Biomedical subjects

John P Hunt

Publications and source records attributed to John P Hunt.

11 recordsLinked to original sources

PubMed2006

Factors affecting the diagnosis and prediction of PTSD symptomatology in children and adolescents.

OBJECTIVE: In a cohort that spanned all of childhood and suffered equivalent types of traumas, the authors examined diagnostic validity and risk factors for posttraumatic stress disorder (PTSD). For older children, parent-child agreement was investigated. METHOD: Sixty-two children ages 0-18 years who were hospitalized with injuries were assessed 2 months later for PTSD. Mothers were interviewed, and concurrent interviews were conducted with 24 adolescents. RESULTS: Children did not attain the DSM-IV threshold of three criterion C items until age 7. The 0-6-year-old group had significantly fewer criterion C symptoms (mean=0.43) than the 12-18-year-olds (mean=1.17). The impact of altering thresholds for criteria C and D was examined. Older children reported symptoms meeting criterion B significantly more often (79.2%) than parents (45.8%). Combined parent-child reports yielded significantly more symptoms and higher rates for criteria B, C, and D (almost a twofold increase) and for the overall diagnosis (37.5%) than parent report alone (4.2%). This 8.9-fold increase in diagnosis from combined reports suggests that the diagnostic rates for children who cannot make self-reports may greatly underestimate the true numbers. The interaction between pretrauma externalizing behavior and witnessing a threat to a caregiver had a significant effect on the total number of PTSD symptoms. CONCLUSIONS: These findings provide additional support for lowering the requirement of three criterion C symptoms for preschool children and raise questions about the appropriateness of this threshold for prepubertal children. The validity of studies that do not assess symptoms with combined parent and child reports is limited.

Adolescent↗

PubMed2005

Circumferential adjustment of ultrasound probe position to determine the optimal approach to the internal jugular vein: a noninvasive geometric study in adults.

Circumferential adjustment of the position of a two-dimensional ultrasound (US) probe around the neck has been recommended as a strategy for reducing the potential for unintentional common carotid artery puncture during internal jugular venous (IJV) cannulation. We obtained multiple high-resolution US images bilaterally from the necks of 107 adult subjects and analyzed these to determine the degree to which this strategy permits identification of a pathway from the skin to the IJV that minimizes venoarterial overlap while maximizing venous target (angular) width. The method consistently permitted identification of an approach to the IJV superior to that obtainable with any one of four popular surface anatomy-based ("blind") approaches and was even more powerful if used in concert with a US-guided 1) adjustment of the degree of head rotation, 2) choice between a high and low approach, and 3) choice between the right and left IJV. Use of a high-resolution US imaging device also permitted identification of the precise boundaries of additional cervical anatomic structures (nontarget vessels, lymph nodes, and the thyroid gland) potentially relevant to selection of an optimal approach to the IJV.

Aged↗

PubMed2004

A 10-year retrospective review of 758 DIEP flaps for breast reconstruction.

This study examined 758 deep inferior epigastric perforator flaps for breast reconstruction, with respect to risk factors and associated complications. Risk factors that demonstrated significant association with any breast or abdominal complication included smoking (p = 0.0000), postreconstruction radiotherapy (p = 0.0000), and hypertension (p = 0.0370). Ninety-eight flaps (12.9 percent) developed fat necrosis. Associated risk factors were smoking (p = 0.0226) and postreconstruction radiotherapy (p = 0.0000). Interestingly, as the number of perforators increased, so did the incidence of fat necrosis. There were only 19 cases (2.5 percent) of partial flap loss and four cases (0.5 percent) of total flap loss. Patients with 45 flaps (5.9 percent) were returned to the operating room before the second-stage procedure. Patients with 29 flaps (3.8 percent) were returned to the operating room because of venous congestion. Venous congestion and any complication were observed to be statistically unrelated to the number of venous anastomoses. Overall, postoperative abdominal hernia or bulge occurred after only five reconstructions (0.7 percent). Complication rates in this large series were comparable to those in retrospective reviews of pedicle and free transverse rectus abdominis musculocutaneous flaps. Previous studies of the free transverse rectus abdominis musculocutaneous flap described breast complication rates ranging from 8 to 13 percent and abdominal complication rates ranging from 0 to 82 percent. It was noted that, with experience in microsurgical techniques and perforator selection, the deep inferior epigastric perforator flap offers distinct advantages to patients, in terms of decreased donor-site morbidity and shorter recovery periods. Mastery of this flap provides reconstructive surgeons with more extensive options for the treatment of postmastectomy patients.

