Second course of recombinant human activated protein C delivered to a severely septic patient after recent surgery.
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APACHE↗
Biomedical subjects
Kenneth Waxman
Publications and source records attributed to Kenneth Waxman.
Gum chewing reduces ileus after elective open sigmoid colectomy.
HYPOTHESIS: Gum chewing after elective open colon resection may stimulate bowel motility and decrease duration of postoperative ileus. DESIGN AND SETTING: Prospective, randomized study in a community-based teaching hospital. PATIENTS: Thirty-four patients undergoing elective open sigmoid resections for recurrent diverticulitis or cancer. MAIN OUTCOME MEASURES: First feelings of hunger, time to first flatus, time to first bowel movement, length of hospital stay, and complications. RESULTS: A total of 34 patients were randomized into 2 groups: a gum-chewing group (n = 17) or a control group (n = 17). The patients in the gum-chewing group chewed sugarless gum 3 times daily for 1 hour each time until discharge. Patient demographics, intraoperative, and postoperative care were equivalent between the 2 groups. All gum-chewing patients tolerated the gum. The first passage of flatus occurred on postoperative hour 65.4 in the gum-chewing group and on hour 80.2 in the control group (P = .05). The first bowel movement occurred on postoperative hour 63.2 in the gum-chewing group and on hour 89.4 in the control group (P = .04). The first feelings of hunger were felt on postoperative hour 63.5 in the gum-chewing group and on hour 72.8 in the control group (P = .27). There were no major complications in either group. The total length of hospital stay was shorter in the gum-chewing group (day 4.3) than in the control group (day 6.8), (P = .01). CONCLUSIONS: Gum chewing speeds recovery after elective open sigmoid resection by stimulating bowel motility. Gum chewing is an inexpensive and helpful adjunct to postoperative care after colectomy.
Chewing Gum↗
The use of vacuum-assisted closure therapy for the treatment of a large infected facial wound.
Chronic wounds in difficult locations pose constant challenges to health care providers. Negative-pressure wound therapy is a relatively new treatment to promote wound healing. Laboratory and clinical studies have shown that the vacuum-assisted closure (VAC) therapy increases wound blood flow, granulation tissue formation, and decreases accumulation of fluid and bacteria. VAC therapy has been shown to hasten wound closure and formation of granulation tissue in a variety of settings. Accepted indications for VAC therapy include the infected sternum, open abdomen, chronic, nonhealing extremity wounds and decubitus ulcers. We report the first case of VAC therapy successfully used on a large infected wound to the face to promote healing.
Bandages↗
The use of tagged white blood cell scans to diagnose appendicitis in pregnant patients.
A prompt and accurate diagnosis of appendicitis in pregnant patients is important in avoiding premature labor and fetal loss. Computed tomography (CT) scans are accurate, but fetal radiation exposure is high. Ultrasound avoids radiation exposure, but is less accurate as the uterus enlarges. A third option involves the use of technetium-99 tagged white blood cell scans (TWBCS), which have less than 5 per cent of the fetal radiation exposure of CT scans. However, in pregnancy, the value of TWBCS has not been studied. Therefore, a retrospective review of all patients who were pregnant and underwent a nuclear medicine study as part of their evaluation was performed. Thirteen patients were identified from 1999 through 2005. Before receiving a TWBCS, each patient had an indeterminate physical examination and an ultrasound or CT. Patients with negative TWBCS were admitted and observed clinically. There was no relationship between the results of TWBCS and the presence of appendicitis (P = 0.538). The sensitivity of the TWBCS was 50 per cent, whereas the specificity was 73 per cent. TWBCS had a false-positive rate of 27 per cent and a false-negative rate of 50 per cent, and its positive predictive value was 25 per cent. The data suggest that TWBCS in pregnancy is not reliable in evaluating for appendicitis.
Adolescent↗
Magnetic resonance imaging is not needed to clear cervical spines in blunt trauma patients with normal computed tomographic results and no motor deficits.
