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Biomedical subjects

F B Miller

Publications and source records attributed to F B Miller.

At least 19 recordsLinked to original sources
PubMed2001

Implementation of a clinic policy of client-regulated methadone dosing.

A six-month interval (baseline) during which methadone doses above 99 mg required individual approval by the clinic's physician was compared with the subsequent 16-month period in which a policy of patient-regulated methadone dosing with no preset upper limit was implemented. During the later phase, all patients were required to remain at each selected dose for a minimum of four days, and standard compliance-based take-home dosing procedures were followed. For patients in the study sample (n=57), the daily maximum methadone dose increased from 165 mg during baseline to 300 mg during the self-regulation period, while their average daily methadone dose increased from 76.84 mg to 80.04 mg (W=473, n=57, p=0.01). Monthly percent of opiate-positive urine specimens decreased significantly from 5.26% during baseline to 1.64% during the self-regulated dose period (W=169, n=57, p<0.01), and use of other drugs remained unchanged. No patient failed to show possession of recalled take-home doses, and no instances of liquid methadone diversion were reported by law enforcement agencies in the area.

Administration, Oral↗
PubMed2001

Multiinstitutional experience with the management of superior mesenteric artery injuries.

BACKGROUND: Superior mesenteric artery (SMA) injuries are rare and often lethal injuries incurring very high morbidity and mortality. The purposes of this study are to review a multiinstitutional experience with these injuries; to analyze Fullen's classification based on anatomic zone and ischemia grade for its predictive value; to correlate the American Association for the Surgery of Trauma-Organ Injury Scale (AAST-OIS) for abdominal vascular injury with mortality; and to identify independent risk factors predictive of mortality, describing current trends for the management of this injury in America. DESIGN: We performed a retrospective multiinstitutional study of patients sustaining SMA injuries involving 34 trauma centers in the US over 10 years. Outcomes variables, both continuous and dichotomous, were analyzed initially with univariate methods. For the subsequent multivariate analysis, stepwise logistic regression was used to identify a set of risk factors significantly associated with mortality. RESULTS: There were 250 patients enrolled, with a mean Revised Trauma Score (RTS) of 6.44 and a mean Injury Severity Score (ISS) of 25. Surgical management consisted of ligation in 175 of 244 patients (72%), primary [corrected] repair in 53 of 244 patients (22%), autogenous grafts were used in 10 of 244 (4%), and prosthetic grafts of PTFE in 6 of 244 patients (2%). Overall mortality was 97 of 250 patients (39%). Mortality versus Fullen's zones: zone I, 39 of 51 (76.5%); zone II, 15 of 34 (44.1%); zone III, 11 of 40 (27.5%); and zone IV, 25 of 108 (23.1%). Mortality versus Fullen's ischemia grade: grade 1, 22 of 34 (64.7%). Mortality versus AAST-OIS for abdominal vascular injury: grade I, 9 of 55 (16.4%); grade II, 13 of 51 (25.5%); grade III, 8 of 20 (40%); grade IV, 37 of 69 (53.6%); and grade V, 17 of 19 (89.5%). Logistic regression analysis identified as independent risk factors for mortality the following: transfusion of greater than 10 units of packed RBCs, intraoperative acidosis, dysrhythmias, injury to Fullen's zone I or II, and multisystem organ failure. CONCLUSION: SMA injuries are highly lethal. Fullen's anatomic zones, ischemia grade, and AAST-OIS abdominal vascular injuries correlate well with mortality. Injuries to Fullen's zones I and II, Fullen's maximal ischemia grade, and AAST-OIS injury grades IV and V, high-intraoperative transfusion requirements, and presence of acidosis and disrhythmias are significant predictors of mortality. All of these predictive factors for mortality must be taken into account in the surgical management of these injuries.

Adolescent↗
PubMed2001

Impact of recent trends of noninvasive trauma evaluation and nonoperative management in surgical resident education.

