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Biomedical subjects

H H Stone

Publications and source records attributed to H H Stone.

At least 19 recordsLinked to original sources
PubMed1990

Pancreatic denervation for pain relief in chronic alcohol associated pancreatitis.

To denervate the pancreas of sensory afferents, 15 patients with intractable pain of chronic alcohol induced pancreatitis underwent left transthoracic splanchnicectomy with concomitant bilateral truncal vagotomy. All were malnourished and 11 were addicted to opiates. No respite had been obtained from 33 previous operative procedures. Each patient experienced almost immediate pain relief. Five, however, later had return of pain, but only to the right epigastrium. These five then underwent right transthoracic splanchnicectomy, after which four noted complete and apparently permanent disappearance of pain. In those 14 with a successful outcome there has been a 29 per cent mean increase in body weight, break of hard drug addition in ten of the 11 so afflicted, and return to gainful work or a relatively normal lifestyle in all 14 at a mean follow-up of 16 months. Although 11 of the 14 do have delayed gastric emptying, only one has required a drainage procedure. There have been no other late complications. This approach for control of incapacitating pain in chronic pancreatitis is both safe and simple and at the same time it appears to be reasonably reliable.

Adult↗
PubMed1990

Pathogenicity of the enterococcus in surgical infections.

The enterococcus has been relegated to a position of unimportance in the pathogenesis of surgical infections. However the increasing prevalence and virulence of these bacteria prompt reconsideration of this view, particularly because the surgical patient has become increasingly vulnerable to infectious morbidity due to debility, immunosuppression, and therapy with increasingly potent antibiotics. The enterococcus is a versatile opportunistic nosocomial pathogen, causing such diverse infections as wound, intra-abdominal, and urinary tract infections; catheter-associated infection; suppurative thrombophlebitis; endocarditis; and pneumonia. Although surgical drainage remains the cornerstone of therapy for enterococcal infections involving a discrete focus, in the circumstances typified by the compromised surgical patient, specific antibacterial therapy directed against the enterococcus is warranted. Recent evidence indicates that parenteral antibiotic therapy for enterococcal bacteremia is mandatory and that appropriate therapy clearly reduces the number of deaths.

Cross Infection↗
PubMed1979

Predictability of present outcome and future recurrence in acute pancreatitis.

Although acute pancreatitis is relatively common, factors useful in predicting immediate outcome or likelihood of recurrence have seldom been studied in greater detail. A ten-year experience with 389 patients hospitalized for 821 separate episodes of acute pancreatitis was reviewed. The overall mortality was 6.7%, being highest on the first admission and considerably greater for white males. Respiratory complications accounting for 27% of the fatalities were the most common causes of death. The incidence of considerable morbidity was 19.5%. Clinical diagnoses of "shock" and "respiratory distress" were associated with mortalities of 88% and 71%, respectively. The overall recurrence rate was 50.1%, with little variation regardless as to the number of previous bouts. Recurrence was more likely if the patient was black, male, older than 30 years of age, and had experienced a second episode of acute pancreatitis. Admission data aid considerably in identifying high-risk patients in whom major complications develop, who die during the present episode, or who have a future recurrent bout of acute pancreatitis.

Acute Disease↗
PubMed1979

Pulmonary burns in children.

Basic concepts have evolved from a 15-yr experience in the management of 101 children with inhalation injuries. Progression through three distinct clinical stages--bronchospasm (1--12 hr post-burn), pulmonary edema (6--72 hr), and bronchopneumonia (after 60 hr)--was often noted. Success in outcome appeared to depend upon treatment that conformed to the pathophysiologic state present, a pulmonary toilet being both thorough and aseptic, tracheotomy being reserved for true glottic or supraglottic airway obstructions, the sharp division of strangulating or suffocating constrictions caused by cervical or thoracic eschars, use of ventilators primarily to maintain arterial pO2 above 60 mm Hg and to reverse otherwise intractable pulmonary edema, corticosteroids being administered as a single intravenous bolus and only for overt bronchospasm, and parenteral antibiotic therapy being based upon sputum smears and cultures for established pneumonia alone, never as prophylaxis.

Adolescent↗
PubMed1979

Prophylactic and preventive antibiotic therapy: timing, duration and economics.

