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Biomedical subjects

Daniel R Margulies

Publications and source records attributed to Daniel R Margulies.

13 recordsLinked to original sources
PubMed2006

Obesity does not affect mortality after trauma.

Although obesity has been proposed as a risk factor for adverse outcomes after trauma, numerous studies report conflicting results. The objective of this study was to compare outcomes of obese and nonobese patients after trauma. The study population consisted of all trauma patients admitted to a surgical intensive care unit in a Level I trauma center from January 1999 to December 2002. Admission data, demographics, injury severity score (ISS), severity of illness, hospital course, complications, and outcomes were compared between obese (OB; body mass index [BMI] > or = 30), and nonobese patients (NOB; BMI < or = 29). A total of 918 patients was included in the study, 135 OB (14.7%) and 783 NOB (85.3%). There was no significant difference in demographic data, ISS, APACHE II score, and hospital stay. Intensive care unit stay was longer for OB patients (6.8 vs 4.8 days, P = 0.04). Overall mortality was 5.9 per cent for OB and 8.0 per cent for NOB patients (P = 0.48). Mortality by mechanism of injury was 3.4 per cent OB versus 7.4 per cent NOB (P = 0.26) for blunt and 10.6 per cent OB versus 10.2 per cent NOB (P = 0.9) for penetrating injury. The three most common complications associated with death were pulmonary, cardiovascular, and neurological deterioration. Using logistic regression analysis, age and ISS and APACHE II scores were associated with mortality, but BMI was not. We conclude that obesity does not appear to be a risk factor for adverse outcomes after blunt or penetrating trauma. Further research is warranted to uncover the reason for discrepant findings between centers.

APACHE↗
PubMed2005

CT angiography in penetrating neck trauma reduces the need for operative neck exploration.

The evaluation of penetrating neck injury has evolved dramatically from mandatory operative exploration of Zone II injuries that penetrate the platysma to selective management based on physical examination and adjunctive studies. More recently, CT angiography has emerged as an efficient, noninvasive method of evaluating penetrating neck injury. We retrospectively reviewed our experience over 10 years with the management of penetrating neck injury. One hundred thirty cases were reviewed with 34 undergoing CT angiogram (Group CTA) and 96 with no CT angiogram (Group nCTA). Group CTA had significantly fewer neck explorations, 1 (3%) versus 32 (33%), P < 0.001. Negative explorations were significantly higher in nCTA as well, with a rate of 22 per cent versus 0 in CTA (P < 0.01). The use of angiogram and esophagram was also significantly lower in CTA versus nCTA (P = 0.02 and P = 0.04). Of the 34 patients in CTA, 4 (12%) also underwent angiography and 4 (12%) received a contrast esophagram. Of the 64 patients in nCTA who did not undergo a neck exploration, 19 (29%) underwent angiography, and 17 (26%) received a contrast esophagram. The use of CT angiogram increased over time with a concomitant decrease in the rate of neck explorations.

Adolescent↗
PubMed2003

Objective indications for early tracheostomy after blunt head trauma.

BACKGROUND: Early tracheostomy has been shown to be beneficial after trauma; however, there are few objective data to identify early in the recovery period which patients will ultimately require tracheostomy after blunt head trauma. METHODS: The charts of all patients admitted to the surgical intensive care unit intubated at a level 1 urban trauma center, over a 5-year period with a primary admission diagnosis of blunt head trauma were retrospectively reviewed. RESULTS: Sixty-four patients met inclusion and exclusion criteria and were divided into two groups: those extubated and those that required tracheostomy. By day 3 the Glasgow Coma Scores for the two groups were significantly different and on day 4 the Simplified Acute Physiology (SAPS) Scores were significantly different. CONCLUSIONS: Calculating objective scores such as GCS and SAPS can aid in identifying those patients who will ultimately require a tracheostomy for prolonged airway protection after blunt head trauma with high positive predictive value.

APACHE↗
PubMed2003

Craniofacial and skull base trauma.

BACKGROUND: Traumatic craniofacial and skull base injuries require a multidisciplinary team approach. Trauma physicians must evaluate carefully, triage properly, and maintain a high index of suspicion to improve survival and enhance functional recovery. Frequently, craniofacial and skull base injuries are overlooked while treating more life-threatening injuries. Unnoticed complex craniofacial and skull base fractures, cerebrospinal fluid fistulae, and cranial nerve injuries can result in blindness, diplopia, deafness, facial paralysis, or meningitis. Early recognition of specific craniofacial and skull base injury patterns can lead to identification of associated injuries and allow for more rapid and appropriate management. CONCLUSION: Early detection and treatment of craniofacial and skull base traumatic injuries should lead to decreased morbidity and mortality. This review discusses the most common of these injuries, their possible complications, and treatment.

Accidents, Traffic↗
PubMed2003

Analysis of causes and prevention of early readmission to surgical intensive care.

