Showing papers by "New York Methodist Hospital published in 1996"

Hyperbaric oxygen therapy for the treatment of radiation‐induced sequelae in children: The University of Pennsylvania experience

Abstract: BACKGROUND. The role of hyperbaric oxygen (HBO) therapy in the treatment of radiation-related sequelae in adults is well known. In contrast, its role in the management of radiation-related sequelae in children has not been well studied. In an effort to define its value better, the authors reviewed the University of Pennsylvania experience and hereby report the results of their analysis. METHODS. Between 1989 and 1994, ten patients who underwent radiation therapy for cancer as children were referred for HBO therapy. Six patients underwent HBO therapy as a prophylactic measure prior to maxillofacial procedures : dental extractions and/or root canals (four patients), bilateral coronoidectomies for mandibular ankylosis (one patient), and wound dehiscence (one patient). Therapeutic HBO was administered to four other patients : one patient for vasculitis resulting in acute seventh cranial nerve palsy and the other three after sequestrectomy for osteoradionecrosis (mastoid bone, temporal bone, and sacrum, respectively). Osteoradionecrosis was diagnosed both radiologically and histologically after exclusion of tumor recurrence. The number of treatments ranged between 9-40 dives (median, 30 dives). Treatments were given once daily at 2 atmosphere absolutes for 2 hours each. Adjunctive therapy in the form of debridement, antibiotics, and placement of tympanotomy tubes was administered to two patients. Ages at HBO treatment ranged from 3.5 to 26 years (median, 14 years). Six patients were male and four were female. The most commonly irradiated site was the head and neck region (eight patients ; brain stem gliomas [one], posterior fossa primitive neuroectodermal tumor [one], rhabdomyosarcomas [three], nasopharyngeal cancer [one], carcinoma of the parotid gland [one], and Hodgkin's disease [one]). The remaining two patients received radiation therapy for pelvic tumors (Ewings's sarcoma and rhabdomyosarcoma). Radiation doses ranged between 4000 and 6660 centigray (cGy) (median, 5500 cGy). The interval between the end of radiation therapy and HBO treatment ranged between 2 months and 11 years (median, 1.5 years). The median follow-up interval after HBO therapy was 2.5 years (range, 2 months-4 years). RESULTS. Except for two patients who had initial anxiety, nausea, and vomiting, the HBO treatments were well tolerated. In all but one patient, the outcome was excellent. In the six patients who had prophylactic HBO, all continued to demonstrate complete healing of their orthodontal scars at last follow-up. In the four patients who received HBO as a therapeutic modality, all 4 had documented disappearance of signs and symptoms of radionecrosis and two patients demonstrated new bone growth on follow-up computed tomography scan. One patient with vasculitis and seventh cranial nerve palsy had transient improvement of hearing ; however, subsequent audiograms returned to baseline. CONCLUSIONS. The use of hyperbaric oxygen for children with radiation-induced bone and soft tissue complications is safe and results in few significant adverse effects. It is a potentially valuable tool both in the prevention and treatment of radiation-related complications.

Let us shorten antibiotic prophylaxis and therapy in surgery

Abstract: Excessive duration of antibiotics for prophylaxis and treatment of surgical infection appears to be the principal reason for "inappropriate" administration in current surgical practice. The main factors to blame are the inability of the clinician to distinguish between contamination, infection, and inflammation. Failure to distinguish between contamination and infection is the reason that prophylaxis is unnecessarily carried through into the postoperative phase for prolonged periods. Failure to distinguish between infection and inflammation misguides surgeons to continue antibiotics for unnecessarily long treatment periods. The concept for shortening courses of antibiotic administration is supported by a forum of experts. The majority of experts also favored a trend away from the use of therapeutic courses of fixed duration, by tailoring the duration of administration to the intraoperative findings to shorten treatment courses. Specific recommendations are (1) contamination: single dose prophylaxis (gastroduodenal peptic perforations operated within 12 hours, traumatic enteric perforations operated within 12 hours, peritoneal contamination with bowel contents during elective or emergency procedures, early or phlegmonous appendicitis, or phlegmonous cholecystitis); (2) resectable infection: 24-hour postoperative antibiotics (appendectomy for gangrenous appendicitis, cholecystectomy for gangrenous cholecystitis, bowel resection for ischemic or strangulated "dead" bowel without frank perforation); (3) advanced infection: 48 hours to 5 days, based on operative findings and patient's condition (intra-abdominal infection from diverse sources); (4) severe infection with the source not easily controllable: longer administration periods may be necessary (e.g., infected pancreatic necrosis).