Previous studies have demonstrated that administered antibiotics must be active against major anticipated pathogens and must have reached sufficient concentrations in the tissue or body fluid at risk by the time of bacterial challenge if prophylactic therapy is to be maximally effective in reducing the infection rate of potentially contaminated surgery. The need for continuing antibiotic prophylaxis beyond the day of operation, however, has been uncertain. In a prospective, randomized, double-blind study of 220 patients undergoing elective gastric, biliary or colonic surgery, perioperative administration of cefamandole plus five days of placebo was compared to perioperative plus five days of postoperative antibiotic therapy; no significant difference was found between the groups in the rate of infection of wound (6 and 5%, respectively), peritoneum (2% each) and elsewhere (6% and 5%). In another prospective, randomized, nonblind study of 451 determinant cases of 1,624 patients undergoing emergency laparotomy, cephalothin was instituted preoperatively but after peritoneal contamination had occurred (i.e., abdominal trauma, etc.); continued postoperative antibiotic again failed to reduce further the wound and peritoneal infection rates, as noted on comparing perioperative therapy alone (infection rates 8 and 4%, respectively) with perioperative plus 5-7 days of postoperative treatment (10% and 5%, respectively). Analysis of these data, as well as of the extra expenses incurred by 463 patients because of infection in a previous prophylactic antibiotic study, revealed an average additional expenditure of $2,686.00 for each instance of postoperative infection of the wound and/or peritoneum; whereas savings of $300.00 per patient at risk were obtained whenever appropriate prophylactic antibiotic had been given.

Anti-Bacterial Agents↗
PubMed1979

Management of perforating colon trauma: randomization between primary closure and exteriorization.

During a 44 month trial, 268 patients with wounds of the colon were entered into a prospective, randomized, nonblinded study. Consideration for primary closure demanded that: preoperative shock was never profound, blood loss was less than 20% of estimated normal volume, no more than two intra-abdominal organ systems had been injured, fecal contamination was minimal, operation was begun within eight hours, and wounds of colon and abdominal wall were never so destructive as to require resection. Once such criteria had been satisfied, colon wound management was dictated by last digit in the randomly assigned hospital number; odd indicated primary closure; even, exteriorization of the wound or primary closure with protection by a proximal vent. Results obtained in 139 determinant patients eligible for randomization revealed that primary closure (67 patients) had a lower infection rate of the incision (48% vs S7%, p > 0.05) and a still lower infection rate for the abdomen proper (15% vs 29%, p < 0.05) on comparison to the 72 patients with a randomized colostomy. Morbidity otherwise for the randomized colostomy was tenfold greater than if a primary closure had been performed. Average postoperative stay was six days longer (p < 0.01) if a colostomy had been created, exclusive of subsequent hospitalization for colostomy closure; while the total extra cost for management of the colon wound by colostomy was approximately $2,700.00. Although immediate mortalities were identical, one late death occurred following colostomy closure. These data not only confirm the safety of primary closure for colon wounds in selected cases, but also indicate that such should become the preferred method of treatment whenever specific criteria have been met.

Clinical Trials as Topic↗
PubMed1979

Management of duodenal wounds.

A 30-year experience with 321 wounds of the duodenum was reviewed. Of the total, 302 had some form of perforation; 19 had intramural hematomas. All patients underwent laparotomy shortly after admission except six cases of radiographically diagnosed submucosal hematoma. Occasional dehiscence of the duodenal suture line and its life-threatening complications (six of 52 cases, or 12%) led to a policy of routine duodenal decompression by gastrostomy plus twin jejunostomies in 1962. Following use of the latter technique in 237 patients, only one leak occurred. By contrast, failure to decompress had an 8% leak rate; direct drainage of the suture line gave an even greater incidence of dehiscence or fistula, 23%. Associated pancreatic injuries were treated as separate wounds by sump drainage of distal pancreatectomy. None of three patients subjected to pancraticoduodenectomy for massive combined pancreatic and duodenal trauma survived. A long-armed T-tube was always inserted for recognized as well as suspected common duct wounds. Although most of the 41 deaths were due to major vascular trauma and sequelae of hemorrhagic shock, duodenal complications did contribute to significant morbidity and five mortalities during the earlier years of review.

Abdominal Injuries↗
PubMed1979

Aspergillus infection of the burn wound.

During a 15-year period, 18 patients with major burns developed a wound infection due to Aspergillus. Ages averaged 28 years, extents of burn were 54% (14-97%) BSA for total surface involvement and 42% (14-85%) BSA for full-thickness injury. Pseudomonas sepsis preceded Aspergillus infection in 16 cases. Thirteen of the episodes occurred in three epidemics, each apparently related to contaminated air-conditioner ducts and filters. Treatment was based upon wound excision in all 18 patients, with recurrence initially in each. Topical and parenteral antifungal agents were never individually successful in controlling the infection. Whenever fungal sepsis involved an extremity alone and thus amputation could rid the body of the entire infected site, survival could then be achieved. The overall mortality rate was 78%. Protection of the wound from Aspergillus colonization appeared to be the only reliable method of preventing this often lethal fungus infection.

Adolescent↗
PubMed1979

Bacteriologic considerations in perforated necrotizing enterocolitis.

