Showing papers by "Lincoln Hospital published in 1991"

Management options in penetrating rectal injuries.

Abstract: A retrospective analysis of 54 patients (1976-1989) with penetrating rectal injuries was carried out to evaluate the options in management. The diagnosis was made on proctosigmoidoscopy in 39 patients and at laparotomy in 15. Three patients died within 24 hours from extensive associated trauma (Abdominal Trauma Index [ATI] 39.2). In the remaining 51 patients, rectal wound repair was performed in seven patients, four without proximal colostomy (mean ATI 16.5) and three with colostomy (mean ATI 24.8) without complications. Colostomy and presacral drainage with or without repair were employed in 43 patients. Twenty-one of these patients had rectal washout in addition. The other 22 patients did not have this procedure. The incidence of pelvic abscess in these two groups, who had comparable mean ATI, was identical (4.7% and 4.5%, respectively). One other patient with an extraperitoneal rectal injury had a colostomy alone without presacral drainage and subsequently developed pelvic abscess. The overall incidence of abscess was three of 51 patients or 5.8%. There were no late deaths from sepsis. It is concluded that colostomy (loop or end) and presacral drainage are the most important components of rectal injury management. Small and isolated rectal or rectosigmoid perforations may be repaired primarily without fecal diversion. The value of distal rectal irrigation remains to be proven, but it may be indicated in high-energy injuries of the rectum.

Management of transperitoneal gunshot wounds of the spine

Abstract: To evaluate the results of a conservative approach to gunshot wounds of the spine with a transperitoneal trajectory, we analyzed our 4-year experience with 21 patients. The management protocol consisted of standard treatment of the intra-abdominal injuries, vigorous irrigation of the missile track, and a 48-hour course of antibiotic therapy. The lumbar spine was involved in 14 patients (67%) and the thoracic spine was injured in seven (33%). Eleven patients (52%) were paraplegic on admission and ten patients (48%) had a fixed partial neurologic deficit. One patient with an ISS of 75 died intraoperatively from exsanguination (mortality, 5%). Early morbidity correlated with ISS greater than 40 and spinal AIS greater than 3. Late nonneurologic morbidity was independent of ISS and spinal AIS. One patient required reoperation for a retroperitoneal abscess secondary to a leak from a repaired ureter. Another patient had a retroperitoneal collection on a CT scan which resolved spontaneously. There were no spinal or paraspinal infectious complications in the presence (five cases) or absence of a colonic injury. No change in neurologic status was observed in any patient during a mean follow-up period of 3 months. This preliminary experience suggests that a conservative approach consisting of irrigation of the missile track and short-term antibiotic therapy without laminectomy or removal of fragments from the spinal canal yields optimal results without increasing infectious complications of the spine.

Fine-needle aspiration of diffuse cervical lymphadenopathy in patients with acquired immunodeficiency syndrome.

Abstract: Although diffuse cervical lymphadenopathy is one of the earliest and most common findings in patients with AIDS, the appropriate diagnostic approach in these patients has yet to be determined. Fine-needle aspiration (FNA) was performed on 26 patients with AIDS in order to evaluate the role of FNA in patients with diffuse cervical adenopathy. Specimens were sent for cytology, bacterial culture, fungal culture, and acid-fast smear and culture. Ten patients had positive findings, including toxoplasmosis, histoplasmosis, tuberculosis, atypical mycobacterium, and methicillin-resistant staphylococcal infection. All patients with either unilateral adenopathy or lymph nodes 3 cm or larger had positive aspirates. A statistically significant difference between patients with lymph nodes smaller than 2 cm and those with nodes larger than 2 cm was found. Fine-needle aspiration of a representative node in patients with AIDS may allow prompt diagnosis of diffuse lymphadenopathy. Rapid initiation of appropriate treatment can lead to symptomatic improvement. The need for excisional biopsy of involved lymph nodes may be obviated. Fine-needle aspiration is recommended as a diagnostic tool in selected patients with diffuse cervical lymphadenopathy and AIDS.

A performance-based method for early identification of medical students at risk of developing academic problems.

Abstract: The authors studied three classes at the Albert Einstein College of Medicine and found that students' performances on examinations administered during the third month (November) of medical school were highly predictive of their subsequent performances during the first two years of medical school. The investigation had two components: (1) a retrospective study of the classes of 1988 and 1989, which found that students' November grades from three first-year courses predicted 76% of the variance in the year-one weighted aggregate score and 41% for the year-two score, and (2) a prospective study of the class of 1992, in which three November of year one examination scores of the students in the lowest quarter of the class were highly predictive of their encountering substantial academic problems, with a sensitivity of .77 and a specificity of .99. This performance-based method was found to be more powerful than using the scores on the 1977 version of the Medical College Admission Test or the students' undergraduate grade-point averages, or both, in identifying individual students who were academically at risk.

A method for teaching human values in clinical clerkships through group discussion

Abstract: Human values discussion groups were introduced in third‐year clerkships at the Albert Einstein College of Medicine to enhance the teaching of human values and to counter the dehumanizing effects of medical training. The discussion groups were found to be more effective than seminars, attending rounds, or working with house staff in helping students cope with emotionally or behaviorally difficult patients; problems working on the wards; or the process of becoming a physician (p < .001). Discussion groups were reported to be helpful in developing self‐awareness and in maintaining compassionate and caring attitudes. Students who participated in these groups were found to discuss difficult patients with their peers more than did nonparticipants (p < .005). The program consisted of weekly small discussion groups for third‐year clerks, co‐led by attending physicians and behavioral scientists. Participation was required but not graded. The study sample consisted of 64 students in the Class of 1988, with 104 memb...

Adrenocortical insufficiency with normal serum cortisol levels and hyporeninaemia in a patient with acquired immunodeficiency syndrome (AIDS).

Abstract: . The acquired immunodeficiency syndrome (AIDS) has been associated with abnormalities of adrenocortical function [1–4], and hypoaldosteronism due to hyporeninaemic hypoaldosteronism (HHA) [15]. We here report the case of a woman with AIDS associated with orthostatic hypotension, persistent hyponatraemia and hyperkalaemia, in whom basal serum cortisol levels were normal and serum renin activity was low. Subsequent post-mortem examination revealed almost complete adrenocortical destruction. A possible explanation of this apparently contradictory combination of findings is discussed, together with the therapeutic implications for similar cases.