Adolescent↗

PubMed2004

Gamma-guided diagnostic peritoneal lavage for detection of bowel perforation.

HYPOTHESIS: Bowel perforation can be diagnosed by detection of orally administered technetium Tc 99m sulfur colloid ((99m)Tc SC) in diagnostic peritoneal lavage (DPL) fluid using a handheld gamma-detection probe. DESIGN: A canine intestinal-injury model was used to test the hypothesis. The (99m)Tc SC (55.5 MBq) was administered in 500 mL of saline via a nasogastric tube. A DPL with 500 mL of saline was performed at 60, 90, and 120 minutes after administration of (99m)Tc SC. The radioactivity in the DPL effluent was measured using a handheld gamma probe. A DPL effluent count that was 3 SDs above the background count was considered a positive test result. Twenty animals with perforation and 5 without perforation (negative control) were studied. RESULTS: There were no false-positive gamma-DPL test results. Sensitivity improved by time up to 90 minutes. The lowest positive count in the DPL effluent measured by the gamma probe corresponded to 0.2% of the administered activity. No radioactivity was detected in blood and urine samples or liver and spleen specimens. The sensitivity, specificity, accuracy, positive predictive values, and negative predictive values at 90 minutes were 95%, 100%, 96%, 100%, and 83%, respectively. CONCLUSIONS: gamma-Guided DPL is a highly sensitive and 100% specific test in the detection of small-bowel perforation. Clinical studies are warranted to determine the patient-specific factors affecting diagnostic accuracy.

Animals↗

PubMed2004

Treatment of superior mesenteric and portal vein thrombosis with direct thrombolytic infusion via an operatively placed mesenteric catheter.

Acute superior mesenteric vein (SMV) and portal vein (PV) thrombosis can be a complication of hypercoagulable, inflammatory, or infectious states. It can also occur as a complication of medical or surgical intervention. Management of mesenteric and portal vein thrombosis includes both operative and nonoperative approaches. Operative interventions include thrombectomy with thrombolysis; this is often employed for patients who present with signs of peritoneal irritation. Nonoperative approaches can be either noninvasive or invasive. Treatment with anticoagulation has been shown to be efficacious, though its rate of recanalization is not as high as with intravascular infusion of thrombolytics. Intravenous catheterization and thrombolytic infusion has the advantage of direct pharmacologic thrombolysis of clot, with decreased infusion required and the possibility to carry out dilation or thrombectomy concurrently. We report the use of recombinant tissue-plasminogen activator (rt-PA) infusion via an operatively placed multi side-hole catheter/5-Fr introducer sheath into the right portal and superior mesenteric vein clot, inserted through a small jejunal vein, in a patient who presented with acute gangrenous appendicitis and thrombosis of the main portal trunk and superior mesenteric vein. A temporary abdominal closure was maintained until 36 hours after the start of infusion of the rt-PA. At this time venous system had normal flow, with complete recanalization of the right portal and superior mesenteric veins.

Acute Disease↗

PubMed2003

The resident experience on trauma: declining surgical opportunities and career incentives? Analysis of data from a large multi-institutional study.