During a ten-year period, 61 infants with perforated necrotizing enterocolitis were managed by bowel resection, enterostomy, and intravenous antibiotics. Aerobic and anaerobic cultures were taken of venous blood, from the peritoneal cavity at operation, and of any subsequent wound and/or intraperitoneal infection. No significant differences between fatal and nonfatal cases were noted with respect to presence of anaerobes in the peritoneal flora (six babies with two deaths) or culture-confirmed bacteremia (73% of the total). However, peritonitis participated in by Pseudomonas aeruginosa (ten babies), or beta-hemolytic streptococcus (five babies) was -niformly lethal, as were complicating bacteremias due to P aeruginosa, beta-hemolytic streptococcus, and Staphylococcus aureus (two each). Anaerobic peritoneal isolates (all gram-positive cocci) were never noted if performation occurred before the eighth day of life; they did not appear to adversely affect survival. Based upon these data, antibiotic therapy should include either gentamicin or tobramycin, with penicillin, until subsequent culture reports dictate otherwise.

Bacteria↗
PubMed1978

Factors influencing intraoperative gastric regurgitation: a prospective random study of nasogastric tube drainage.

A prospective study was conducted to determine the incidence of "silent" gastric regurgitation and aspiration during general anesthesia in 146 patients randomized with respect to presence of a nasogastric tube. A bland dye was instilled in the stomach to serve as the determinant marker. The overall incidence of regugitation was 8.9% and of aspiration, 2.1% in spite of the uniform use of an endotracheal tube. The incidence of regurgitation was twice as high when anesthesia was given by an inexperienced anesthetist (11% vs 5.6%) and in patients without nasogastric tubes (12% vs 6%), although such differences were not statistically significant. The primary agent used, difficulty of endotracheal intubation, location of surgical incision, and duration of anesthesia did not alter the incidence of regurgitation or aspiration. No correlation was found between the detection of subclinical aspiration and the development of postoperative pulmonary complications.

Adolescent↗
PubMed1978

Cefamandole in treatment of peritonitis.

Cefamandole was evaluated as the sole antimicrobial agent used to treat bacterial peritonitis in 113 patients. Dosage varied between 1 and 2 g given intravenously every 6 hr. Laparotomy for excision of infected or gangrenous tissues, closure of gastrointestinal perforations, or drainage of an established abscess was required in 99 of the cases. A good clinical response was obtained in 107 patients, or 95% of the total group. Of the six deaths only one could be attributed to infection. No evidence of renal, hepatic, or hematopoietic toxicity was noted. There were no allergic reactions, although 13 patients (12%) developed phlebitis in a vein used for antibiotic administration. Bacteriological studies revealed aerobic peritonitis in 99% of the patients, with anaerobe participation in 60% of these cases. Sensitivity testing by the disk diffusion and tube dilution methods confirmed the appropriateness of cefamandole therapy; 91% of the gram-negative rods and 61% of the anaerobes were susceptible. From results of this study, it would appear that cefamandole is a reliably effective antibiotic for use in treatment of most forms of acute peritonitis. Its role in surgical prophylaxis may be even more promising.

Adult↗
PubMed1978

Abdominal drainage following appendectomy and cholecystectomy.

Consecutive patients undergoing emergency appendectomy (283) or urgent cholecystectomy (51) were prospectively studied for the development of post-operative incisional or peritoneal sepsis. Severity of the original peritoneal infection was carefully recorded, while use of a Penrose dam to drain the peritoneum was randomized according to pre-assigned hospital number. Both aerobic and anaerobic cultures were taken from the abdomen at the time of operation as well as from all postoperative infectious foci. Results demonstrated no essential differences in incidence of wound and peritoneal infection following appendectomy for simple or suppurative appendicitis (187) or following cholecystectomy for acute cholecystitis (51). However, with gangrenous or perforative appendicitis (94), incisional and intra-abdominal infection rates were 43% and 45%, respectively, when a drain was used; yet only 29 and 13%, respectively, without a drain. These latter differences were significant (p < 0.001). In addition, intra-abdominal abscesses were three times as likely to drain through the incision than along any tract provided by the rubber conduit. Cultures revealed that hospital pathogens accounted for a greater proportion of wound and peritoneal sepsis after cholecystectomy and appendectomy for simple or suppurative appendicitis if a drain had been inserted than if managed otherwise. By contrast, a mixed bacterial flora was responsible for most infections following appendectomy for gangrenous or perforated appendicitis, irrespective as to use of a drain.

Abdomen↗
PubMed1977

Tobramycin in the treatment of peritonitis.