The purpose of this study was to analyze causes of early readmission to the surgical intensive care unit (SICU), to determine whether readmission can be predicted or prevented, and to compare outcomes of patients readmitted to the SICU with patients not requiring readmission. All patients admitted to the Cedars-Sinai SICU from January 1, 1996, to December 31, 2001, were included. Clinical data was prospectively collected in an on-line computer system. The charts of all early readmission patients were retrospectively reviewed. SICU and hospital outcomes were abstracted from a computerized data warehouse. During the study period, 10,840 patients were admitted to the SICU including 97 (0.89%) early readmissions. SICU admission APACHE II and SAPS I scores, SICU and hospital length of stay, and mortality were significantly higher in readmitted patients compared to patients not requiring readmission. The majority of early SICU readmissions were due to respiratory and neurologic deterioration. Upon review, 62 per cent of all readmissions met appropriate SICU discharge criteria and were not predictable while only 5 per cent of SICU discharge were felt to have been premature. Patient outcomes are adversely affected by early readmission to the SICU. Careful neurologic assessment, meticulous attention to respiratory care transfer orders, and prompt respiratory therapy on floor care may significantly decrease the need for early readmission to the SICU.

APACHE↗
PubMed2003

The value of laparoscopy in management of abdominal trauma.

The role of laparoscopy (LS) in abdominal trauma is controversial. Concerns remain regarding missed injuries and safety. Our objective for this study was to determine the safety and better define the role of LS in abdominal trauma victims. We performed a retrospective review of all patients who sustained abdominal trauma and underwent LS in a level I trauma center. The main outcome measures were age, gender, mechanism of injury (MOI), indication for laparoscopy, presence of intra-abdominal injury (IA), therapeutic laparoscopy (TxLS), need for laparotomy, length of hospital stay (LOS), missed injuries, complications, and deaths. Forty-eight patients underwent LS (62 per cent male; average age, 28 years; MOI, 35 (85%) penetrating, 7 (15%) blunt; mean ISS, 8). At laparoscopy, 58 per cent of patients had no intra-abdominal injury. IA injury was treated with laparotomy in 14 (29%) and TxLS in 6 (13%). One patient had a negative laparotomy (2%). No injuries were missed. No patients required reoperation. There was one complication: a pneumothorax. There were no deaths. LS was most valuable in penetrating trauma, avoiding laparotomy in more than two-thirds of patients with suspected intra-abdominal injury. LS can serve as a useful adjunct for the evaluation of blunt trauma. In a level I trauma center with LS readily available, the procedure is associated with a low rate of complications and missed injury.

Abdominal Injuries↗
PubMed2002

Outcome of elderly patients with appendicitis: effect of computed tomography and laparoscopy.

HYPOTHESIS: Elderly patients who have appendicitis have a greater morbidity and mortality rate when compared with younger patients. We hypothesized that recent changes in the diagnosis and management of appendicitis in elderly patients might affect the outcome. DESIGN: Retrospective review. SETTING: Large metropolitan teaching hospital. PATIENTS: All patients aged 70 years and older who underwent appendectomy for appendicitis between January 1, 1991, and December 31, 2000, were divided into groups 1 (those treated from January 1, 1991, through December 31, 1995) and 2 (those treated from January 1, 1996, through December 31, 2000). MAIN OUTCOME MEASURES: Age, sex, preoperative evaluation, operative duration and findings, postoperative course, duration of hospital stay, and mortality rate. Continuous and categorical variables were analyzed using t and chi(2) tests, respectively. RESULTS: Ninety-five patients met inclusionary criteria. The mean age (78 years), sex, preoperative suggestion of appendicitis (group 1, 39 [83%] of 47 patients; group 2, 45 [94%] of 48 patients), and duration of the preoperative hospitalization over 24 hours (group 1, 11 patients [23%]; group 2, 9 patients [19%]) were similar in both groups. There was an increasing use of diagnostic computed tomography (group 1, 13 patients [28%]; group 2, 32 patients [67%]; P<.001) and laparoscopy (group 1, 14 patients [30%]; group 2, 23 patients [48%]; P =.02) between the 2 study periods associated with no significant difference in the duration of hospitalization, frequency of appendiceal perforation or abscess, occurrence of complications, or mortality. The length of operating time increased in the second period (ie, January 1, 1996, through December 31, 2000). CONCLUSIONS: Appendicitis in elderly patients continues to be a challenging surgical problem. While computed tomography may represent a useful diagnostic tool and laparoscopic appendectomy may be appropriate therapy for selected patients, neither has affected outcome when measured for morbidity and mortality rates. Overall results might improve with earlier consideration of the diagnosis in elderly patients with abdominal pain, followed by prompt surgical consultation and operation.

Acute Disease↗
PubMed2002

Endoscopically placed nasogastrojejunal feeding tubes: a safe route for enteral nutrition in patients with hepatic encephalopathy.