BACKGROUND: The use of ultrasonography and nonoperative management of solid organ injury has become standard practice in many trauma centers. Little is known about the effects of these changes on resident educational experience. METHODS: We retrospectively reviewed resident evaluation of abdominal trauma and trauma operative experience as reported to the residency review committee between 1994 and 1999. RESULTS: A total of 4,052 patients underwent one or more of three diagnostic modalities. The nontherapeutic laparotomy rate as a result of positive diagnostic peritoneal lavages decreased from 35% to 14%. Although resident operative trauma experience was stable because of increases in operative burns and nonabdominal trauma, the number of abdominal procedures declined. CONCLUSION: Noninvasive diagnostic tests have allowed more rapid trauma evaluation and fewer nontherapeutic laparotomies. As nonoperative experience grows, the opportunity for operative experience decreases. These trends may adversely affect the education of residents and suggest that novel approaches are needed to ensure adequate operative experience in trauma.

Abdominal Injuries↗
PubMed2000

Evolution in the management of hepatic trauma: a 25-year perspective.

OBJECTIVE: To define the changes in demographics of liver injury during the past 25 years and to document the impact of treatment changes on death rates. SUMMARY BACKGROUND DATA: No study has presented a long-term review of a large series of hepatic injuries, documenting the effect of treatment changes on outcome. A 25-year review from a concurrently collected database of liver injuries documented changes in treatment and outcome. METHODS: A database of hepatic injuries from 1975 to 1999 was studied for changes in demographics, treatment patterns, and outcome. Factors potentially responsible for outcome differences were examined. RESULTS: A total of 1,842 liver injuries were treated. Blunt injuries have dramatically increased; the proportion of major injuries is approximately 16% annually. Nonsurgical therapy is now used in more than 80% of blunt injuries. The death rates from both blunt and penetrating trauma have improved significantly through each successive decade of the study. The improved death rates are due to decreased death from hemorrhage. Factors responsible include fewer major venous injuries requiring surgery, improved outcome with vein injuries, better results with packing, and effective arterial hemorrhage control with arteriographic embolization. CONCLUSIONS: The treatment and outcome of liver injuries have changed dramatically in 25 years. Multiple modes of therapy are available for hemorrhage control, which has improved outcome.

Cause of Death↗
PubMed2000

Should trauma surgeons do general surgery?

OBJECTIVE: Many trauma centers have separated emergency and general surgery from trauma care. However, decreased trauma volume and more frequent nonoperative management may limit operative experience and the economic viability of the trauma service. Trauma surgeons at our Level I trauma center have long provided all emergency surgical care and elective surgery. We sought to determine the impact of this policy. METHODS: We reviewed all admissions to the trauma service from June of 1992 to July of 1998 and cross-referenced this with our trauma registry. The number of major and minor procedures performed was also determined, and we reviewed all operative procedures by the trauma service for June of 1996 to October of 1998. RESULTS: Total admissions by the trauma service averaged 3,003 patients/year (range, 2,798-3,198 patients). Nontrauma patients accounted for 34% of all trauma service admissions (range, 26-40%). During this time period, there was no change in volume of operative or intensive care unit procedures, whereas minor procedures recently decreased from a peak of 141/month to 50/month. This was largely due to decreased use of diagnostic peritoneal lavage (surgeon reimbursable) and an increased use of computed tomographic scan and ultrasound (not presently reimbursed) to evaluate blunt abdominal trauma. During the past 2 years, nontrauma cases accounted for 33% of all operative procedures by the trauma service. CONCLUSIONS: Maintenance of emergency and general surgical care by the trauma service has allowed us to buffer impact of variations in trauma volume and to maintain operative skills in an era of increased nonoperative management of many injuries.

Abdominal Injuries↗
PubMed1999

Interventional techniques are useful adjuncts in nonoperative management of hepatic injuries.