Tobramycin is a new aminoglycosidic aminocyclitol antibiotic which has a broad spectrum of activity against aerobic and facultative Gram-negative bacilli. It is particularly effective against Pseudomonas aeruginosa, including some strains of this organism which are resistant to gentamicin. The newer aminoglycosidic aminocyclitol antibiotics all consist of a "backbone" of 2-deoxystreptamine, to which are attached several amino-containing sugar groups. These agents inhibit protein synthesis in bacteria at the level of the ribosome and are bactericidal although the precise mechanism by which they kill bacteria is still not known. There are a number of processes by which bacteria can become resistant to the action of the aminoglycosidic aminocyclitol antibiotics. Among these, the ability of bacteria to produce inactivating enzymes (usually mediated by R-factors or plasmids) appears to be the most important in current clinical isolates of bacteria. Aminoglycosidic aminocyclitol antibiotics which are resistant to these enzymes may have an enhanced spectrum of activity.

Aminoglycosides↗
PubMed1977

Management of liver trauma in children.

The charts of 203 consecutive children undergoing emergency laparotomy for management of an acute liver injury were reviewed. Although drainage was all that was required in the majority of cases, massive hemorrhage, usually arising from disrupted hepatic veins, appeared to demand liver resection (as performed in 17 children, with a mortality of 18%) during earlier years of the survey. Control of exsanguinating bleeding from such liver wounds by packing with viable autogenous tissue (pedicled omentum) subsequently eliminated almost entirely the need for resection. Fatalities resulting from either hemorrhagic shock or loss of liver substance then became relatively rare. Additional significant problems were associated organ injuries, postoperative wound and intra-abdominal sepsis, bleeding diatheses, and late instances of hemobilia. The overall mortality was 6%.

Adolescent↗
PubMed1977

Renal decapsulation in the prevention of post-ischemic oliguria.

The delayed onset of anuria/oliguria in acute tubular necrosis has been theorized to represent a complicating compartment syndrome, i.e., parenchymal swelling within an unyielding capsule. To test this proposition, 12 monkeys had suprarenal aortic cross-clamping, followed by unilateral renal decapsulation to create an experimental as well as a control kidney unit in the same animal. Histologic examination uniformly confirmed tubular necrosis at death or sacrifice. Subsequent split renal function studies (creatinine, urea, and free water clearances) indicated significantly greater maintenance of renal function by the decapsulated kidney than by its paired control. Clinical evaluation in 21 hemorrhagic shock patients, with the capsule of one kidney stripped, revealed on follow-up that 15 developed a renal failure consistent with acute tubular necrosis. Although three patients with polyuric failure died before split studies could be run and two others have been too recent for computer analysis to have been completed, nine of the remaining ten had significantly greater renal plasma flows (194 versus 121 ml/min M(2), p < .01) and significantly greater urine flows (.99 versus .18 ml/min M(2), p < .01) on the decapsulated side than on the control, as determined by differential renal scans. No significant difference in these same lateralized renal functions was noted in the tenth patient with renal failure and in the six survivors without renal failure. Renal decapsulation as prophylaxis reduced the anticipated incidence of oliguria/anuria from an expected 75% to 7% (p < .01) in these 21 shock patients. Such data suggest that delayed renal ischemia, possibly based on a compartment syndrome, may be the cause for a progression of acute tubular necrosis from polyuria to oliguria and then to anuria.

Adolescent↗
PubMed1977

Gastric surgery.

In a prospective, double-blind, randomized study of patients subjected to gastric surgery, parenteral cefazolin begun before operation significantly reduced the would infection rate. Infection developed only when incisional contamination occurred during operation and either when the antibiotic was not present in the tissues of the wound at the time of inoculation or when the offending bacteria were already resistant to the antimicrobial used. To be reliably effective, antimicrobial prophylaxis should always be instituted preoperatively in patients at high risk of infection, ie, those with conditions not associated with gastric hyperacidity. On the other hand, since patients with duodenal ulcer disease and resulting gastric hypersecretion usually have a relatively sterile stomach lumen, antibiotic prophylaxis for gastric operations in these cases is probably not indicated.

Adult↗
PubMed1977

Factors involved in disruption of intestinal anastomoses.

Bowel anastomoses, as performed on 181 dogs, were studied: (1) by interposing segments of colon into small bowel and vice versa, (2) by comparing clean anastomoses to those contaminated by feces before and after suturing, (3) with and without parenteral preoperative antibiotic, and (4) with and without coaptation of an inverted serosa. All animals with a timed sacrifice as well as an unexplained death had careful autopsy. Results demonstrated no difference in the healing capacity of large (91%) versus small (92%) intestine under identical circumstances. Intraluminal bacteria were of importance only if spillage caused contamination during operation and thereby subsequent infection of the peritoneal surface of the suture line. Peritonitis preceded all 28 leaks, yet the converse never occurred. Likelihood of a complicating peritonitis (67%) and thus an anastomotic leak (24%) was significantly reduced through the preoperative administration of prophylactic cefazolin (19 and 4%, respectively). A "serosal seal" also appeared important in obviating suture line disruption. Our data emphasize the value of an inverted and serosal lined anastomosis, bowel preparatory measures, prophylactic antibiotic, and the disruptive action of local bacterial peritonitis.

Animals↗