Complete nonsurgical resolution of a spontaneous spinal epidural hematoma

Abstract: Spontaneous spinal epidural hematomas (SSEH) are heralded by spinal pain and progressive cord compression syndromes which may lead to permanent neurological disability or death if emergent neurosurgical intervention is delayed. It therefore must be considered early in the differential diagnosis of acute spinal cord compression syndrome. A case of spontaneous spinal epidural hematoma presenting as an acute myelopathy in a clarinet player who chronically used a nonsteroidal anti-inflammatory medication is presented. The case was remarkable for the rare complete spontaneous resolution of neurological function. Approximately 250 cases of SSEH have been reported in the medical literature, although only a handful of these patients have recovered spontaneously. This is the sixth report of such an event. The etiologies, contributing factors, disease progression, and treatment recommendations are discussed.

Complications from the use of thrombolytic agents in patients with cocaine associated chest pain

Abstract: Previous investigators have noted that patients with cocaine associated chest pain frequently have abnormal electrocardiograms, including ST segment elevation, in the absence of ongoing myocardial ischemia. The effects of these nonischemic ST segment elevations have not been evaluated. We report two patients with cocaine associated chest pain and ST segment elevations who received thrombolytic agents in the absence of myocardial ischemia. Neither patient sustained a myocardial infarction, nor had clinical evidence of reperfusion. The ST segment elevations persisted after resolution of chest pain in both patients, and both of the patients experienced complications of thrombolytic therapy. One patient sustained a hemorrhagic stroke and one had minor oral-pharyngeal bleeding. Given the lack of documented efficacy, concerns about safety, and poor specificity of the electrocardiogram for myocardial ischemia in patients with cocaine associated chest pain, thrombolytic therapy should be used with caution in these patients.

Serial Electrocardiograms for Chest Pain Patients with Initial Nondiagnostic Electrocardiograms: Implications for Thrombolytic Therapy

Abstract: Objectives: To determine the proportion of acute myocardial infarction (AMI) patients without ST–segment elevation who subsequently develop ST–segment elevation during their hospital courses; and to compare demographics and presenting features of AMI patient subgroups: those with initial ST–segment elevation, those with in–hospital ST–segment elevation, and those with no ST–segment elevation. Methods: A retrospective cohort analysis of admitted chest pain patients who had a hospital discharge diagnosis of AM1 was performed. Each chart was examined for initial ECG interpretation, serial ECG analysis, patient age, gender, cardiac risk factors, in-hospital survival, time between sequential ECGs, and number of ECGs performed within the first 48 hours of hospital admission. Results: Of the 114 charts reviewed, 20 patients had ECGs meeting thrombolytic criteria on arrival. Of the 94 AM1 patients who had nondiagnostic ECGs on arrival, 19 (20%) subsequently developed ECG changes meeting thrombolytic criteria. Seven patients developed these changes within eight hours of the initial ECG, four from eight to 12 hours after, two from 12 to 24 hours after, and six more than 24 hours after. Most patients who had documented AMIs did not develop ECG criteria for thrombolytic therapy during their hospitalizations. Male gender and smoking history were more commonly associated with late ST-segment elevation for those presenting with nondiagnostic ECGs. All the patients who had late diagnostic ECG changes survived to hospital discharge. Serial ECGs were performed more frequently in the group who had initially diagnostic ECGs and least frequently in the group who did not develop ST-segment elevation during their hospitalizations. Conclusions: Most patients with AM1 do not meet ECG criteria for the administration of thrombolytic therapy. A significant minority (20%) of the admitted chest pain patients with subsequently confirmed AMIs developed ECG criteria for thrombolytics during their hospitalizations. Further attention to such patients who have delayed ST-segment elevation is warranted. A standardized in-hospital serial ECG protocol should be considered to identify admitted patients who develop criteria for thrombolytic or other coronary revascularization therapy.

Colocutaneous fistula: a rare and silent complication of percutaneous endoscopic gastrostomy.

Abstract: Percutaneous endoscopic gastrostomy (PEG) is a relatively safe procedure for maintaining long-term enteral nutrition. A very rare complication of this procedure is colocutaneous fistula. We report an unusual case of colocutaneous fistula that was discovered in a 64-year-old man one year following insertion of a PEG tube.

