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Biomedical subjects

Mary-Margaret Brandt

Publications and source records attributed to Mary-Margaret Brandt.

16 recordsLinked to original sources
PubMed2005

Diagnosis and management of bile leaks after blunt liver injury.

BACKGROUND: Nonoperative management (NOM) of blunt liver injuries (BLIs) is common, but little data exist on the management of complications related to NOM. Furthermore, bile leaks are emerging as frequent complications of NOM. The goal of this study was to determine which BLI patients are at greatest risk for bile leaks and how to manage this complication. METHODS: Patients treated with NOM, including angiographic embolization (AE) and observation, were compared with those undergoing operation (OR). Mortality, hospital length of stay, liver-related complications, and severity of liver injury were compared among the groups. RESULTS: Two hundred eighty-one patients sustained a BLI from 1997 through 2004. The Injury Severity Score and age of the groups were similar. The mortality rate of the OR patients was higher (P = .02). All bile leaks occurred in patients with a liver Abbreviated Injury Score (AIS) of > or = 4. For survivors of more than 4 days, 71% of OR, 50% of AE, and 17% of observed patients developed bile leaks. For the OR and AE groups, HIDA scanning detected all leaks, leading to earlier drainage procedures. Detection of a bile leak in NOM patients before 5 days of hospitalization led to shorter HLOS, P = .02. No patient with a negative HIDA scan developed a subsequent bile leak. CONCLUSIONS: NOM of BLIs is associated with lower mortality, but significant complications. Bile leaks are more common in patients with higher liver AIS, and in this study presented in only those with liver AIS > or = 4. HIDA scanning successfully diagnosed all patients with bile leaks and led to less invasive drainage procedures over time and shorter HLOS.

Adult↗
PubMed2004

Delayed repair for blunt thoracic aortic injury: is it really equivalent to early repair?

BACKGROUND: Blunt thoracic aortic injury (BTAI) is a severe injury that traditionally has mandated immediate surgical repair. Delaying operative intervention for BTAI can allow other life-threatening injuries to be managed first, but potentially increases the risk of aortic rupture and death. The objective of this study was to evaluate the outcome of delayed repair (DR) compared with early repair (ER) for BTAI and to assess the effectiveness of a protocol for medical control of systolic blood pressure and heart rate in those patients whose repairs were delayed. METHODS: This study is a retrospective review of University of Michigan Health System (UMHS) data from January 1, 1992, through March 1, 2003. ER was defined as operative repair within 16 hours from the time of injury. A similar analysis was conducted for patients with BTAI selected from the National Trauma Data Bank. RESULTS: For the UMHS data, there were 45 patients in the DR group and 33 patients in the ER group. Mortality in the ER group versus the DR group was 9% versus 20%. Multivariate analysis adjusting for age, Injury Severity Score, abdominal Abbreviated Injury Scale score, Glasgow Coma Scale score, and intubation status demonstrated an odds ratio for death from ER compared with DR of 1.72 (p = 0.57). Patients undergoing DR had an absolute increase in hospital length of stay (33.1 vs. 20.9 days) and complication rate (2.1 vs. 1.5 incidents per patient). A similar result was obtained for multivariate analysis of the National Trauma Data Bank data, with an odds ratio of 1.40 (p = 0.51) for death from ER versus DR. UMHS patients whose repairs were delayed achieved target systolic blood pressure and heart rate for 76% and 74% of the hourly measurements recorded, respectively. CONCLUSION: Patients with BTAI can safely undergo delayed aortic repair if other injuries warrant a higher treatment priority without increasing their overall risk of mortality. Delayed repair is, however, associated with a higher complication rate.

Adult↗
PubMed2004

Beta-blocker use is associated with improved outcomes in adult burn patients.

