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Biomedical subjects

M D Kerstein

Publications and source records attributed to M D Kerstein.

At least 73 records · Page 4Linked to original sources
PubMed1996

Is the incidence of hemorrhagic stress ulceration in surgical critically ill patients affected by modern antacid prophylaxis?

Hemorrhagic stress ulceration (HSU), a known complication in the Surgical Intensive Care Unit (SICU) patient population, has a reported incidence rate of 25 to 75 per cent. The goal of this study was to evaluate whether the use of prophylactic antacid agents significantly reduced the frequency of HSU in critically ill patients, or whether improved care reflected the decrease in HSU. A total of 425 consecutive patients were reviewed for occurrence of HSU; of these, 304 were eligible for the study. Admitting diagnoses were trauma including head injury, postoperative patients, and patients with surgical complications. Inclusion criteria were length of stay in the SICU for at least 48 hours; antral gastric pH subsequently measured every 6 to 8 hours and maintained at > or = 4; and absence of the history of peptic ulcer disease or gastrointestinal bleeding. One group included 251 (83%) patients who were started on prophylactic agents (H2 blockers with or without antacids); the second group of 53 (17%) patients had no prophylaxis. The Injury Severity Score on admission to the SICU was 27.5 +/- 7.5, Apache II score was 26.4 +/- 6.4, and Revised Trauma Score was 4.3 +/- 2.3, with no difference in severity (P < 0.05). Thirteen (4%) patients were found to have evidence of HSU: 11 of 251 (4%) in the first group and 2 of 53 (4%) in the second. No statistically significant difference was found in the incidence of HSU between the two groups (P = 0.86). Results of this study suggest that modern prophylaxis for HSU did not significantly alter the incidence of stress ulceration in SICU patients.

Adolescent↗
PubMed1995

Are postoperative complications related to resident sleep deprivation?

This real-world study compares the outcome of surgery and the sleep-deprivation status of the resident surgeon. Residents who operated the day after a 24-hour on-call period were considered sleep deprived; all other resident surgeons were considered non-sleep-deprived. We retrospectively reviewed data on 6,371 surgical cases and identified 351 postoperative complications. The complication data were analyzed using logistic regression analysis, with outcome being the presence or absence of surgical complications. No statistically significant change in complication incidence was noted when the resident surgeon was sleep deprived.

Clinical Competence↗
PubMed1995

Vaginal evisceration.

An 89-year-old woman had small intestinal prolapse through the vagina while straining at stool. She had had a vaginal hysterectomy 24 years earlier. Resuscitation, reduction, and repair resulted in survival.

Aged↗
PubMed1995

Pharyngo-esophageal perforation due to blunt trauma.

Pharyngoesophageal perforation due to blunt external trauma is a relatively rare and unreported injury. A patient is presented with such an injury secondary to assault, and the modes of diagnosis and management are discussed.

Esophageal Perforation↗
PubMed1995

Cause of temporary closure of an inner-city trauma center.

The number of trauma admissions, types of injury, and reasons for temporary closure were studied. Trauma patients admitted numbered 1120 in 1991, 989 in 1992, and 1164 in 1993; blunt trauma accounted for 77 percent, 74 percent, and 80 percent, whereas penetrating trauma accounted for 23 percent, 26 percent, and 20 percent of the admissions by year, respectively. A mean of 81 percent of the blunt trauma studies were for head injuries. The trauma center closed for a total of 260 hours in 1991, 211 hours in 1992, and 240 hours during 1993. Of the total hours closed, the unavailability of computed tomography (CT) scanning due to mechanical reasons was the leading cause for closure, accounting for 59 percent of hours closed. Other reasons for closure included operating (OR) unavailability (33%), acute care beds full (3.4%), blood bank stock shortage (1.4%), insufficient OR nursing teams (0.6%), unavailability of anesthesiologists (0.5%), unavailability of surgical team (1.4%), and hospital water problems (1.4%). It is concluded that designated major trauma centers may need two available CT scanners if they have a greater than 75 percent blunt trauma admission rate, or greater than 500 blunt trauma patient admissions.

Efficiency, Organizational↗
PubMed1995

Treating wounds associated with decreased sensibility.

