Showing papers by "Lincoln Hospital published in 1998"

Intra-abdominal hypertension after life-threatening penetrating abdominal trauma: prophylaxis, incidence, and clinical relevance to gastric mucosal pH and abdominal compartment syndrome.

Abstract: Objective: To define the incidence, prophylaxis, and treatment of intra-abdominal hypertension (IAH) and its relevance to gut mucosal pH (pHi), multiorgan dysfunction syndrome, and the abdominal compartment syndrome (ACS). Methods: Seventy patients in the SICU at a Level I trauma center (1992-1996) with life threatening penetrating abdominal trauma had intra-abdominal pressure estimated by bladder pressure. pHi was measured by gastric tonometry every 4 to 6 hours. IAH (intra-abdominal pressure> 25 cm of H 2 O) was treated by bedside or operating room laparotomy. Results: Injury severity was comparable between patients who had mesh closure as prophylaxis for IAH (n = 45) and those who had fascial suture (n = 25). IAH was seen in 10 (22.2%) in the mesh group versus 13 (52%) in the fascial suture group (p = 0.012) for an overall incidence of 32.9%. Forty-two patients had pHi monitoring, and 11 of them had IAH. Of the 11patients, eight patients (72.7%) had acidotic pHi (7.10± 0.2) with IAH without exhibiting the classic signs of ACS. The pHi improved after abdominal decompression in six and none developed ACS. Only two patients with IAH and low pHi went on to develop ACS, despite abdominal decompression. Multiorgan dysfunction syndrome points and death were less in patients without IAH than those with IAH and in patients who had mesh closure. Conclusions: IAH is frequent after major abdominal trauma. It may cause gut mucosal acidosis at lower bladder pressures, long before the onset of clinical ACS. Uncorrected, it may lead to splanchnic hypoperfusion, ACS, distant organ failure, and death. Prophylactic mesh closure of the abdomen may facilitate the prevention and bedside treatment of IAH and reduce these complications.

A Critical Reappraisal of Indications for Fasciotomy After Extremity Vascular Trauma

Abstract: Objective: To critically reevaluate the indications for fasciotomy in vascular trauma of the extremities Design: Case-control study Setting: Level I trauma center Materials and Methods: One hundred sixty-three vascular injuries to the extremeties were analyzed Fasciotomy as an adjunct to vascular repair was performed in 45 limbs (28%), based either on the nature of injury or measured compartment pressure of greater than 35 mm Hg Main Outcome Measures: Need for fasciotomy or limb amputation Results: Fasciotomy was performed for 295% of isolated arterial injuries, 152% of isolated venous injuries, and 316% of combined arterial and venous injuries, and was not related to venous repair or ligation Seven delayed fasciotomies were performed either for vascular repair failure (5 patients) or compartment syndrome (2 patients) The highest incidence was for popliteal vessel injury (arterial 57%, combined 61%) Of the 33 lower-extremity fasciotomies, 58% were for popliteal vessel injury In 51 combined injuries of the lower extremity, only 7 (19%) of 38 patients with injury above the knee required fasciotomy, as compared with 8 (62%) of 13 with injury to the popliteal vessels (P<001), with or without venous repair There were 3 amputations, all resulting from vascular repair failure Conclusions: The presence of a combined vascular injury or the need for venous ligation does not necessitate routine fasciotomy The need for fasciotomy may be maximal for injuries to popliteal vessels

Evaluation of an Instructional Model for Emergency Ultrasonography

Abstract: OBJECTIVE To evaluate a 4-hour ultrasonography course in the setting of an emergency medicine (EM) training program. METHODS EM residents and faculty at a large urban center were provided a 4-hour emergency ultrasonography course. Then, during an 18-month period, a nonconsecutive sample of ultrasonographic examinations were videotaped and later reviewed. The interpretations of the emergency, physician examinations were compared with the following reference standards: 1) an official ultrasound performed and interpreted by the departments of radiology or cardiology; 2) an operative report; 3) A CT scan or i.v. pyelogram (IVP); or 4) a cardiologist's or a radiologist's interpretation of the videotaped examinations. RESULTS Of 258 examinations reviewed, 28 (11%) of these were excluded because the cardiologist or radiologist reviewing the videotape determined them to be "technically limited" studies. Of the remaining 230 examinations, there were: 127 gallbladder studies [disease prevalence = 0.58; sensitivity = 0.89; specificity = 0.80; kappa (kappa) = 0.69; 95% CI: 56-82%]; 39 echocardiograms to rule out pericardial effusions [disease prevalence = 0.15; sensitivity = 0.83; specificity = 0.97 kappa = 0.80; 95% CI: 54-100%]; 25 abdominal ultrasounds to rule out free peritoneal fluid [disease prevalence = 0.32; sensitivity = 0.88; specificity = 0.94; kappa = 0.81; 95% CI: 26-95%]; 16 renal ultrasounds to rule out hydronephrosis [disease prevalence = 0.25; sensitivity = 1.0; specificity = 0.92; kappa = 0.84; 95% CI: 56-100%]; 12 pelvic ultrasounds to rule in an intrauterine pregnancy [disease prevalence = 0.67; sensitivity = 1.0; specificity = 0.75; kappa = 0.80; 95% CI: 43-100%]; and 11 abdominal ultrasounds to rule out abdominal aortic aneurysms [disease prevalence = 0.09; sensitivity = 1.0; 95% CI: 2.5-91%; specificity = 1.0; 95% CI: 68-100%]. CONCLUSIONS This 4-hour ultrasonography course has potential to serve as a foundation for an instructional model for ultrasonography training in the setting of an EM residency program.

