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Biomedical subjects

D G Jacobs

Publications and source records attributed to D G Jacobs.

At least 37 records · Page 2Linked to original sources
PubMed1996

Hemodynamic and fibrinolytic consequences of intermittent pneumatic compression: preliminary results.

OBJECTIVE: To elucidate the time course and magnitude of hemodynamic and fibrinolytic changes associated with sequential gradient intermittent pneumatic compression (SGIPC). DESIGN: Two-phase, intervention and response investigation in normal volunteers. MATERIALS AND METHODS: Subjects were assigned to control (phase I) or compression (phase II) groups. Serial blood samples were obtained via femoral venous catheters for tissue plasminogen activator (tPA), plasminogen activator inhibitor (PAI-1), tPA-PAI-1 complex (tPA-PAI), and euglobulin lysis time (ELT) from all subjects and for fibrin degradation products (FbDP) and fibrinogen degradation products (FgDP) from phase II subjects. Duplex venous scanning was carried out on phase II subjects before and during SGIPC. RESULTS: Catheter placement caused elevations in PAI-1 and tPA-PAI, which stabilized within 4 hours of catheter insertion. In phase II, SGIPC induced significant increases in FbDP, FgDP, and tPA-PAI and decreases in ELT and PAI-1, all of which quickly reverted to baseline on termination of compression. Femoral venous blood flow increased by more than 100% with SGIPC. CONCLUSIONS: Sequential gradient intermittent pneumatic compression induces prompt, but short-lived, alterations in both fibrinolytic and hemodynamic function. Noncontinuous SGIPC may result in suboptimal thromboembolic prophylaxis.

Adult↗
PubMed1995

Automated telephone screening survey for depression.

OBJECTIVE: To test the application of fully automated telephone screening using computerized digital voice recordings and touch-tone responses to assess symptoms of depression. DESIGN: A cross-sectional study of a 2-week-long telephone survey. SETTING: Toll-free telephone calls placed from home, work, or school to a central telephone/computer system at a telecommunications company in the Boston, Mass, area. PARTICIPANTS: A total of 1812 participants called the system. Of these, 278 were students and faculty at a large midwestern state university, 725 were employees of a large northeastern high-technology firm, and 809 did not identify which site they were calling from. MAIN OUTCOME MEASURES: The 20-question multiple-choice Zung Depression Scale was used to screen for depressive symptoms, and additional questions gathered demographic and caller satisfaction information. RESULTS: No technical problems were encountered during the trial. Of 1812 callers, 1597 (88.1%) completed all questions. Of these, 412 callers (25.8%) met criteria for "moderate or marked" depression and another 194 (12.1%) met criteria for "severe or extreme" depression. The majority of callers scoring positive for depression had received no previous treatment for depression. Of callers who completed the screening questionnaire, 74.6% reported the call to have been at least "moderately" helpful. CONCLUSION: Readily available low-cost technology provides a fully automated, widely accessible, and confidential method of screening for a common mental illness.

Adult↗
PubMed1995

Polypropylene mesh closure after emergency laparotomy: morbidity and outcome.

BACKGROUND: Alternative methods for abdominal wall closure may be necessary after emergency laparotomy. The purpose of this study was to determine the morbidity and outcome of emergency fascial closure with polypropylene mesh. METHODS: A retrospective review was performed of all patients undergoing emergency fascial closure with polypropylene mesh from January 1990 to March 1994. RESULTS: Seventy patients were identified. Indications for mesh placement included visceral edema (40), infected/necrotic fascia (21), and planned reexploration (7). Enteric fistulas developed in five patients (7.1%). When omentum was interposed between intestine and mesh, the incidence of fistula was significantly reduced (0 of 51 vs 5 of 19, p < 0.01). Forty-two patients (60%) survived with wound closure, accomplished by skin flaps in 19 (45%), skin grafting in 11 (26%), and secondary healing in 6 (14%). The mesh was removed in six patients (14%). Complications of mesh extrusion and hernia occurred less often after skin flap closure compared with skin grafting or secondary healing (1 of 19 vs 9 of 17, p < 0.01). No mesh infection occurred. CONCLUSIONS: Polypropylene mesh placement is an effective alternative for abdominal closure after emergency laparotomy, even when intraabdominal sepsis is present. Fistulas associated with its use may be effectively eliminated by the interposition of omentum between bowel and mesh. Wound closure with full-thickness skin flaps is the preferred method for soft tissue coverage when mesh is used.