PURPOSE: The surgical resident experience with trauma has changed. Many residents are exposed to predominantly nonoperative patient care experiences while on trauma rotations. Data from a large multicenter study were analyzed to estimate surgical resident exposure to trauma laparotomy, diagnostic peritoneal lavage (DPL), and focused abdominal sonography for trauma (U/S). METHODS: Centers completed a self-report questionnaire on their institutional demographics, admissions, and procedure for a 2-year period (1998-1999). RESULTS: A total of 82 trauma centers that provide resident teaching were included. The included centers represent over 247,000 trauma admissions. The majority of trauma centers (65.9%) had > 80% blunt injury. Although all centers performed laparotomies, other results were more variable. For U/S, 24.2% performed none at all and 47.0% performed fewer than two U/S examinations per month. For DPLs, 3.8% performed none and 66.7% performed fewer than two per month. Assuming 1 night of 4 on call, the average surgical resident training at a trauma center performing > 80% blunt trauma has the potential to participate in only 15 trauma laparotomies, 6 diagnostic peritoneal lavages, and 45 ultrasound examinations per year. In addition, the resident will care for an average of 500 blunt trauma patients before performing a splenectomy or liver repair. CONCLUSION: Surgical resident experience on most trauma services is heavily weighted to nonoperative management, with a relatively low number of procedures, little experience with DPL, and highly variable experience with ultrasound. These data have serious implications for resident training and recruitment into the specialty.

Attitude of Health Personnel↗

PubMed2003

Surgical cricothyroidotomy in trauma patients.

BACKGROUND: Surgical airway intervention is occasionally necessary due to contraindicated or failed endotracheal intubation. In cricothyroidotomy patients, a choice exists between continued long-term ventilation via the cricothyroidotomy portal or conversion to tracheostomy. We examined whether conversion to tracheostomy reduces the risk of acute complications. METHODS: We retrospectively identified 46 patients with cricothyroidotomies performed at our level I trauma center over a 63-month period. We reviewed the success rate, indications, etiology, and complications. RESULTS: An airway was obtained in all cases. The most common indicator for surgical airway intervention was unsuccessful endotracheal intubation. The cause of death among nonsurvivors was not due to airway complications. Of the 15 surviving patients, 8 had conversions to tracheostomy and 7 patients did not have conversions but had decannulations. The converted group had a greater percentage of acute complications than the nonconverted group. CONCLUSION: Rate of acute complications with prolonged ventilation via cricothyroidotomy portal is equal to, if not lower than, via converted tracheostomy. Cricothyroidotomy in trauma patients may be used long term without any increase in acute complications.

Adolescent↗

PubMed2002

Barrier precautions in trauma: is knowledge enough?

OBJECTIVES: The risk of blood and body fluid exposure and, therefore, risk of blood-borne disease transmission is increased during trauma resuscitations. Use of barrier precautions (BPs) to protect health care workers (HCWs) from exposure and infection has been codified in hospital rules and in national trauma education policy. Despite these requirements, reported rates of BP compliance vary widely. The reasons for noncompliance are not known. This study assesses self-reported rates of BP usage during resuscitations among trauma professionals, explores reasons for noncompliance, and compares self-reported compliance rates with actual observed compliance rates. METHODS: A survey regarding BPs was distributed to all HCWs involved in trauma resuscitations at our Level I trauma center. All surgical and emergency medicine residents as well as attending faculty from both disciplines and nursing staff were included in this study. A total of 161 surveys were distributed and 123 were returned. RESULTS: Most HCWs (114 of 123 [93%]) reported at least one exposure (usually intact skin contact) to blood or other body fluids. A considerable variation in the type of BP used was reported for those HCWs who reported use of BPs "all of the time." Of the HCWs who reported universal use of BPs, reported usage rates were as follows: gloves, 105 of 123 (85%); eyewear (no side protectors), 58 of 123 (47%); eyewear (side protectors), 20 of 123 (16%); gowns, 22 of 123 (18%); and masks, 5 of 123 (4%). The two most common reasons for noncompliance were "time factors" (61%) and "BPs are too cumbersome" (29%). Observed compliance rates were statistically significantly lower than self-reported rates in all BPs except gloves (p < 0.02). CONCLUSION: The wide variation in BP use and the gap between perceived and actual usage that we have observed suggest that the effectiveness of current educational approaches to ensure BP use is inadequate.