BACKGROUND: Nonoperative management has become the standard of care for hemodynamically stable patients with complex liver trauma. The benefits of such treatment may be obviated, though, by complications such as arteriovenous fistulas, bile leaks, intrahepatic or perihepatic abscesses, and abnormal communications between the vascular system and the biliary tree (hemobilia and bilhemia). METHODS: We reviewed the hospital charts of 135 patients with blunt liver trauma who were treated nonoperatively between July 1995 and December 1997. RESULTS: Thirty-two patients (24%) developed complications that required additional interventional treatment. Procedures less invasive than celiotomy were often performed, including arteriography and selective embolization in 12 patients (37%), computed tomography-guided drainage of infected collections in 10 patients (31%), endoscopic retrograde cholangiopancreatography with endoscopic sphincterotomy and biliary endostenting in 8 patients (25%), and laparoscopy in 2 patients (7%). Overall, nonoperative interventional procedures were used successfully to treat these complications in 27 patients (85%). CONCLUSION: In hemodynamically stable patients with blunt liver trauma, nonoperative management is the current treatment of choice. In patients with severe liver injuries, however, complications are common. Most untoward outcomes can be successfully managed nonoperatively using alternative therapeutic options. Early use of these interventional procedures is advocated in the initial management of the complications of severe blunt liver trauma.

Abdominal Injuries↗
PubMed1999

Blunt carotid artery injuries: difficulties with the diagnosis prior to neurologic event.

OBJECTIVE: To evaluate the incidence, timing of diagnosis, clinical factors for adverse outcome, and role of anticoagulant, surgical therapy, or endovascular intervention for patients with blunt carotid artery injury (BCAI). METHODS: Retrospective review of the records of patients who sustained BCAI between 1987 and 1997. RESULTS: There were 18 men and 12 women, with an average age of 29 years. The diagnosis of BCAI was initially suspected in 15 patients after a major or new neurologic event, and in 15 patients after changes were shown by computed tomography. BCAI was confirmed by arteriography in 29 patients and by magnetic resonance angiography in 1 patient. Treatment consisted of antiplatelet therapy (n = 9), anticoagulation (n = 8), surgical repair (n = 6), observation (n = 4), and endovascular embolization (n = 3). With some type of treatment, 14 patients with no neurologic deficits remained stable; however, treatment improved the final neurologic outcome in 8 patients (20%). Three patients remained with severe deficits, and five patients died. CONCLUSION: The consequences of BCAI may be devastating. In our study, there were no reliable means to suspect this injury before neurologic symptoms or abnormalities show on computed tomographic scan. Although external signs are occasionally helpful, most patients have no pattern of injury to suggest BCAI. For patients whose findings after neurologic examination do not correlate with those on the computed tomographic scan, an immediate angiogram is indicated. Occasionally, a proximal injury can be surgically repaired, but in most patients, anticoagulation therapy appears to be the best treatment to avoid or improve neurologic deficits.

Adolescent↗
PubMed1998

Non-operative management of blunt hepatic trauma.

BACKGROUND: Non-operative management is currently considered the treatment of choice in over 50 per cent of adult patients with blunt liver injury. This report reviews the criteria for non-operative management and its potential downside. METHODS: English language publications were reviewed. RESULTS: Most reports from major trauma centres in the USA support the non-operative treatment of patients with blunt liver injury if well established criteria are met. Using such criteria, non-operative treatment is successful in 50-80 per cent of cases. Adjunctive radiological techniques may be helpful in managing some complications of non-operative treatment. CONCLUSION: Non-operative management is safe in haemodynamically stable patients with blunt liver injury. Computed tomography (CT) of the abdomen is extremely useful to document the extent of the damage and the presence of associated injuries, but it is not possible, based on CT alone, to predict failure; careful physiological monitoring in selected patients is indicated to avoid catastrophic complications.

Adult↗
PubMed1998

Impact of trauma attending surgeon case volume on outcome: is more better?