Abdominal Injuries↗
PubMed1995

Transcranial gunshot wounds: cost and consequences.

Poor outcomes following transcranial gunshot wounds (TC-GSW) and the perception of significant financial loss have led some institutions to adopt a fatalistic attitude towards these patients. This study was undertaken to define those factors predictive of mortality following TC-GSW as well as to determine the costs and benefits associated with providing care to these individuals. We reviewed the medical records of 57 TC-GSW patients seen at our Level I Trauma Center between January 1990 and December 1992. Overall mortality was 75 percent, and was statistically associated with an admission Glasgow Coma Score of 4 or less, a respiratory rate of less than 10, and self-inflicted wounds. Complete financial information was available for 37 of the 57 patients. Reimbursements for this group were $306,156 and exceeded costs by $62,257. Organ donation efforts were successful in 44.2 per cent of the nonsurvivors (19/43), yielding 60 organs and 29 tissues for transplantation. Nonsurvivors who became organ donors were clinically and demographically indistinguishable from those in whom organs/tissues could not be retrieved. Despite the poor outcome following TC-GSW, vigorous resuscitation and stabilization is justified in all patients, in that nearly one half of nonsurvivors will become organ and/or tissue donors. Concerns regarding excessive monetary looses by treating facilities are unfounded.

Adolescent↗
PubMed1994

Value of laparoscopy in trauma ICU patients with suspected acute acalculous cholecystitis.

Patients who require prolonged intensive care following traumatic injuries are at risk for developing acute acalculous cholecystitis (AAC). The diagnosis of AAC is often difficult to establish, resulting in increased morbidity and mortality in this critically ill population. We reasoned that diagnostic laparoscopy might provide a more accurate and timely method of diagnosis. Laparoscopy was performed in nine trauma ICU patients with suspected AAC. Four procedures were considered positive and five were negative. There were no false-positive or false-negative laparoscopic exams, and no procedure-related morbidity occurred. Comparison of multiple clinical, laboratory, and radiologic findings showed that only laparoscopy accurately distinguished between those patients with AAC and those without AAC. We conclude that diagnostic laparoscopy is safe and definitive in trauma ICU patients with suspected AAC and should be performed prior to proceeding with laparotomy.

Acute Disease↗
PubMed1994

Outcome of serious blunt cardiac injury.

BACKGROUND: Although serious blunt cardiac injury (BCI) is usually fatal, patients who reach the hospital alive can have a spectrum of abnormalities. We attempted to define the clinical features that helped identify serious BCI and to evaluate outcome. METHODS: Patients with serious BCI at a level I trauma center were identified during a 3-year period. RESULTS: Twelve patients had serious BCI. Six patients had cardiac arrest, and six had unexplained hypotension. Specific injuries included acute myocardial rupture (two patients); valvular disruption (two); myocardial contusion associated with either cardiac failure (two), complex ventricular arrhythmias (two), or delayed myocardial rupture (one), or present at autopsy (two); and coronary artery thrombosis (one). Seven of eight patients who did not have associated fatal injuries survived. Electrocardiography suggested cardiac injury in all nine patients in whom it was done, and echocardiography was useful to establish the diagnosis in four of five patients. Creatine phosphokinase isoenzyme levels did not distinguish serious injuries. CONCLUSIONS: The outcome of serious blunt cardiac injury can be favorable if patients have signs of life on arrival at the hospital, the signs of injury are recognized promptly, and other injuries do not supervene.

Adolescent↗
PubMed1994

Idiopathic necrotizing fasciitis: recognition, incidence, and outcome of therapy.

Early recognition and treatment of necrotizing fasciitis (NF) is essential for survival. The diagnosis of primary or idiopathic NF may be particularly challenging because it occurs in the absence of a known causative factor or portal of entry for bacteria. Patients with NF treated between 1989 and 1993 were reviewed to determine the incidence, clinical features, bacteriology, and results of treatment in patients with idiopathic NF. Idiopathic NF occurred in nine (18%) of 51 patients, five men and four women, ranging in age from 21 to 67 years. Associated conditions included diabetes mellitus (4), alcoholism (3), remote infection (3), and pregnancy (2). NF affected the lower extremity in eight and the perineum in one patient. Pain and tenderness occurred in all patients, soft tissue gas was recognized in two, and the presence of erythema and edema was variable. Idiopathic NF was monomicrobial in seven (78%) patients, compared to 21 per cent of patients with secondary NF (P = 0.003). S. pyogenes was the causative organism in five of seven monomicrobial infections. Time from admission to operation was significantly longer (62.3 +/- 54.8 hours) in patients with idiopathic NF compared to patients with secondary NF (17.0 +/- 16.6 hours) (P = 0.001). Treatment included operative debridement (means = 3.3) and limb amputation (n = 1) to control infection. Three patients (33%) with idiopathic NF died. Primary or idiopathic NF is principally a monomicrobial infection usually caused by S. pyogenes that most commonly occurs in the extremities. Mortality is high but is comparable to secondary NF. It is important to recognize that NF may occur spontaneously, and it should be suspected in patients with unexplained soft tissue pain and tenderness.

