outcome of aortic valve replacement in elderly versus young patients.

One hundred and fifty-two patients age 70 years or more underwent aortic valve replacement (AVR) at Emory University Hospital between July 1, 1974 and July 1, 1982. Of these, 98 had isolated AVR (elderly AVR group) and 54 had concomitant coronary artery bypass grafts (elderly AVR/CABG group). Results of surgery in these patients were compared to results in patients aged 20 to 69 years operated on in the same period (young AVR/CABG groups). Comparative descriptors with statistically significant differences included a higher incidence of both stable and unstable angina in patients undergoing concomitant CABGs ; less cardiomegaly in the young AVR/CABG group; less hypertension, a higher incidence of pure aortic regurgitation, and less frequent use of inotropes in the young AVR group; a higher perioperative stroke rate in elderly AVR/CABG patients; a higher perioperative psychosis rate in patients having CABGs regardless of age; and a longer postoperative hospital stay for the elderly patients. There were no significant differences between the four groups for the following descriptors: sex ratio; history of congestive heart failure; the presence of atrial fibrillation; left ventricular end diastolic pressure, ejection fraction and contractility; number of diseased coronary arteries; number of vessels bypassed; use of the intra-aortic balloon pump; re-exploration for hemorrhage; perioperative myocardial infarction rate; and major wound infection rate. Operative mortality was 5.1% for the elderly AVR group, 5.6% for the elderly AVR/CABG group, 1.9% for the young AVR group, and 5.1% for the young AVR/CABG group (p = NS). Overall, hospital mortality was 3.3%. Actuarial survival curves for all elderly versus all young patients showed no significant difference. The curve for elderly patients compares favorably with the actuarial survival of the same age group in the general population. Actuarial survival curves for the four subgroups did not differ significantly when compared at a follow-up of 36 months after surgery. We conclude that AVR with or without concomitant CABGs can be performed in elderly patients with an acceptably low mortality and morbidity, and the postoperative survival compared favorably both with younger patients and with the general population of the same age.

Actuarial Analysis↗
PubMed1989

Reconstruction of the pharynx after resection for cancer. A comparison of methods.

Repair of the pharynx after extirpation of malignancy may require the introduction of independently vascularized tissue either at the time of resection (primary reconstruction) or later for undesirable sequelae, such as fistula or stenosis. A ten-year retrospective study compares two methods of pharyngeal reconstruction, the pectoralis major musculocutaneous flap (MCF) and the jejunal free autograft. One hundred and seventeen patients undergoing laryngopharyngectomy at Emory University affiliated hospitals between 1977 and 1987 were reconstructed with either the pectoralis major musculocutaneous flap (24 patients) or with the jejunal free autograft (93 patients) Primary repair with the pectoralis MCF was attempted on 12 patients (Group I) with initial success in 5 patients (42%), fistula in 7 patients (58%), and salvage surgery necessary in 6 patients (86%). Primary reconstruction with jejunal free autograft (Group II) was performed in 70 patients with 44 initial successes (63%), 9 graft failures (13%), 5 of which were salvaged by a second jejunal free autograft. Seventeen fistulas occurred (24%). Of these, nine (53%) closed with nonoperative therapy and five (29%) required surgery. Secondary reconstruction with the pectoralis major MCF was attempted in 12 patients with initial success in 3 patients (25%), and fistula in 9 patients (75%). Of these 9 fistula patients, 3 (33%) closed with nonoperative therapy and 6 required salvage surgery, which was successful in only 2 patients. Secondary repair with jejunal free autograft was performed in 23 patients with 13 (56%) initial successes and 8 patients resolving with nonoperative therapy (89%) for a total success rate of 21/23 or 91%. The higher initial success rates and more expeditious resolution of problems demonstrates that the jejunum is the superior method of reconstruction for the pharynx.

Constriction, Pathologic↗
PubMed1998

Pancreatic necrosis: results of necrosectomy, packing, and ultimate closure over drains.

OBJECTIVE: The treatment of pancreatic necrosis at a tertiary referral center was reviewed to effect better patient outcome. SUMMARY BACKGROUND DATA: Pancreatic necrosis is a devastating disease that leads to death in 10% to 50% of cases. Infected necrosis is particularly deadly because 80% of deaths from necrosis are due to infection or its complications. Therapeutic strategies center on aggressive support of organ systems and prevention and treatment of infectious complications. METHODS: Records of all patients who underwent pancreatic necrosectomy from 1990 to 1996 at Emory University Hospital were reviewed. Patients with infected necrosis were debrided as soon as the diagnosis was made. Reoperation for completion necrosectomy with ultimate closure over lavage catheters was performed as necessary. RESULTS: Of the 244 patients admitted with acute pancreatitis in the study period, 50 underwent pancreatic debridement. The mean age was 52 years, and 74% of patients were transferred from other institutions. Eighty-four percent of patients had infected necrosis, and all patients underwent sequential debridement with eventual closure over drains. Organ failure occurred in 72% of cases, and the overall mortality rate was 12%. The mean length of stay was 54 days. CONCLUSIONS: The management of pancreatic necrosis demands the allocation of extensive resources. An aggressive operative strategy of multiple debridements with ultimate closure over drains can lead to a low mortality rate in patients with this complex disease, but the determination of when to explore patients with sterile necrosis remains difficult.