Mycotic aneurysm: A diagnostic challenge

Abstract: Infected "mycot ic" aneurysms are an uncommon entity, with an incidence of nearly 3% of all abdominal aortic aneurysms. ~ The diagnosis poses a challenging problem for the emergency physician because symptomatology is frequently minimal or nonspecific during the early stages, and a high index of suspicion is essential. The importance of making such a diagnosis cannot be overemphasized, because without surgical intervention, this usually leads to uncontrolled sepsis and catastrophic hemorrhage. Survival is markedly improved by a prompt diagnosis and aggressive surgical intervention. Surgery performed after rupture carries high morbidity and mortality rates. Experience with a patient having this diagnosis and no reported cases from the English-language emergency medicine literature form the basis of this report.

The role of serum phosphate level and acute ischemic bowel disease

Abstract: The objectives of this study were to determine whether an elevated serum phosphate level is predictive of acute ischemic bowel disease and whether it serves as a prognostic indicator in patients with intestinal ischemia. A retrospective chart review was performed at an urban teaching hospital emergency department. Twenty-three patients with documented acute ischemic bowel disease from 1990 through 1994 were compared with 27 patients with acute abdominal disease entities unrelated to intestinal ischemia. The sensitivity, specificity, and positive and negative predictive values of serum phosphate were 26%, 85%, 60%, and 58% respectively. Levels of phosphate in patients with intestinal ischemia versus controls were 4.20 versus 3.41 mg/dL (P = .1338). The length of bowel necrosis in the experimental group with elevated phosphate versus normal phosphate level was 57.53 cm versus 99.00 cm (P = .4132). Although not statistically significant, linear regression revealed slightly positive correlations in those with elevated phosphate versus normal phosphate level (in the experimental group) with the length of bowel necrosis and duration of hospital stay as r= .155 (P = .4813) and r= .134 (P= .5418), respectively. Serum phosphate level independently has no diagnostic or prognostic value in acute ischemic bowel disease.

Clinical Science Review: Current Aspects of Thrombolytic Therapy in Women with Acute Myocardial Infarction

Abstract: Acute myocardial infarction (AMI) remains the greatest threat to health in our society and is the most common cause of death in the United States and in many other Western industrialized countries. Recent data demonstrate that mortality from MI is continuing to decline. In these days of more aggressive management of acute MI (AMI) there has been a resurgence of interest in advances in thrombolytic therapy. However, observational studies of patients with AMI have shown that women sustaining an AMI have a worse prognosis than men. AMI is the number-one killer of women in the United States ; approximately 247,000 of more than 520,000 deaths due to AMI that occur each year are among women, and almost one-third of the women are younger than forty-five years old. While there have been great advances in thrombolytic therapy, these advances have benefited men to a more significant degree than they have benefited women. The purpose of this paper is to critically review the efficacy of thrombolytic therapy in women with AMI with consideration of some of the key components of its effectiveness : mortality, bleeding risk, infarct-artery patency, ventricular function, and cardiac arrhythmia.

Abdominal Tuberculosis or Ovarian Carcinoma: Management Dilemma Associated With an Elevated CA-125 Level.

Abstract: The CA-125 antigen is useful for detecting residual disease in women treated for ovarian cancer. Its role in screening for ovarian cancer is questionable, however, because anumber of other benign and malignant causes can elevate its level. In this case, a patient with genital tract tuberculosis was initially misdiagnosed with ovarian cancer.

Giant hepatic hemangioma studied with intravenous total body arteriography technique. A case report.

Abstract: Hepatic hemangiomas are the most common benign tumors of the liver They are usually single, small, and asymptomatic However, giant hepatic hemangiomas have been reported in the past, usually detected as incidental findings Radionuclide blood pool imaging studies are used to confirm the presence o

Financial Morbidity: Recognition and Treatment of the 'Rich-Boy Syndrome'

Abstract: AS MANAGED health care systems take over American medicine, the free-spending era is reaching the beginning of its end. Current efforts directed at curtailing costs involve the use of primary care or non-physician gatekeepers to tell us what is right or wrong. Concurrently, the phenomenon of a financial incentive to provide "less care" is generating unease. We (surgeons), who are being blamed for spending so much money and doing almost nothing about it, must not be surprised that the resource controls are being gradually taken away from us. Sure, we pay lip service to the idea of cost containment in lecture halls and board meetings; we also publish articles about cost-effectiveness, clinical pathways, and algorithms. But practically, in daily life, how many of us are actively preoccupied with the financial issues evolving around our surgical practice? For how many of us is cost an issue in selecting diagnostic or therapeutic