OBJECTIVE: To examine the relationship between annual trauma volume per surgeon and years of attending experience with outcome in a Level I trauma center with a large panel of trauma attending surgeons. METHODS: The outcomes of trauma patients were examined in 1995 and 1996 in relationship to surgeon annual trauma volume and years of experience. Outcome variables studied included overall mortality, mortality stratified by Trauma and Injury Severity Score, mortality in patients with an Injury Severity Score greater than 15, and preventable or possibly preventable deaths. Morbidity outcomes examined were overall complication rate and length of stay per attending surgeon. Additionally, five difficult problems were evaluated for critical management decisions by the attending surgeons, and these outcomes were correlated to annual volume and experience. RESULTS: There was no difference in outcome in either morbidity or mortality that correlated with annual volume of patients treated or years of experience. Critical management errors occurred sporadically and were not related to volume or experience. CONCLUSIONS: Outcome after trauma seemed to be related to severity of injury rather than annual volume of cases per surgeon. Although our results may not be applicable to other institutions, they should urge caution in adopting and promulgating volume requirements for individual attending surgeons in trauma centers.

Emergencies↗
PubMed1998

Alternatives in the management of penetrating injuries to the iliac vessels.

BACKGROUND: The high mortality and morbidity rates after iliac vessel injuries remain a challenging problem for trauma surgeons. Several controversial issues surround the management of iliac vessel injuries, including the value of abbreviated laparotomy, the role of extra-anatomic bypass reconstruction (EABR), the use of vascular prostheses in the presence of contamination, and the need and timing for fasciotomy. METHODS: Retrospective review of the records of patients who sustained an injury to the iliac vessel between 1987 and 1996. RESULTS: A total of 64 patients were treated, including 23 with isolated iliac vein injuries, 17 with arterial injuries, and 24 with combined arteriovenous injuries. Vascular prostheses were placed in 17 patients with arterial injuries, including 12 with associated intestinal wounds. Graft infection did not occur. Of the 24 patients with combined injuries, 11 underwent abbreviated laparotomy and 1 died. Five deaths, however, occurred in 13 patients in whom no attempts were made for damage control laparotomy. Significant differences between survivors and nonsurvivors included final arterial pH, final prothrombin time, length of hypotension, and number of transfusions. Arterial ligation with EABR was performed in five patients and failed in two. Deep venous thrombosis and pulmonary embolism occurred in four patients, in three of them after venous injuries were ligated. The overall mortality rate was 23%. CONCLUSION: Our findings show that (1) abbreviated laparotomy reduces mortality in iliac injuries; (2) EABR should be performed early after stabilization to prevent limb ischemia; (3) the use of vascular prostheses with associated intestinal injuries did not appear to increase the incidence of graft infection; and (4) after vein ligation, early fasciotomy and prophylaxis against extremity swelling, deep venous thrombosis, and pulmonary embolism should be considered.

Adolescent↗
PubMed1998

Effect of a clinical pathway for severe traumatic brain injury on resource utilization.

BACKGROUND: The usefulness of clinical pathways for the complex trauma patient is unclear. We analyzed the effect of a clinical pathway for severe traumatic brain injury (TBI) on resource utilization. METHODS: A clinical pathway for severe TBI (Glasgow Coma Scale (GCS) score < or = 8 at 24 hours) was developed by a multidisciplinary team and used for all patients with severe TBI. Data were gathered prospectively for 15 months and compared with data from historical controls from the previous year. Patients who survived < 48 hours were excluded. RESULTS: The clinical pathway was used for 84 patients with severe TBI and compared with 49 historical controls. No differences in Injury Severity Scores (27 vs. 27) or GCS scores at 24 hours (6.2 vs. 6.5) existed between control or pathway patients. There was an overall increase in the mortality rate of pathway patients (from 12.2 to 21.4%), but this was entirely attributable to withdrawal of care that was initiated by family members in patients with an average age of 71 years, an average GCS score of 4.7, and an average Injury Severity Score of 29. Among survivors, pathway patients had a significant decrease in ventilator days (11.5 +/- 0.9 vs. 14.6 +/- 1.2; p < 0.05), intensive care unit days (16.7 +/- 1.0 vs. 21.2 +/- 1.4; p < 0.05), and hospital days (23.4 +/- 1.2 vs. 31.0 +/- 3.0; p < 0.05). There were no differences in the incidence of complications or functional outcomes. CONCLUSION: The use of a clinical pathway for severe TBI resulted in a significant reduction in resource utilization. This study suggests that clinical pathways may be a useful component of patient care after blunt trauma.