HYPOTHESIS: Trauma patients with normal motor examination results and normal cervical spine helical computed tomographic (CT) scans with sagittal reconstructions do not have significant cervical spine injury. DESIGN: Prospectively collected registry data. SETTING: Level II community-based trauma center. PATIENTS: All patients admitted to the trauma service from January 1, 1999, to December 31, 2003. MAIN OUTCOME MEASURES: Injury detected by CT and/or magnetic resonance imaging (MRI) of the cervical spine. Neurologic examination and need for surgery were secondary outcomes. RESULTS: During the study period, 2854 trauma patients were admitted, of whom 91.2% had blunt trauma. Of these patients, 56.2% had a closed head injury. One hundred patients had cervical spine and/or spinal cord injuries. Eighty-five patients had a cervical spine injury diagnosed by CT. Fifteen patients had admission neurologic deficits not seen on CT, and 7 of these patients had non-bony abnormalities on MRI. Ninety-three patients had a normal admission motor examination result, a CT result negative for trauma, and persistent cervical spine pain, and were examined with MRI. All MRI examination results were negative for clinically significant injury. Seventeen patients had MRIs that showed degenerative disc disease, and 6 had spinal canal stenosis secondary to ossification. Twelve comatose patients (Glasgow Coma Scale score, <9), moving all 4 extremities on arrival, with normal CT results of the cervical spine, were examined with MRI. All of these MRI examination results were negative for injury. None of the patients experienced neurologic deterioration. No patient required operative management of spinal injury. CONCLUSION: Blunt trauma patients with normal motor examination results and normal CT results of the cervical spine do not require further radiologic examination before clearing the cervical spine.
Adult↗
Cervical spine clearance in blunt trauma: evaluation of a computed tomography-based protocol.
BACKGROUND: Prompt identification of cervical spine injuries has been a critical issue in trauma management. In 1998, the authors developed a new protocol to evaluate cervical spines in blunt trauma. This protocol relies on clinical clearance for appropriate patients and helical computed tomography instead of plain radiographs for patients who cannot be clinically cleared. The authors then prospectively collected data on all cervical spine evaluations to assess the sensitivity and specificity of their approach. METHODS: Any patient without clinical evidence of neurologic injury, alcohol or drug intoxication, or distracting injury underwent cervical spine evaluation by clinical examination. Patients who did not meet these criteria underwent helical computed tomographic scanning of the entire cervical spine. For patients who had neurologic deficits, a magnetic resonance image was obtained. If the patient was not evaluable secondary to coma, the computed tomographic scan was without abnormality, and the patient was moving all four extremities at arrival in the emergency department, the cervical spine was cleared, and spinal precautions were removed. Data were collected for all patients admitted to Santa Barbara Cottage Hospital trauma service between 1999 and 2002. The authors selected for analysis patients with blunt trauma and further identified those with closed head injuries (Glasgow Coma Scale score < 15 and loss of consciousness). In addition, all blunt cervical spine injuries were reviewed. RESULTS: During the period of study, 2,854 trauma patients were admitted, of whom 2,603 (91%) had blunt trauma. Of these, 1,462 (56%) had closed head injuries. One hundred patients (7% of patients admitted for blunt trauma) had cervical spine or spinal cord injuries, of which 99 were identified by the authors' protocol. Only one injury was not appreciated in a patient with syringomyelia. Fifteen percent of patients with spinal cord injury had no radiographic abnormality; all of these patients presented with neurologic deficits. The sensitivity for detecting cervical spine injury was thus 99%, and the specificity was 100%. The risk of missing a cervical spine injury in these blunt trauma patients was 0.04%. The authors missed no spine injuries in patients with head injuries. CONCLUSION: The use of the authors' protocol resulted in excellent sensitivity and specificity in detecting cervical spine injuries. In addition, it allowed early removal of spinal precautions.
Adolescent↗
Percutaneous thrombin injection to treat a post-traumatic hepatic pseudoaneurysm.
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Adult↗
Is repeated head computed tomography necessary for traumatic intracranial hemorrhage?
This study was performed to determine the need for repeat head computed tomography (CT) in patients with blunt traumatic intracranial hemorrhage (ICH) who were initially treated nonoperatively and to determine which factors predicted observation failure or success. A total of 1,462 patients were admitted to our level II trauma center for treatment of head injury. Seventeen per cent (255/1,462) were diagnosed with ICH on initial head CT. Craniotomy was initially performed in 15.7 per cent (40/255) of patients with ICH. Two hundred sixteen patients with ICH were initially observed. Ninety-seven per cent (179/184) of observed patients with ICH and repeat head CT never underwent a craniotomy, 2.7 per cent (5/184) of patients with ICH initially observed underwent craniotomy after repeat head CT, and four patients (80%) had deteriorating neurologic status. Multivariate analysis revealed the following significant admission risk factors were associated with a need for repeat head CT indicating the need for craniotomy: treatment with anticoagulation and/or antiplatelet medications, elevated prothrombin time (PT), and age greater than 70 years. In patients with blunt traumatic intracranial hemorrhage initially observed, there is little utility of repeated head CT in the absence of deteriorating neurologic status. The only admission risk factors for a repeat CT indicating the need for craniotomy were advanced age and coagulopathy.