Acute Disease↗
PubMed1998

Surgeon-performed ultrasound: its use in clinical practice.

OBJECTIVE: To highlight areas where surgeon-performed ultrasound (US) is an effective diagnostic and therapeutic tool. SUMMARY BACKGROUND DATA: The success of US in trauma and technologic advances have enhanced the interest and ability of surgeons to perform their own US examinations. METHODS: General surgeons perform US examinations of the thyroid gland, breast, gastrointestinal tract, peritoneal cavity (laparoscopy), and vascular system. Essentials of these examinations are discussed and a plan for educating surgical residents in US is outlined. RESULTS: Focused assessment for the sonographic examination of the trauma patient, or FAST, is replacing central venous pressure measurements to detect hemopericardium and diagnostic peritoneal lavage to detect hemoperitoneum. Bedside US can be used to detect a pleural effusion so well in critically ill patients that lateral decubitus x-rays are rarely needed. US-directed biopsy of breast lesions is a common office procedure. Laparoscopic US allows tumor staging without formal celiotomy, and many hepatic and pancreatic surgical procedures include US as an adjunct. Endoscopic and endorectal US have added a new dimension to the assessment of many gastrointestinal lesions. Color flow duplex imaging and endoluminal US have significantly expanded the diagnostic and therapeutic aspects of vascular imaging. The training program developed at Emory University and Grady Memorial Hospital is offered as a model for educating surgical residents in US techniques. CONCLUSIONS: US is a valuable addition to the general surgeon's diagnostic armamentarium and is rapidly becoming an integral part of the surgeon's clinical practice.

Breast Diseases↗
PubMed1999

Long-term follow-up of patients with rectal cancer managed by local excision with and without adjuvant irradiation.

OBJECTIVE: The long-term outcomes of patients undergoing local excision with or without pelvic irradiation were examined to define the role of adjuvant irradiation after local excision of T1 and T2 rectal cancers. METHODS: Ninety-nine patients with T1 or T2 rectal cancers underwent local excision with or without adjuvant irradiation at Massachusetts General Hospital and Emory University Hospital between January 1966 and January 1997. Of these, 52 patients were treated by local excision alone and 47 patients by local excision plus adjuvant irradiation. Twenty-six of these 47 patients were treated by irradiation in combination with 5-fluorouracil chemotherapy. The outcomes of these groups were compared. RESULTS: The 5-year actuarial local control and recurrence-free survival rates were 72% and 66%, respectively, for the local excision alone group and 90% and 74%, respectively, for the adjuvant irradiation group. This improvement in outcome was evident despite the presence of a higher-risk patient population in the adjuvant irradiation group. Adverse pathologic features such as poorly differentiated histology and lymphatic or blood vessel invasion decreased local control and recurrence-free survival rates in the local excision only group. Adjuvant irradiation significantly improved 5-year outcomes in patients with high-risk pathologic features. Four cases of late local recurrence were seen at 64, 72, 86, and 91 months in the adjuvant irradiation group. CONCLUSIONS: The authors recommend adjuvant chemoradiation for all patients undergoing local excision for T2 tumors, and for T1 tumors with high-risk pathologic features. The four cases of late local failures beyond 5 years in the adjuvant irradiation group underscores the need for careful long-term follow-up in these patients.

Actuarial Analysis↗
PubMed2002

The National Surgical Quality Improvement Program in non-veterans administration hospitals: initial demonstration of feasibility.

OBJECTIVE: To assess the feasibility of implementing the National Surgical Quality Improvement Program (NSQIP) methodology in non-VA hospitals. SUMMARY BACKGROUND DATA: Using data adjusted for patient preoperative risk, the NSQIP compares the performance of all VA hospitals performing major surgery and anonymously compares these hospitals using the ratio of observed to expected adverse events. These results are provided to each hospital and used to identify areas for improvement. Since the NSQIP's inception in 1994, the VA has reported consistent improvements in all surgery performance measures. Given the success of the NSQIP within the VA, as well as the lack of a comparable system in non-VA hospitals, this pilot study was undertaken to test the applicability of the NSQIP models and methodology in the nonfederal sector. METHODS: Beginning in 1999, three academic medical centers (Emory University, Atlanta, GA; University of Michigan, Ann Arbor, MI; University of Kentucky, Lexington, KY) volunteered the time of a dedicated surgical nurse reviewer who was trained in NSQIP methodology. At each academic center, these nurse reviewers used NSQIP protocols to abstract clinical data from general surgery and vascular surgery patients. Data were manually collected and then transmitted via the Internet to a secure web site developed by the NSQIP. These data were compared to the data for general and vascular surgery patients collected during a concurrent time period (10/99 to 9/00) within the VA by the NSQIP. Logistic regression models were developed for both non-VA and VA hospital data. To assess the models' predictive values, C-indices (0.5 = no prediction; 1.0 = perfect prediction) were calculated after applying the models to the non-VA as well as the VA databases. RESULTS: Data from 2,747 (general surgery 2,251; vascular surgery 496) non-VA hospital cases were compared to data from 41,360 (general surgery 31,393; vascular surgery 9,967) VA cases. The bivariate relationships between individual risk factors and 30-day mortality or morbidity were similar in the non-VA and VA patient populations for over 66% of the risk variables. C-indices of 0.942 (general surgery), 0.915 (vascular surgery), and 0.934 (general plus vascular surgery) were obtained following application of the VA NSQIP mortality model to the non-VA patient data. Lower C-indices (0.778, general surgery; 0.638, vascular surgery; 0.760, general plus vascular surgery) were obtained following application of the VA NSQIP morbidity model to the non-VA patient data. Although the non-VA sample size was smaller than the VA, preliminary analysis suggested no differences in risk-adjusted mortality between the non-VA and VA cohorts. CONCLUSIONS With some adjustments, the NSQIP methodology can be implemented and generates reasonable predictive models within non-VA hospitals.