Adult↗
PubMed1998

Late follow-up and functional outcome after traumatic reproductive tract injuries in women.

The aim of this study was to assess female reproductive tract injuries and late effects on sexual and reproductive function. This was a review of women presenting to a Level I trauma center with reproductive tract injuries over 12 years. Thirty-one women (average age, 30 years) were divided into coital (19) and noncoital (12) injury groups. One-third of coital trauma presented late, one-fourth was abuse related, and seven women presented in shock. All had vaginal lacerations, and 15 required repair. Follow-up in 6 of 19 (32%) women averaged 4.5 years. Noncoital injuries resulted primarily from vehicular trauma, and two-thirds had associated abdominal injuries. Interventions included: vaginal laceration irrigation/repair (4), salpingectomy (2), ovariectomy (2), repair uterine perforation (1), and emergency cesarean section (2). The average Injury Severity Score was 25, with two deaths. Follow-up in 6 of 10 (60%) survivors averaged 6.1 years. The combined group has had seven subsequent pregnancies, and two women have minor dyspareunia after pelvic fracture. Women with coital injuries may develop shock, requiring rapid resuscitation and operative repair. Noncoital injuries are often associated with multiple severe injuries and require operative intervention. Late sequelae are minimal in both groups, and even severe injuries do not preclude normal pregnancy and sexual function.

Abdominal Injuries↗
PubMed1997

Bedside percutaneous endoscopic gastrostomy. A safe alternative for early nutritional support in critically ill trauma patients.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is a good alternative that provides long-term nutritional support and is associated with minimal morbidity. METHODS: During a 24-month period, we studied 54 critically injured patients who underwent early PEG to provide enteral nutritional support. Patients were selected due to the inability to tolerate intake by mouth secondary to multiple associated injuries, especially to the central nervous system. RESULTS: All patients sustained multiple injuries with an average Injury Severity Score of 27. The mean Glasgow Coma Scale at the time of admission was 7 and at the time of the PEG was 10. Eleven patients (20%) had an intracranial pressure (ICP) device, and there was no significant increase in the mean ICP before, during, or after the procedure. In 63% of patients, tube feedings were interrupted for a variety of problems in the 72 h preceding the PEG, and in 70% of patients an average of five radiographs were obtained to document tube position. In 95% of patients, the nutritional goal was achieved within 48 h of PEG placement. There were one immediate and two delayed complications after PEG placement. There were two deaths, neither related to the PEG placement. CONCLUSIONS: Early PEG in critically injured patients is a safe and effective method of providing access to the GI tract for nutritional support. In patients with significant brain injuries, adequate sedation and the presence of an ICP monitor help to minimize secondary insults to the brain.

Adolescent↗
PubMed1997

Percutaneous dilational tracheostomy for airway control.

BACKGROUND: Endoscopic percutaneous dilational tracheostomy (PDT) is a good alternative to obtain safe and secure long-term airway control, and is associated with minimal morbidity and mortality. STUDY DESIGN: During a 14-month period, we prospectively studied 35 intensive care unit (ICU) trauma patients who underwent early PDT for the sole purpose of obtaining long-term airway control. All patients were determined to need a tracheostomy owing to extubation inability, need to maintain a patent airway, or need for continuous airway access for management of secretions. RESULTS: All patients had sustained multiple injuries with an average Injury Severity Score (ISS) of 29. The time from ICU admission to placement of the PDT was 8 +/- 5 days. The mean Glasgow Coma Scale at the time of the PDT was 10 (range 4 to 15), and 11 patients (31%) had an intracranial pressure device in place. The procedure was completed with bronchoscopic guidance in 33 patients, and in 2 it was converted to surgical tracheostomy (ST). There were no significant complications associated with the placement of the PDT. Two deaths were documented, neither related to the PDT placement. Compared with standard ST, charges were reduced by $1,750. CONCLUSIONS: Bedside endoscopic PDT for selected critically ill trauma patients is justified as a safe and effective alternative to ST. The low incidence of complications in PDT suggests that it can be done safely at bedside in the ICU.

