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James E Barone

Publications and source records attributed to James E Barone.

18 recordsLinked to original sources
PubMed2006

Correlation of urinalysis and dipstick results with catheter-associated urinary tract infections in surgical ICU patients.

OBJECTIVE: To determine the utility of urinalysis and dipstick results in predicting urinary tract infections in catheterized ICU patients. DESIGN AND SETTING: Urine samples were collected for 4months from patients admitted a ten-bed surgical ICU of an urban public teaching hospital designated by the state of New York as a level I trauma center. The correlation was analyzed between urinalysis and dipstick results from urine samples and subsequent quantitative culture results. PATIENTS: All patients with indwelling urinary catheters admitted to the ICU were considered eligible; 106 patients were enrolled, and 300 individual urine samples were analyzed. MEASUREMENTS AND RESULTS: There were 44 catheter-associated urinary tract infections. Nitrite presence was the best indicator of infection (91.8% specificity) but was not a reliable clinical test due to a sensitivity of 29.5% and positive and negative likelihood ratios of 3.52 and 0.56, respectively. None of the other parameters (leukocyte esterase, white blood cell count, urobilinogen, presence of yeast or bacteria) were independently correlated with the culture results either individually or in combination. CONCLUSIONS: Based on our data we cannot recommend the use of urinalysis or dipstick in screening for potential catheter-associated urinary tract infections.

Carboxylic Ester Hydrolases↗
PubMed2006

Should an Allen test be performed before radial artery cannulation?

BACKGROUND: This study aims to determine the current status of the Allen test for assessing the circulation of the hand. METHODS: The Ovid electronic database was searched using multiple search terms and keywords. Bibliographies of pertinent articles were examined. Data involving results of Allen tests, criteria for abnormality and outcomes, specifically those related to adverse events, were extracted. RESULTS: The criteria for an abnormal Allen test are not agreed upon. The significance of an equivocal or abnormal test is unclear. The test is not accurate in predicting postcannulation hand ischemia. Results of the test suffer from poor interrater reliability. Most critically ill patients cannot cooperate for the performance of the test as described. CONCLUSIONS: Performance of an Allen test before radial artery cannulation should not be considered a "standard of care."

Blood Specimen Collection↗
PubMed2005

The drive to survive: unplanned extubation in the ICU.

STUDY OBJECTIVES: To assess the consequences of unplanned extubation (UE) in the ICU. DESIGN: Case-control study. SETTING: Fourteen-bed, medical-surgical ICU of a university-affiliated community teaching hospital. PATIENTS: One hundred patients who underwent UE compared to 200 control patients who underwent mechanical ventilation (MV) without UE between January 1, 1999, and June 30, 2004. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Patients with UE had longer ICU and hospital length of stay (LOS) and longer duration of MV than did control subjects. Hospital mortality was 20% among UE and 35% among control patients (p = 0.011). Of the 100 patients with UE, reintubation within 48 h (UE R+) was required in 44 patients and no reintubation within 48 h (UE R-) was required in 56 patients. ICU and hospital LOS; duration of MV; rate of ICU-acquired infections; ICU pharmacy, laboratory and diagnostic imaging charges; and mortality were all much higher among UE R+ patients than among UE R- patients. Multiple logistic regression analysis revealed that age was the only predictor of the need for reintubation after UE and that age and the need for reintubation were the only predictors of mortality after UE. CONCLUSIONS: UE was associated with increased hospital and ICU LOS but decreased mortality in this heterogeneous population of critically ill adult patients. These findings were entirely explained by the divergent outcomes of the UE R+ and UE R- groups. Patients with UE who did not require reintubation had remarkably good outcomes. It remains incumbent on ICU teams to institute protocols for regular identification of patients ready to be liberated from MV.

Adult↗
PubMed2005

Evidence-based medicine applied to sentinel lymph node biopsy in patients with breast cancer.

Sentinel lymph node biopsy (SLNB) has not been examined using the principles of evidence-based medicine (EBM). Specifically, likelihood ratios have not been used to assess the validity of SLNB. The Surveillance, Epidemiology, and End Results (SEER) public database of the National Cancer Institute was used to establish the baseline or pretest probability of finding a positive lymph axillary node for each stage of breast cancer. Rates of false negative results of SLNB for all breast cancer stages were determined from the surgical literature. Positive and negative likelihood ratios (LR) were calculated. For each stage of breast cancer, the Bayesian nomogram was used to find the post-test probability of missing a metastatic axillary node when the SLN was negative. The SEER database of 213,292 female patients with breast cancer yielded the following rates of positivity of axillary lymph nodes for each breast tumor size: T1a, 7.8 per cent; T1b, 13.3 per cent; T1c, 28.5 per cent; T2, 50.2 per cent; T3, 70.1 per cent. The combined data from 13 published studies of SLNB (6444 successful SLNBs) demonstrated a false negative rate of 8.5 per cent. The LR of a negative test is 0.086. According to the nomogram, the chances of missing a positive node for stage of cancer are as follows: T1a, 0.7 per cent; T1b, 1.5 per cent; T1c, 3.0 per cent; T2, 7 per cent; T3, 18 per cent. The risk of missing a positive axillary node can accurately be estimated for each stage of breast cancer using the LR, which is much more useful than the simple false negative rate. Surgeons should use this information when deciding whether to perform SLNB and in their informed consent discussions.