Feasibility Studies↗
PubMed1978

Evaluation of a gross anatomy program without dissection.

Freshman medical students have been participating in an experimental multimedia gross anatomy program at Emory University for five years. The program includes audiovisuals, computer-assisted instruction, and tutorial sessions using prosected specimens. No lectures are given nor is dissection permitted. Experimental and traditional groups were compared by intramural written and practical examinations and by an extramural written examination prepared by the National Board of Medical Examiners and the Association of Anatomy Chairmen. Study of 35 intramural examinations given to five classes showed students in the traditional course with significantly higher performance in three examinations and students in the experimental course with significantly higher performance in six examinations. Neither group's performance was significantly higher on any extramural examination. It was concluded that, as measured by conventional examinations, students in the multimedia program with prosection tutorials learned human anatomy as well as those in the traditional lecture-dissection program.

Anatomy↗
PubMed1997

Demographic and clinical features of Alzheimer disease in black Americans: preliminary observations on an outpatient sample in Atlanta, Georgia.

This exploratory study describes the frequency, demographic features, and clinical manifestations of Alzheimer disease (AD) in a sample of demented black outpatients evaluated at the Emory University Alzheimer's Disease Center. The study reviews prospectively collected research data from 88 demented black outpatients who completed a standardized diagnostic evaluation. Forty-seven percent of these patients met NINCDS-ADRDA criteria for probable AD, and 29% met NINCDS-ADRDA criteria for possible AD. The majority of the probable AD patients were women, and many were suffering from comorbid medical illnesses. In the probable AD patients, there was an association between higher levels of education and a higher frequency of affective symptoms, and an association between longer duration of cognitive symptoms and the presence of parkinsonism. Possible AD was also common in this sample of demented black outpatients and was often encountered mixed with vascular dementia.

Black or African American↗
PubMed2004

Efficacy and safety of transjugular intrahepatic portosystemic shunt in the treatment of nongastric extraesophageal variceal bleeding.

OBJECTIVES: Although esophageal varices are the most common site of variceal bleeding, extraesophageal varices cause up to 30% of variceal bleeding. Unlike esophageal variceal bleeding, the experience in management of extraesophageal variceal bleeding, especially nongastric extraesophageal variceal bleeding is limited, and there are no established guidelines for treatment of nongastric extraesophageal variceal bleeding. This study aims to provide experience in treatment of nongastric extraesophageal variceal bleeding with transjugular intrahepatic portosystemic shunt in a tertiary medical center. METHODS: We retrospectively reviewed all cases, admitted or transferred to Emory University Hospital, with extraesophageal variceal bleeding who had transjugular intrahepatic portosystemic shunt as the final resolution to control bleeding over a period of 4 years, from January 1999 to January 2003. We also compared the outcomes after transjugular intrahepatic portosystemic shunt for bleeding from gastric varices and nongastric extraesophageal varices. RESULTS: Forty-one patients (33 gastric varices and 8 nongastric extraesophageal varices) with extraesophageal variceal bleeding who had transjugular intrahepatic portosystemic shunt performed were identified in this study period. Bleeding was controlled immediately in 90% (37/41) of those patients. The mortality was 7% (3/41). The rebleeding rate was 10% (4/41). Encephalopathy occurred in 24% (10/41) of the patients. Patients with gastric varices bleeding appeared to have more advanced liver disease than patients with nongastric extraesophageal varices bleeding. The outcomes after transjugular intrahepatic portosystemic shunt for bleeding from gastric varices and nongastric extraesophageal varices were similar. CONCLUSIONS: Transjugular intrahepatic portosystemic shunt is an effective and safe treatment of extraesophageal variceal bleeding, including bleeding from gastric varices and nongastric extraesophageal varices.

Esophageal Diseases↗