Adolescent↗
Preoperative oral rofecoxib and postoperative pain in patients after laparoscopic cholecystectomy: a prospective, randomized, double-blinded, placebo-controlled trial.
Cyclooxygenase-2 (COX-2) inhibitors are a class of drugs that may avoid some of the side effects of narcotics and nonsteroidal anti-inflammatory drugs (NSAIDs). We performed a randomized, double-blinded, placebo-controlled trial giving a single oral dose of the COX-2 inhibitor rofecoxib 25 mg or placebo preoperatively to determine the impact upon postoperative pain, complications, narcotic use, and hospital stay after laparoscopic cholecystectomy. Investigators and patients were blinded. Pain was measured on a 10-point visual analogue scale. Eighty patients were randomized: 40 to the rofecoxib group and 40 to the placebo group. The amount of pain between the two groups postoperatively was equivalent. Pain was recorded at 1 hour, 4.03 +/- 1.93 in the rofecoxib group versus 4.38 +/- 1.34 in the placebo group (P = 0.36); at 6 hours, 3.00 +/- 1.12 in the rofecoxib group versus 2.78 +/- 0.78 in the placebo group (P = 0.42); and at 24 hours, 1.64 +/- 0.67 in the rofecoxib group versus 2.68 +/- 1.90 in the placebo group (P = 0.17). The amount of pain medication received and lengths of hospital stay was not significantly different between the two groups. Our data demonstrate no significant benefit of preoperative oral rofecoxib in patients undergoing laparoscopic cholecystectomy.
Administration, Oral↗
Marathon pancreatitis: is the etiology repetitive trauma?
Abdominal pain frequently occurs after long-distance running. The cause of the pain may be due to dehydration, diaphragmatic ischemia, muscular spasm, or myonecrosis. However, data regarding the frequency of these purported causes are currently lacking. Pancreatitis can also occur after long-distance running, but few cases have been reported, and the etiology is controversial. We report a case of pancreatitis in a thin, muscular marathon runner. We suggest the etiology in this case may be traumatic as the pancreas may have suffered repetitive injury against the posterior abdominal wall and spine.
Adult↗
Local anesthetic infusion pumps improve postoperative pain after inguinal hernia repair: a randomized trial.
Pain after an open inguinal hernia repair may be significant. In fact, some surgeons feel that the pain after open repair justifies a laparoscopic approach. The purpose of this study was to determine if the use of local anesthetic infusion pumps would reduce postoperative pain after open inguinal hernia repair. We performed a prospective, double-blind randomized study of 45 open plug and patch inguinal hernia repairs. Patients were randomized to receive either 0.25 per cent bupivicaine or saline solution via an elastomeric infusion pump (ON-Q) for 48 hours, at 2 cc/h. The catheters were placed in the subcutaneous tissue and removed on postoperative day 3. Both groups were prescribed hydrocodone to use in the postoperative period at the prescribed dosage as needed for pain. Interviews were conducted on postoperative days 3 and 7, and patient's questionnaires, including pain scores, amount of pain medicine used, and any complications, were collected accordingly. During the first 5 postoperative days, postoperative pain was assessed using a visual analog scale. Twenty-three repairs were randomized to the bupivicaine group and 22 repairs randomized to the placebo group. In the bupivicaine group, there was a significant decrease in postoperative pain on postoperative days 2 through 5 with P values <0.05. This significant difference continued through postoperative day 5, 2 days after the infusion pumps were removed. Patients who had bupivicaine instilled in their infusion pump had statistically significant lower subjective pain scores on postoperative days 2 through 5. This significant difference continued even after the infusion pumps were removed. Local anesthetic infusion pumps significantly decreased the amount of early postoperative pain. Pain relief persisted for 2 days after catheter and pump removal.
Adolescent↗
Preoperative sestamibi localization combined with intraoperative parathyroid hormone assay predicts successful focused unilateral neck exploration during surgery for primary hyperparathyroidism.