Breast Neoplasms↗
PubMed2005

The rate of adenocarcinoma in endoscopically removed colorectal polyps.

The purpose of this study was to determine the rate of cancer in a modern series of colorectal polyps. All pathology reports from colon and rectal polyps from 1999 to 2002 were reviewed. Reports of bowel resections, cancer-free polyps, and polyp-free mucosal biopsies were excluded. Polyps were grouped by size, and the rate of adenocarcinoma was determined. x2 was used for analysis. A total of 4,443 polyps were found, of which 3,225 were adenomatous [2,883 (89.4%) tubular adenomas, 399 (9.3%) tubulo-villous adenomas, 32 (1.0%) villous adenomas, and 11 (0.3%) carcinomas]. The rate of adenocarcinoma by size was 0.07 per cent for polyps <1 cm, 2.41 per cent for polyps 1-2 cm, and 19.35 per cent for polyps >2 cm, representing significantly fewer cancers for each category of polyp size than the accepted standard. The rate of carcinoma in colon polyps is much lower than previously thought and currently stated in many texts. These data do not alter the recommendations for polyp removal, however, failure to retrieve a specimen in a polyp <1 cm in size is unlikely to have an adverse outcome because the chances of malignancy are very low.

Adenocarcinoma↗
PubMed2004

Resident work hours: the five stages of grief.

The authors describe their reactions, as surgical educators, to the mandate of the Accreditation Council for Graduate Medical Education to reduce resident work hours. They explain these reactions in terms of Dr. Elizabeth Kübler-Ross's five stages of grief: denial, anger, bargaining, depression, and finally acceptance ("which should not be mistaken for a happy stage"). The authors describe each stage of grief and use it to make specific comments on the difficulties that the mandate imposes. They then reveal that their views about the work-hours regulations differ: Dr. Ivy now sees them as an opportunity to grow and improve, and likens the resistance to the new restrictions to that of Europeans to the printing press. But Dr. Barone ("the older of the coauthors and a known curmudgeon") is not so sure, and shares many of the concerns described earlier in the five stages of grief, even though he has outwardly accepted the work-hours rules and insists on full compliance by his residents and faculty. In particular, he is saddened that some residents feel they have the absolute right to go home regardless of the situation on the surgery service, and this feeling is validated by the work-hours rules.

Attitude of Health Personnel↗
PubMed2003

Liberal use of computed tomography scanning does not improve diagnostic accuracy in appendicitis.

BACKGROUND: Based on a study at our hospital in 1994, we established a practice guideline for appendicitis patients. The practice guideline was followed well except for an increased number of preoperative computed tomography (CT) scans. METHODS: Data collected from the previous study of 100 patients were compared with data from consecutive patients, 118 total, seen over a similar time period in the year 2000. RESULTS: The percentage of CT scans ordered for the diagnosis of patients who underwent appendectomy markedly increased from 11% in 1994 to 48.3% in 2000. (P <0.001) The percentage of normal appendixes removed did not change significantly from 12% in 1994 to 17.8% in 2000 (P = 0.317). Patients who had a CT scan were no less likely to have a normal appendix at surgery (P = 0.386) and a significant increase in preoperative Emergency Department length of stay (P <0.001). CT was accurate 80% of the time in 2000 and 81% of the time in 1994. Only 14 of 57 CT scans were ordered by surgeons. CONCLUSIONS: The use of preoperative abdominal CT scanning has not improved the accuracy of the diagnosis of appendicitis at our institution. It has resulted in a significant increase in Emergency Department preoperative length of stay and the finding of a normal appendix at surgery. As nonsurgeons ordered the majority of preoperative CT scans, earlier input by surgeons might increase the rate of accurate clinical diagnosis and decrease the number of CT scans ordered.

Adult↗
PubMed2003

Those were the days.

Explore the source record for details and available documents.

Emergency Service, Hospital↗
PubMed2003

Requirement for hourly Glasgow Coma Scores in the emergency department: process or outcome based?