Adult↗
PubMed1994

Pelvic hematoma necessitans--a delayed complication of massive hemorrhagic pelvic fracture: case report.

Pelvic hematoma necessitans (PHN), a complication of massive hemorrhagic pelvic fracture, is reported in a 48-year-old pedestrian hit by an automobile. It was manifested by a tense hematoma of the buttocks and perineum that spontaneously "necessitated" or drained posterior to the anus 11 days after injury, resulting in complex anorectal morbidity and fecal contamination of a retroperitoneal hematoma and pelvic fracture sites. Early recognition, prompt diverting colostomy, and aggressive wound management are necessary after open pelvic fracture to prevent local and systemic infectious sequelae of PHN.

Fractures, Closed↗
PubMed1994

Potential of laparoscopy to reduce non-therapeutic trauma laparotomies.

Standard diagnostic methods used to evaluate patients sustaining abdominal trauma result in non-therapeutic laparotomy rates ranging from 5 to 40 per cent depending upon the clinical situation. The purpose of this study was to assess the safety and efficacy of diagnostic laparoscopy in the identification of intra-abdominal injuries in stable trauma patients. Twenty-one hemodynamically stable adult patients underwent laparoscopy prior to laparotomy for blunt (n = 10) or penetrating (n = 11) trauma, and the findings from each procedure were directly compared. Laparoscopy was 100 per cent accurate in detecting the need for laparotomy, although a number of specific injuries were not identified. There were no complications related to the procedure. Emergency laparoscopy is safe and should be considered in hemodynamically stable trauma patients with indications for laparotomy based on standard diagnostic criteria in order to minimize the incidence of non-therapeutic laparotomy.

Abdominal Injuries↗
PubMed1992

CT evidence for the "osseous pinch" mechanism of traumatic aortic injury.

OBJECTIVE: Our prior experiments suggested that traumatic laceration of the aorta induced by rapid deceleration results from pinching of the aorta between the spine and the anterior bony complex (manubrium, clavicle, and first rib). This study examines that hypothesis with in vivo CT data. MATERIALS AND METHODS: In 22 patients with angiographically and surgically proved lacerations of the proximal descending aorta, chest CT scans were obtained before (18) or after (four) surgical repair. The point of impact of the anterior bony complex with the anterior surface of the thoracic spine during compression of the thorax was predicted by simulated rotation of the first rib based on calculations made from the CT scans. RESULTS: In all 22 patients, the projected site of impact of the anterior bony complex with the spine corresponded to the actual injured aortic segment as determined with angiography. CONCLUSION: Our data further support the proposed "osseous pinch" mechanism of injury to explain traumatic tears of the aorta.

Aorta, Thoracic↗
PubMed1992

Antibiotic prophylaxis for injured patients.

Infection is the major cause of serious complication in injured patients. This article addresses antibiotic use in the injured patient and clarifies the limitations of antimicrobials in the prevention of infection.

Abdominal Injuries↗
PubMed1990

Peritoneal lavage white count: a reassessment.

Of 29 blunt trauma victims with a diagnostic peritoneal lavage white blood cell count (DPL:WBC) greater than or equal to 500/mm3 as the sole positive lavage criterion, only four underwent laparotomy at admission, and only one of these had sustained intestinal perforation. Two of the remaining 25 succumbed to extra-abdominal injuries within 24 hours, leaving 23 patients, who were followed clinically for an average of 34.7 days. None was ever discovered to have sustained intestinal perforation. Throughout the study period, 27 patients were seen who had sustained intestinal perforation from blunt abdominal trauma. Nine were explored based upon an initial physical examination suggestive of peritonitis. The remaining 18 underwent DPL: 17 demonstrated gross blood, and only one patient was diagnosed solely by an elevated DPL:WBC. We conclude that DPL:WBC is a nonspecific indicator of intestinal perforation from blunt abdominal trauma, and prospective studies are needed to properly define its role. Sequential determinations of DPL:WBC may be useful in the diagnosis of intestinal perforation.