Patients with hepatic encephalopathy are at particular risk for aspiration when given oral or gastric feedings. An ideal strategy might combine distal enteral feeding with proximal gastric decompression, which is offered by a nasogastrojejunal (NGJ) feeding tube. One objective was to determine the efficacy and safety of endoscopically placed NGJ feeding tubes in patients with hepatic encephalopathy. Charts of patients who underwent NGJ tube placements between April 1997 and January 2000 were retrospectively reviewed. Two endoscopic techniques ("push" and "pull") were used. Eighteen patients (nine male and nine female) underwent 32 procedures. Twelve patients had undergone liver transplantation, four had decompensated cirrhosis, and two had fulminant hepatic failure. Twenty procedures used the push technique and 12 required the pull technique. The insertion time was shorter for the push technique compared with the pull technique (21.8 vs 39.6 min, P < 0.05). Enteral feedings were begun at an average of 5.2 hours after tube placement. The tubes remained in place for an average of 13.9 days. Complications related to the NGJ tubes included self-removal in eight, tube clogging in five, proximal migration in four, and intraduodenal migration of the gastric port in one. No aspiration episodes occurred. We conclude that NGJ feeding tubes may be placed endoscopically as a bedside procedure for patients with hepatic encephalopathy and provide a safe, efficacious, and rapid route for enteral nutrition in these patients.

Adult↗
PubMed2002

Percutaneous dilatational tracheostomy is as safe as open tracheostomy.

Although percutaneous dilatational tracheostomy (PDT) has been advocated as an alternative to open tracheostomy (OT) its relative safety has been questioned repeatedly. This study prospectively compared the safety and complications of PDT and OT. Ninety-four patients underwent PDT and 252 patients underwent OT at this institution from December 1998 through April 2000 with the choice of procedure left to the operator. OT was performed in the operating room whereas PDT was performed in intensive care units (ICUs). PDT was performed by surgeons and medical intensivists under a strict institutional policy and procedure governing patient selection and conduct of the procedure. Complications were defined as bleeding, loss of airway, hypotension, hypoxia, tracheostomy tube malposition, subcutaneous emphysema, infection, and conversion of PDT to OT. All patients survived the operation. PDT and OT had similar complication rates: 2.1 per cent for PDT versus 2.8 per cent for OT (P = not significant). Postoperative bleeding, which was the most frequent complication, occurred in one PDT patient and four OT patients. One PDT patient required conversion to OT as a result of extensive tracheal fibrosis. Subcutaneous emphysema, soft-tissue infection, and a malpositioned tracheostomy tube were the remaining complications in the OT patients. We conclude that the complication rates of PDT and OT are comparable. The choice of PDT or OT should be dictated by the surgeon's training and experience, the patient's condition, neck anatomy, and stability for transfer to the operating room.

Aged↗
PubMed2002

Decompressive craniectomy in trauma patients with severe brain injury.

Decompressive craniectomy in the treatment of severe traumatic brain injury (TBI) is controversial. We conducted a retrospective review of prospectively collected data on all patients requiring surgery for TBI from 1995 through 2001 at Cedars-Sinai Medical Center. Patients were separated into two groups: Group A, craniectomy, and Group B, craniotomy. We had 120 patients; 24 (20%) had craniectomy and 96 (80%) had craniotomy. There were no significant differences in demographics or Injury Severity Scores. The craniectomy group had significantly more TBI as evidenced by more frequently collapsed basilar cisterns on CT scan (P = 0.0001). There was no significant difference in actuarial survival between the groups: 52.8 per cent in the craniectomy group and 79.2 per cent in the craniotomy group (P = 0.08). Calculated mortality for craniectomy was 37.5 per cent versus 18.8 per cent for craniotomy (P = NS). We found four preoperative findings to be significant predictors of mortality: 1) Glasgow Coma Scale score, 2) Injury Severity Score, 3) Simplified Acute Physiology Score, and 4) Acute Physiology and Chronic Health Evaluation II. The type of surgery was not found to be a significant predictor of death even when adjusted for severity of injury. Craniectomy may be helpful for patients with TBI associated with preoperative CT scan evidence of basilar cistern collapse. This is evidenced by similar survival rates between the two groups despite clinical evidence of greater TBI among craniectomy patients.

APACHE↗
PubMed2002

Intensive care unit outcome of vehicle-related injury in elderly trauma patients.

Vehicle-related trauma is a common mechanism of injury in elderly (age > or = 65 years) trauma patients. Several hospital-based studies have shown that patients with pedestrian injury have a higher mortality compared with those with motor vehicle collision (MVC) injury partially because of older patients found in the former group. In addition the injury patterns also differ significantly between these two mechanisms of vehicle-related trauma. The purpose of the present study is to compare the demographics, injury severity, injury patterns, and outcomes of elderly patients with pedestrian injury admitted to a surgical intensive care unit (SICU) of a Level I trauma center between January 1, 1994 and December 31, 2000 with those admitted with MVC injury. During the study period there were 187 elderly patients admitted to the surgical intensive care unit with vehicle-related injury. Fifty-one per cent of the patients had MVC injury. Patients were divided into two groups based on their mechanisms of injury (pedestrian vs MVC) for comparison. There was no difference in the mean age and gender between the two groups. Injury Severity Score, admission Simplified Acute Physiology Score, and mortality were significantly higher in the pedestrian group compared with the MVC group. Using logistic regression analysis three factors were found to be independently predictive of mortality: Simplified Acute Physiology Score, intracranial hemorrhage with mass effect on CT scan, and cardiac complications.

Abdominal Injuries↗