BACKGROUND: The lack of hourly Glasgow Coma Score (GCS) documentation in trauma patients while in the emergency department (ED) is frequently cited by American College of Surgeons (ACS) Trauma Center Verification Review Committee site visitors. The basis for this requirement is unclear. We suspected that hourly recording of GCS has no impact on patient outcome. METHODS: The trauma registry of a 300-bed ACS-verified, state-designated Level II trauma center was reviewed retrospectively for head trauma patients over 16 years of age. Demographic data, field and ED GCS, presence or absence of hourly GCS in the ED, objective injury scores, complications, discharge status, and hospital length of stay were determined. RESULTS: A total of 463 patients were identified. Hourly GCS was recorded in the ED in 244 (53%) patients. No significant difference was found in the Trauma and Injury Severity Score or the Abbreviated Injury Score of the head between those who had hourly GCS recorded and those who did not. Patients who had hourly GCS recorded were significantly younger, 42.3 +/- 19.7 years vs 53.9 +/- 24.9 years for those who did not have hourly GCS recorded (P < 0.001). Seventy percent (126/179) of patients involved in a motorcycle or motor vehicle crash had hourly GCS recorded while only 39% (69/175) of patients admitted for falls had hourly GCS (P < 0.001). There were no differences in mortality or complication rates between the groups. CONCLUSION: The recording of hourly GCS on head injured patients is reflective of the initial presentation of the patient and not an objective evaluation of the patient. The presence or absence of hourly GCS in the ED was not associated with any increase in complications or mortality. The ACS should reevaluate the requirement for hourly recording of GCS in trauma patients.

Accidental Falls↗
PubMed2002

Isolated free fluid on computed tomographic scan in blunt abdominal trauma: a systematic review of incidence and management.

BACKGROUND: Abdominal computed tomographic (CT) scan is accepted as the primary diagnostic modality in stable patients with blunt abdominal trauma. A recent survey of 328 trauma surgeons demonstrated marked variation in the management of patients with head injuries and the finding of free intra-abdominal fluid without solid organ injury on CT scan. This study was undertaken to attempt to determine what to do when free fluid without solid organ injury is seen on abdominal CT scan in patients with blunt trauma. METHODS: Articles concerning the incidence and significance of free intra-abdominal fluid on CT scan of blunt trauma patients without solid organ injury were systematically reviewed. A MEDLINE search was performed using terms such as tomography-x-ray computed, wounds-nonpenetrating, small intestine/injuries, time factors, and abdominal trauma and diagnostic tests. Bibliographies of pertinent articles were reviewed. Appropriate articles were evaluated for quality and data were combined to reach a conclusion. RESULTS: Meta-analysis could not be performed because no randomized, prospective, controlled trials could be found. Forty-one articles were excluded from the analysis because they looked at only patients with known injuries to intestine, diaphragm, or pancreas and the investigation of the CT scan findings did not include negative scans. Ten articles, which described CT scan results for all patients presenting with blunt abdominal trauma for a defined period of time, formed the basis of this study. Isolated free fluid was seen in 463 (2.8%) of over 16,000 blunt trauma patients scanned. A therapeutic laparotomy was performed in only 122 (27%) of these patients. CONCLUSION: The isolated finding of free intra-abdominal fluid on CT scan in patients with blunt trauma and no solid organ injury does not warrant laparotomy. Alert patients may be followed with physical examination. Patients with altered mental status should undergo diagnostic peritoneal lavage.

Abdominal Injuries↗
PubMedDate not supplied

The Leapfrog Initiative: a potential threat to surgical education.

PURPOSE: The Leapfrog Initiative was established in January 2000 by the Business Roundtable (BRT) in response to the Institute of Medicine report on quality and safety of medical care. The BRT is composed of chief executive officers of U.S. corporations representing more than 28 million employees. Leapfrog has proposed 3 hospital safety measures-computerized physician order entry, intensive care unit physician staffing standards and evidence-based hospital referral, which states that hospitals must meet certain volume/year criteria. Three of these criteria are pertinent to general surgery. They are abdominal aortic aneurysm (AAA) repair greater than or equal to 30/year, carotid endarterectomy (CE) greater than or equal to 100/year, and esophageal cancer surgery (ECS) greater than or equal to 7/year. Hospitals failing to meet these requirements would not be eligible to treat patients employed by BRT corporations. METHODS: Data were obtained from the Residency Review Committee (RRC) for Surgery Resident Statistics Summary for 1999 to 2001. Comparisons were made between the numbers of the Leapfrog index cases required and the actual number of cases performed by each graduating chief resident. Data from the Connecticut Hospital Association (CHA) for fiscal year 2000 were also analyzed. Outcomes for procedures at The Stamford Hospital were reviewed. RESULTS: Data obtained from the RRC reveal that the mode numbers for each of the 3 evidence-based standards for each graduating chief resident in 2000 and 2001 are 5 and 3 for AAA, 15 and 17 for CE, and 0 in both years for ECS. Extrapolation using the mode for each procedure reveals that hospitals with 5 or 6 graduating chief residents may be ineligible to treat patients for AAA and CE. Hospitals with less than or equal to 5 chief residents would be excluded from performing CE. Very few institutions are performing adequate numbers of ECS. Only 4 of 31 CT hospitals would be allowed to perform AAA, and only 3 of 31 could perform CE. Only 1 Connecticut hospital performed more than 7 ECS cases in FY 2000. It is apparent that Leapfrog standards will have serious economic impact on many hospitals, as well as displacing patients to other cities for care. CONCLUSIONS: Surgical chairs and program directors should be aware of the Leapfrog standards and assess their own programs and institutions for compliance. Performance improvement and outcomes data for all evidence-based standards should be reviewed.

Aortic Aneurysm↗