Penetrating ureteric injuries

Abstract: Injury to the ureter is relatively rare. We retrospectively reviewed our experience with 21 cases of ureteric injury from penetrating trauma at the Lincoln Medical Center. Two injuries resulted from stab wounds and 19 from gunshot wounds. Total ureteric disruption occurred in 14 cases, partial transection in four and contusion in three. Preoperative screening was unreliable in accurately predicting the injury with hematuria being present in 66 per cent of cases. Similarly, intravenous urogram was diagnostic in 14 per cent and suspicious in another 42 per cent. Most injuries were diagnosed intraoperatively and exploration of the retro peritoneum remains the only definitive method of excluding ureteric injuries. Most patients were critically ill (mean ISS 27) due to associated injuries (90 per cent). Neither peritoneal contamination associated with hollow viscous injuries nor hypotension adversely affected the healing of ureteric anastomoses. Anastomotic leak developed in three (14 per cent) cases and one of them required operative correction. Another two patients developed infections related to the urinary tract.

Group psychoeducation of relatives of schizophrenic patients : Two-year experiences

Abstract: In order to assess the feasibility and acceptability of group psychosocial education for the relatives of schizophrenics in the community, a 2-year project was carried out in two cities: Jinan and Shanghai, China. The completed sample included 682 cases in the experimental group and 366 cases in the control group. The experimental group received group psychotherapy including 14 lectures and five group discussions with conventional services, and the control group had conventional services only. The annual relapse rate in the experimental group was much lower than that in the control group (17.6 and 23.2%, P < 0.01) and the rate of regular work in the experimental group was higher than that in the control group (37.5 and 30.0%, P < 0.05). At the end of the second year, the relatives in the experimental group had less care burden, better mental and physical health status and more knowledge of caring for schizophrenics than those in the control group. This approach was well accepted by both mental health workers and relatives of schizophrenics and the rate of drop-out was 18.4% only during the 2-year period.

Combined cervical and intraoral approach to lingual thyroid: a case report.

Abstract: Background. Lingual thyroid is a rare anomaly that may require surgical intervention. Lesions have been approached either via the neck or transorally. Advantages and limitations exist with each technique. Methods. A 10-year-old female on long-term suppression therapy for lingual thyroid developed progressive dysphagia; surgical excision was performed. Suprahyoid pharyngotomy was used to dissect the posterior limits of the tumor. Resection was completed via a transoral approach. Results. Cervical exposure allowed safe access to the posterior tumor margins. Transoral exposure permitted direct dissection of the anterior margin of the lesion, rendering complete excision simple. Conclusion. A combined surgical approach to lingual thyroid is a safe technique that affords excellent visualization and facilitates resection.

Cutaneous cryptococcosis mimicking basal cell carcinoma in a patient with AIDS.

Abstract: Antecedents: La cryptococcose est une infection opportuniste causee par la levure encapsulee appelee Cryptococcus neoformans. Cet organisme tres repandu est souvent observe chez les patients dont le systeme immunitaire est deficient, et particulierement chez ceux qui sont atteints d'une tumeur maligne sous-jacente, qui ont subi une transplantation d'organe ou qui souffrent du syndrome d'immunodeficience acquise (SIDA). Dix a quinze pour cent des patients victimes d'une arteinte systemique presente des manifestations cutanees de la cryptococcose. Or, ces lesions de la peau peuvent simuler differentes entites cliniques. Methodes: Presentation d'un cas de cryptococcose simulant un carcinome basocellulaire. Resultats: Un patient sidatique presentant une cryptococcose cutanee non disseminee simulant un carcinome basocellulaire a ete traite energiquement pour prevenir toute maladie systemique occulte. Conclusion: La cryptococcose cutanee peut simuler d'autres affections dermatologiques.

New recessive syndrome characterized by increased chromosomal breakage and several findings which overlap with Fanconi anemia

Abstract: We describe four cases with several findings of Fanconi anemia (FA), but without hypersensitivity to DNA cross-linking that is the distinguishing characteristic of FA. Two of the cases are male and female sibs of Hispanic origin, age 6 years and 11 months, respectively. Both have short stature, failure to thrive, absent thumbs, short palpebral fissures, and skin pigmentation abnormalities. The girl also has developmental "dysplasia" of her hips. Presently, both siblings are hematologically normal. Elevated baseline chromosome breakage was observed in the boy, but not in the girl. Neither sib showed elevated diepoxybutane (DEB)-induced chromosomal breakage. In a subsequent pregnancy, prenatal studies showed slightly elevated baseline and DEB induced chromosome breakage (greater than normal, but lower than the established range for FA). The fetus had intrauterine growth retardation and an absent right thumb. A review of cases referred to the International Fanconi Anemia Registry for DEB testing showed one additional case with similar findings. That patient, a girl, of Caucasian English ancestry, age 14 years, had short stature, a history of failure to thrive, skin pigmentation abnormalities, absent right thumb, hypoplastic left thumb, and hydrocephalus that resolved spontaneously. Elevated baseline chromosome breakage was observed in skin fibroblasts but not in lymphocytes. We postulate that these cases represent a previously undescribed autosomal recessive syndrome. These and other previously reported cases provide evidence for alternative genetic mechanisms that may result in developmental anomalies similar to those seen in FA.