Neuropathic wounds are a problem most often associated with diabetes, particularly in those patients with decreased sensibility. More often than not, the patient is unaware of the insidious progression of dysfunction and its direct impact on tissue necrosis. Even when the underlying cause is discovered, often no mechanism is present to compensate for the loss of sensory protection. Current pharmacologic treatment for peripheral neuropathy is palliative with capsaicin and amitriptyline, used most frequently to treat symptoms of painful peripheral neuropathy. Orthotists and prosthetists are helpful in developing shoes or support devices to provide relief or lifts from weight-bearing areas in the insensate patient. Proper patient education and primary-care monitoring can greatly decrease the number of non-heating foot lesions and amputations.

Amitriptyline↗
PubMed1995

Barium and fecal impaction: an unusual case of bilateral hydronephrosis.

We present an interesting case report of the second adult female reported to suffer from bilateral ureteral hydronephrosis, secondary to a fecal impaction, and the first caused by complications from residual barium. This elderly patient suffers from many associated neurologic, bowel, and urinary tract problems; this case report demonstrates their close proximal relationship. Through ureteral stent placement and manual disimpaction of the barium fecaloma, the patient was able to recover her normal renal and bowel functions. Aided by the use of excellent figures, it is our intent to inform physicians that they should consider fecal impaction as a cause for bilateral ureteral hydronephrosis in predisposed patients, and also the necessity of purging the GI tract of residual barium following radiologic studies.

Aged↗
PubMed1995

Neuropathic wounds.

Neuropathic wounds commonly seen in the diabetic patient are particularly challenging diagnostic and management entities. An overview of this disorder along with clinical manifestations and treatment options are discussed.

Diabetic Foot↗
PubMed1995

A more cost-effective use of medical air evacuation personnel.

Air transport of severely traumatized patients has evolved from novel pilot programs into integral services provided by tertiary care health centers. Medical air evacuation (MedEvac) effectiveness is mainly due to the rapid transport of critically injured (90% blunt trauma) patients to the hospital by highly trained medical personnel. A recent self-study of a University-based MedEvac crew showed that 67 per cent of their on-duty time was "available." Only 33 per cent of duty time was flying or related patient care. In this era of cost containment, the optimal use of materials and services must be reassessed. The most cost-effective use of the crew may require expanding the role of the MedEvac to include Emergency Department responsibilities as part of the job description. This represents change and stressful group dynamics. However, by coordinating the Emergency Department and MedEvac schedules, the hospital is able to make more efficient use of resources. No flight was delayed by this work proposal.

Aircraft↗
PubMed1995

Moist wound healing: the clinical perspective.

Wound dressings can have a profound effect on the repair process and patient quality of life. Topical treatment modalities have been found to influence reepithelialization, granulation tissue formation, the degradation of fibrin and necrotic tissue, the incidence of wound infections, the pH of the wound as well as airborne dispersal of bacteria, pain and cost of care. Clinical studies have shown that, compared to conventional gauze, most moisture-retentive dressings will reduce time to healing, the rate of wound infections, patient pain and the cost of care. However, clinical studies have also revealed differences among some of the moisture-retentive dressings available today. As our knowledge about the effect of wound care interventions continues to expand, treatment decisions should be made based on the results of controlled clinical studies.

Humans↗
PubMed1995

Relationship of runoff vessels to results following thrombolysis and revascularization for synthetic graft occlusions.

The objective of this study was to evaluate the relation between runoff vessels and the prognosis in patients who have had an occlusion of a previously placed peripheral arterial bypass graft. Over a 4-year period 77 occluded synthetic grafts were treated with urokinase and reconstruction after angiographic study. Follow-up ranged from 1 to 1627 days. The cases were divided into three groups according to the number of patent tibial vessels. Group I consisted of patients who had no vessel runoff. Group II consisted of patients who had single vessel runoff. Group III consisted of patients who had two or three runoff vessels. In Group I, the 1, 2, and 3-year patency rates were 35.8%, 8.9%, and 8.9%; and the limb salvage rates were 50.2%, 40.2%, and 40.2% for 1, 2, and 3 years, respectively. The Group II patency rates were 31.2%, 26.0%, and 13.0% and the limb salvage rates were 72.3%, 62.9%, and 62.9%. The Group III patency rates were 50.0%, 26.1%, and 20.9%; and the limb salvage rates were 93.1%, 79.1%, and 79.1%. There is no statistically significant difference in patency rates among any of the groups. The limb salvage rate was significantly increased in Group III, compared to I (P < 0.01) and Group II (P < 0.05), and in Group II, compared to Group I (P < 0.05). These results indicate that the higher rate of limb salvage in this study statistically correlated with the number of runoff vessels.