Blood-Borne Pathogens↗

PubMed2002

Colorectal cancer in patients younger than 40 years of age.

Previous studies have suggested a poor outcome for patients presenting with colorectal cancer under the age of 40 years. This study was conducted to evaluate the outcomes of these patients during a 10-year period at the Medical Center of Louisiana in New Orleans. A retrospective study was designed to review all patients under the age of 40 with a diagnosis of colorectal cancer from January 1990 to December 2000. There were 664 patients presenting with colorectal cancer during the 10-year period; of these 24 presented for surgery under the age of 40. There were 17 male and seven female patients. The median age was 35 years (range 22-39). Eleven (44%) patients had a positive family history of colorectal cancer. Seven lesions were right sided, one transverse, eight left sided, and eight rectal. Histologically 20 lesions were typical adenocarcinomas and four were mucinous. Twelve were stage IV, six stage III, five stage II, and one stage I. Twenty-one patients underwent resection, six with stoma formation; three patients had stoma formation only for a total of nine stomas (38%). The mean operative duration was 3.3 +/- 1.9 hours. The operative mortality was 4 per cent with a complication rate of 17 per cent. The eight rectal cancer patients received preoperative chemoradiation therapy (33%). Twelve (50%) patients with colon cancer received postoperative 5-fluorouracil-based chemotherapy. The mean survival for all patients was 24.7 +/- 23.2 months. Estimated 5-year survival using Kaplan-Meier analysis was 30 per cent. We conclude that colorectal cancer patients less than 40 years of age present at an advanced stage and tend to have a positive family history. In general patients tolerate surgery well, with stoma formation in more than one-third. Long-term survival is as predicted for their advanced stage of presentation. The study highlights the need for early diagnosis in this patient group.

Adenocarcinoma↗

PubMed2002

Stoma complications: a multivariate analysis.

Construction of a gastrointestinal stoma is a frequently performed surgical procedure. We sought to analyze a large cohort to document the frequency and types of ostomy complications and the risk factors associated with them. The charts of patients undergoing a procedure which resulted in ostomy during a 3-year period were reviewed. Demographics, indication, ostomy type/location, perioperative risk factors, and complications were recorded. Case-control methodology was used to determine crude odds ratios and multiple logistic regression was used to calculate adjusted odds ratios. A P value of less than 0.05 was considered significant. An ostomy was constructed in 204 patients and records were available for 164. Forty-one patients (25.0%) had ostomy complications. Sixteen of these complications (39.0%) occurred within one month of the procedure. Complications included prolapse in nine (22%), necrosis in nine (22%), stenosis in seven (17%), irritation in seven (17%), infection in six (15%), bleeding in two (5%), and retraction in two (5%). Gender, cancer, trauma, diverticulitis, emergency surgery, ileostomy, and ostomy location/type were not associated with a stoma complication. Significant predictors of ostomy malfunction are presented as odds ratios (ORs) with 95 per cent confidence intervals (CIs) and include inflammatory bowel disease (OR = 4.49; 95% CI = 1.16-17.36) and obesity (OR = 2.66; 95% CI = 1.15-6.16). The care of an enterostomal nurse was found to prevent complications (OR = 0.15; 95% CI = 0.03-0.69). We conclude that ostomies have a high risk of complication, which is not related to stoma location or type. Obesity and inflammatory bowel disease predispose to complications. Enterostomal nursing may be instrumental in preventing complications.

Adolescent↗

PubMedDate not supplied

New Orleans Charity Hospital--your trauma center at work.

The Medical Center of Louisiana at New Orleans-Charity Hospital stands with pride as one of only two level I trauma centers in the state and one of the largest trauma centers in the United States, seeing over 4,000 trauma patients per year. Despite perennial funding issues, Charity Hospital's Emergency Department treated almost 200,000 patients in 2003. This brief report gives an overview of the emergency- and trauma-related services provided by Charity Hospital and underscores its value as a critical asset to healthcare in the Louisiana.

Adult↗