A retrospective review of 54 cases of primary hyperparathyroidism operated upon by five general surgeons at Santa Barbara Cottage Hospital between March 1998 and March 2001 was performed to determine whether positive preoperative sestamibi localization (PSL) of a solitary adenoma combined with intraoperative parathyroid hormone assay (IOPHA) could predict successful focused unilateral neck exploration. A solitary adenoma was found in each of 50 patients (93%). PSL for solitary adenomas had an accuracy of 87 per cent, positive predictive value (PPV) of 96 per cent, sensitivity of 90 per cent, and specificity of 50 per cent. Forty-five patients (83%) achieved a 50 per cent reduction in IOPHA at 10 minutes after excision of a solitary adenoma for an accuracy of 85 per cent, PPV of 97 per cent, sensitivity of 88 per cent, and specificity of 50 per cent. All patients remain eucalcemic. The combination of PSL and IOPHA resulted in a PPV of 97.5 per cent and a sensitivity of 100 per cent. From these data we conclude that a focused unilateral neck exploration could have been performed successfully in 78 per cent of the cases.
Adenoma↗
Disability and chronic pain after open mesh and laparoscopic inguinal hernia repair.
Proponents of laparoscopic inguinal hernia repair maintain that the associated costs and risks are offset by faster recovery and less postoperative pain. It was our hypothesis that the incidence of chronic pain in both groups of our patients was not as high as reported in the literature. Patients for the study were identified from a community hospital medical record database. A total of 229 patients were available and agreed to participate in the study. Data collected included the patient's current pain level at the hernia site, pain medication currently used, narcotics currently used, return to normal work, and return to normal activity. Overall, 19.7 per cent of patients complained of mild pain, but only 2.2 per cent classified this as moderate or severe. Mild pain was noted more often in the open repair patients compared with the laparoscopic group. However, there was no difference in the frequency of moderate or severe pain. The time to return to work was longer in the open repair group than the laparoscopic repair group, but there were large ranges in both groups. The inability to return to full preoperative activity was infrequent and equivalent in both open and laparoscopic hernia repair groups. In our study of 229 patients undergoing elective open or laparoscopic inguinal hernia repair at a community hospital, we have found a low incidence of moderate or severe chronic pain. In addition, we found that this procedure did not interfere with return to work at 6 months or return to daily activities in either the laparoscopic or open repair group.
Activities of Daily Living↗
Appendicitis, 2002: relationship between payors and outcome.
As the status of health-care insurance changes in the United States, studies have indicated that uninsured patients are less likely to receive timely and quality health care. Previous studies of appendicitis have shown that insurance status may effect the stage of presentation and outcome. However, these studies were based on databases lacking information regarding stage of presentation, timeliness of diagnosis and treatment, and character of hospitalization (length of stay, duration of antibiotic therapy, hospital costs). We accomplished a case control study, retrospective analysis of 975 patients treated for acute appendicitis between January 1996 and December 1999. Times to operation, number of preoperative outpatient visits, number of studies, severity of presentation, length of antibiotics and hospital stay, and hospital costs were analyzed [analysis of variance (ANOVA) techniques, P < 0.05 significant]. We sought answers to the following: (1) Did insurance status affect the timeliness of diagnosis and treatment? (2) Did insurance status affect the stage of presentation? (3) Did insurance status affect hospitalization, as measured by length of stay, duration of antibiotic therapy, and hospital costs? (4) Did age affect outcome independent of insurance status? There were no correlations between insurance status and timeliness of diagnosis or severity of presentation. Length of stay and hospital costs were also not different between insurance categories. Pediatric patients (< 12 years old) and the elderly (> 65 years old) presented with more advanced appendicitis, independent of insurance category. In contrast to previously published data, the treatment of acute appendicitis is not affected by insurance coverage in the sample community. Age and timeliness of presentation were the only factors correlating to outcomes.
Adult↗
Does gallbladder ejection fraction predict pathology after elective cholecystectomy for symptomatic cholelithiasis?
Patients with symptomatic cholelithiasis are selected for elective cholecystectomy with the expectation that their symptoms will improve after operation. However, some patients fail to improve because their preoperative symptoms were not related to gallbladder disease. A test that would indicate the severity of gallbladder disease in patients with gallstones would therefore have great potential benefit. Twenty-five patients who presented as outpatients with episodic abdominal pain and gallstones were scheduled for elective cholecystectomy. On the day before operation patients underwent nuclear medicine cholescintigraphy with measurement of ejection fraction. All patients then underwent laparoscopic cholecystectomy. Pathologic specimens were reviewed by a pathologist who was blinded to the ejection fraction results and scored for degree of inflammation on a scale of zero to three. There was a wide range of ejection fractions measured (0-84%). There was, however, no correlation between ejection fractions and degree of gallbladder inflammation. We conclude that gallbladder ejection fraction does not predict the degree of gallbladder inflammation at the time of elective cholecystectomy. This test is therefore unlikely to predict which patients with cholelithiasis will have symptomatic relief after cholecystectomy.
Cholecystectomy, Laparoscopic↗