Abdominal Injuries↗
PubMed1989

Effect of esophageal ligation on the growth of fetal rabbits.

Controversy continues regarding the nutritional value to the fetus of swallowed amniotic fluid. To clarify this issue further, esophageal ligations were performed to prevent deglutition in utero in 63 fetal rabbits during the final trimester of pregnancy. Compared with sham-operated littermate controls, the fetuses that were ligated for periods of 4, 5, or 6 days showed significant reductions in weight of 6.1, 18.9, and 9.2%, respectively. These results compare well with the magnitude of weight reduction seen clinically in patients with esophageal atresia. Significant but less consistent reductions were also noted in crown-rump length and biparietal diameter. No significant differences were seen in either body composition or gastrointestinal tract histology. These results indicate that swallowed amniotic fluid does play a role in fetal nutrition and may be particularly important in the later stages of gestation when placental function is limited.

Amniotic Fluid↗
PubMed1987

Injury severity, whole body protein turnover, and energy expenditure in pediatric trauma.

The purpose of this study was to quantify the changes in energy expenditure and protein turnover imposed by blunt trauma in children and to correlate them with the Injury Severity Score (ISS). We studied 19 children (mean age 10 +/- 1 year, mean ISS 20 +/- 2). Basal metabolic rate (BMR) was measured in the postabsorptive state by open-circuit indirect calorimetry. Whole body protein turnover (Q) and synthesis (S) were determined by the 15N enrichment of urinary ammonia in a 12-hour collection following a single dose of 15N glycine. Twelve-hour total urinary nitrogen excretion (E) was also determined. Because nitrogen intake was 0 during the study period, Q was equivalent to protein breakdown (B). Eleven patients were restudied at 3- to 5-day intervals during hospitalization and eight were restudied after discharge (mean 34 +/- 6 days post injury). There was a significant increase in BMR, Q, S, and E following injury, when compared with post injury baseline values. However, while BMR increased by 14%, there were 93% and 82% increases in Q (B) and S, respectively. Negative nitrogen balance resulted from the fact that protein breakdown increased more than protein synthesis. The initial increase in BMR varied directly with the severity of injury, as reflected in the ISS (r = 0.56, P less than .02). There was no significant correlation between ISS and any of the parameters of protein metabolism. These results suggest that the metabolic response of pediatric patients to multiple trauma may differ from that of adults. In addition, they imply that the ISS may not be a reliable indicator of the severity of tissue injury.

Adolescent↗
PubMed1986

Growth and development in patients operated on for islet cell dysplasia.

Neonatal hypoglycemia caused by islet cell dysplasia (ICD), sometimes called nesidioblastosis, may lead to psychomotor retardation and neurologic dysfunction in up to 50% of patients who are not given early aggressive treatment. In 1979, we adopted a more aggressive protocol for treating this condition that consists of the following steps: immediate insertion of a silastic central venous line for reliable venous access; continuous intravenous infusion of glucose and glucagon to maintain euglycemia; oral diazoxide; and near total pancreatectomy if the first steps fail to overcome the hypoglycemia or the patient cannot be weaned off intravenous therapy. Twelve consecutive patients who underwent pancreatectomy for control of hypoglycemia between 1979 and 1984 were recalled and evaluated for growth delay, neurologic dysfunction, and psychomotor retardation using the Revised Yale Developmental Schedules, the Peabody Picture Vocabulary, and the Draw a Man Test. Follow-up ages ranged from 1.2 to 6.0 years with a median of 3.6 years. No significant growth abnormalities were identified. No patient exhibited focal neurologic dysfunction, although some demonstrated soft neurologic signs, which did not appear to be related to their earlier hypoglycemia. Psychomotor function for the group as a whole was normal, with a mean developmental quotient (DQ) of 99.2. The DQ was average for five patients and above average for four; no patient had a DQ in the frankly subnormal range. Psychomotor development correlated better with the family's socioeconomic and educational status than with the neonatal hypoglycemia. These children are developmentally and neurologically normal despite severe neonatal hypoglycemia. Continued follow-up will be necessary to detect any late sequelae.(ABSTRACT TRUNCATED AT 250 WORDS)

Body Height↗