Adult↗
PubMed1997

Venous thromboembolism in the high-risk trauma patient: do risks justify aggressive screening and prophylaxis?

OBJECTIVE: Deep venous thrombosis (DVT) and pulmonary embolism (PE) are considered to be a major source of morbidity and mortality among trauma patients. Several reports have identified high-risk patients with recommendations for management ranging from frequent duplex scanning to placement of prophylactic inferior vena cava (IVC) filters. We reviewed our experience with a large trauma population to determine whether such approaches are justified. METHODS: We analyzed 2,868 consecutive trauma admissions over 22 months and identified 280 patients (10%) in high-risk groups who survived > or = 48 hours: (1) severe closed head injury with mechanical ventilation > or = 72 hours, (2) closed head injury with lower extremity fractures, (3) spinal column/cord injury, (4) combined pelvic and lower extremity fractures, and (5) major infrarenal venous injuries. The remaining nonthermal injury patients constituted the low-risk group. RESULTS: There were 280 high-risk patients, 213 of whom (76%) received prophylaxis with compression therapy. There were 12 cases of DVT (5%) with four nonfatal PE (1.4%). Six patients (2%) had therapeutic IVC filters inserted and only one patient had prophylactic placement. There were 38 deaths in this group, attributable primarily to severe closed head injury or spine injuries, and none were caused by PE. In the 2,249 low-risk patients, there were three cases of DVT (0.1%, p < 0.05 vs. high risk) and no PE (p < 0.05 vs. high risk). CONCLUSIONS: Although these patients were at increased risk for thromboembolic events, the overall incidence of DVT was still extremely low with no apparent PE deaths. In our patient population, aggressive screening and prophylactic IVC filters would not have benefited 95% of "high-risk" patients without DVT and would not have prevented any deaths. We could not identify any population, except perhaps venous injuries, where such expensive and potentially harmful maneuvers seemed justified. Our experience with DVT and PE does not support either aggressive screening or prophylactic IVC filters as the standards of care.

Adolescent↗
PubMed1997

Impact of level III verification on trauma admissions and transfer: comparisons of two rural hospitals.

PURPOSE: To study the impact of Level III verification and other changes in rural hospitals on trauma delivery and to examine factors affecting transfer to a Level I trauma center. SETTING: Two rural Kentucky hospitals and a Level I trauma center. METHOD OF REVIEW: Concurrent review of all trauma patients in 1988 and re-review of the same parameters in 1995. FINDINGS: In 1988, both hospitals had similar management practices in trauma care. A significant number of patients were transferred for (a) patient choice, (b) serious and/or multiple trauma, (c) specialty care in non-life threatening situations, and (d) to exclude a potentially serious problem seen on radiologic evaluation (usually questionable cervical spine or widened mediastinum). Both hospitals had major changes in trauma delivery. One hospital received Level III verification, and the other had changes that lessened the general surgeon's involvement with initial evaluation and treatment. A re-review in 1995 disclosed major changes at both institutions. Transfers to exclude radiologic abnormalities had virtually disappeared. The Level III status had increased the surgical involvement in that hospital; there was actually an increase in patients transferred to the Level I hospital and an increase in patient acuity. More operations were performed locally, and the care was more efficiently delivered. The other hospital had a large increase in transfers and decreased admissions locally as general surgical involvement decreased. CONCLUSIONS: The factors related to patient transfer for trauma care are complex and require careful elucidation to improve care. The development of a Level III trauma service appeared to increase the number of seriously injured patients treated in the rural hospital and the efficiency of the care delivered.

Concurrent Review↗