Adult↗
PubMed1995

Venous injury: to repair or ligate, the dilemma revisited.

Controversy continues over management of major venous injuries. The records of 322 patients with venous injury were reviewed. Isolated venous injury was present in 83 patients; 54 (65%) underwent ligation of the injured vein. Combined arterial and venous injuries were present in 239 patients; 170 (71%) patients had ligation. Injured were the inferior vena cava, iliac, femoral, popliteal, distal leg, and arm veins; all were confirmed at surgery. Arterial injuries were repaired with standard techniques; venous injuries were ligated or repaired by end-to-end or lateral phleborrhaphy. Adjunctive fasciotomy was used as clinically indicated. The patients were followed an average of 32 months. No patient with isolated venous injury developed permanent sequelae, although 29 (35%) had transient extremity edema. Transient edema developed in 86 (36%) patients with combined injury, and permanent edema occurred in 4 (2%). Edema developed regardless of vein injury ligation or repair. No extremity was lost after venous injury ligation. While repair of all venous vascular injuries is still the surgical ideal, in civilian practice permanent sequelae of venous injury ligation are rare and in patients with hemodynamic instability from blood loss, extensive local injury, associated organ injury, anesthesia requirements, or other concerns venous ligation is acceptable.

Adolescent↗
PubMed1995

Venous injuries: military versus civilian experience.

The acute management of venous injuries remains a controversial topic among practicing surgeons. A literature review encompassing the last half century was performed to clarify the different philosophies proposed in the operative treatment of venous injuries. From a military perspective, the Vietnam Vascular Registry provided the largest single military experience and follow-up of venous injuries to date. The data presented support the concept of the importance of venous repair in attempts at limb salvage when faced with a high-velocity missile wound. The civilian experience (1960-1992) supports the notion that venous ligation in particular circumstances results in little, if any, added morbidity to the patient and may be life-saving in certain instances. The two basic viewpoints are reviewed with regard to pertinent literature and conclusions drawn from these data.

Firearms↗
PubMed1995

The Navy Nurse and combat with a focus on the casualty processing unit.

This article describes a flexible and versatile tri-care triage medical system within a combat arena in which the Navy nurse, integrating with other factions of the military, provided the injured sailor and Marine consistent and optimal care. A systemized approach to casualty flow created a simple, multi-purposed, and accelerated system that proved effective to both fighting troops and military operations. Personal experiences in the Desert Storm arena focused on the advantage of short-distance evacuations.

Humans↗
PubMed1994

Prospective, multicenter study of managing lower extremity venous ulcers.

Seventy patients with 90 venous ulcers were randomly assigned to hydrocolloid or conventional dressing and compression therapy at four study centers. The ulcers had been present for a mean of 47.8 in the control and 46.2 weeks in the treatment group and 42% of all patients had recurrent ulcers. Ulcers treated with hydrocolloid dressings reduced 71% and control treated wounds reduced 43% in area after 7.2 weeks of treatment. Thirty-four percent of all ulcers healed. Mean time to healing was 7 weeks for the hydrocolloid dressing group and 8 weeks for the control group. Most ulcers were less painful at final evaluation, but reduction in pain was more pronounced in hydrocolloid-dressed ulcers (p = 0.03). At baseline as well as during follow-up, significant differences between study centers were observed. Ulcers in patients in the United Kingdom were larger and less likely to heal (p = 0.001). Size of the ulcer at baseline was associated with treatment response and time to healing (p = 0.002). Percent reduction in ulcer area after 2 weeks was also correlated with treatment outcome (p = 0.004) and time to healing (p = 0.002). When all treatment outcome predictors were analyzed together, only percent reduction in area after 2 weeks remained statistically significant (p = 0.002), with percent reduction during the first 2 weeks of treatment > 30% predicting healing.

Aged↗
PubMed1994

Overview of wound healing in a moist environment.

Maintaining a moist wound environment facilities the wound-healing process. The beneficial effects of a moist versus a dry wound environment include: prevention of tissue dehydration and cell death, accelerated angiogenesis, increased breakdown of dead tissue and fibrin, i.e., pericapillary fibrin cuffs, and potentiating the interaction of growth factors with their target cells. In addition, pain is significantly reduced when wounds are covered with an occlusive dressing. Concerns that moisture in wounds would increase the risk of clinical infection over traditional therapies are unfounded. The use of hydrocolloid occlusive dressings in maintaining a moist wound environment has proved to be a useful adjunct in facilitating wound healing.

Humans↗