BACKGROUND: There is no direct evidence that beta-blockers improve mortality in burn victims. Beta-blockers attenuate hypermetabolic states in burned children, and perioperative use in elective adult cases has beneficial effects, which suggests that beta-blockers may also improve burn outcomes. However, beta-blockers decrease cardiac output and may decrease oxygen delivery, and theoretically may increase mortality. What is the effect of beta-blockers on healing time and mortality in burn patients? METHODS: This was a retrospective cohort study. We identified three cohorts of adult burn patients between 1996 and 2001: all who were on beta-blockers (BB) before their injury (PMH BB); all who were initiated on BB during their hospitalization for management of hypertension or tachyarrhythmia (HOSP BB); and control, who were never treated with beta-blockers. For each patient in the PMH BB and HOSP BB groups, two patients were placed in the control cohort by matching age and total body surface area burn. Premorbid conditions such as diabetes, hypertension, cardiac disease, renal insufficiency, and diuretic and calcium channel blocker use were analyzed. Multivariate regression models were used to identify independent modifiers. RESULTS: There were 21 PMH BB, 22 HOSP BB, and 86 control patients. All PMH BB patients remained on their BB regimen in the hospital. HOSP BB patients were initiated on beta-blockers at a mean of 8.8 days postinjury. There were no differences in age (mean, 58 +/- 17 years), total body surface area burned (mean, 14 +/- 12%), or mechanism of injury among the cohorts. The mortality rate was 5% for the PMH BB cohort, 27% for the HOSP BB cohort, and 13% for controls. The mean healing times were 51 +/- 29 days for PMH BB patients, 79 +/- 54 days for HOSP BB patients, and 60 +/- 39 for controls. In multivariate analyses, PMH BB was associated with a significant decrease in fatal outcome and healing time (p < or = 0.05 compared with control). CONCLUSION: Beta-blockers have the potential to improve adult burn outcomes. Postinjury treatment should be studied in a randomized, clinical trial.

Adrenergic beta-Antagonists↗
PubMed2004

Computed tomographic scanning reduces cost and time of complete spine evaluation.

BACKGROUND: We hypothesize that data collected from computed tomographic (CT) scans obtained for workup of chest or abdominal injuries provide data that are sufficient to screen for spinal fractures and will decrease the cost and time of spine evaluation after trauma. METHODS: We reviewed plain radiographs from 55 selected trauma patients who also underwent CT scanning of the chest, abdomen, and pelvis. We also timed the radiologic workup of 50 consecutive trauma patients to determine the time required to complete radiographic spine evaluation. RESULTS: Forty-seven patients had thoracolumbar fractures. Thirteen patients were found to have 33 thoracolumbar spine fractures identified by CT scan but not plain radiography. Fractures were found on initial trauma CT scans of the chest, abdomen, and pelvis obtained to evaluate for visceral injuries. No injuries seen on plain film were missed on CT scan. CONCLUSION: We recommend using the data acquired from CT scans to evaluate the spine, supplementing them with additional studies only when needed for further clarification.

Accidental Falls↗
PubMed2003

Normal D-dimer levels do not exclude thrombotic complications in trauma patients.

BACKGROUND: Deep venous thrombosis (DVT) and pulmonary embolism (PE) are common complications in trauma patients. These diagnoses can be difficult and expensive to make. Recent studies report that a negative D-dimer test excludes thrombotic complications. We questioned the predictive value of a D-dimer test to exclude DVT and PE. METHODS: Adult trauma patients admitted March 1999 to March 2001, with an Injury Severity Score > or =9 and expected length of stay >3 days, were approached for enrollment. Bilateral lower extremity duplex ultrasounds and d-dimer levels were performed within 36 hours of admission, day 3-4, day 7, and weekly until discharge. RESULTS: Twenty-three patients were diagnosed with DVTs, with 18 DVTs detected within the first week of admission. Five DVT patients had normal D-dimer levels. One of three PE patients tested had a normal D-dimer level. The false negative rate for DVT by d-dimer assay was 24%, and the sensitivity was 76%. The negative predictive value for D-dimers was 92%. All false negative d-dimer tests occurred in patients diagnosed with DVT or PE within the 4 days after admission. CONCLUSION: In the early postinjury phase, a negative d-dimer test does not exclude DVT or PE. However, the negative predictive value of a D-dimer test after the first 4 days from admission rose to 100%. Patients with clinical signs and symptoms of DVT or PE in the immediate postinjury phase should undergo further screening to exclude thromboembolic complications.

False Negative Reactions↗
PubMed2003

Does bronchoalveolar lavage enhance our ability to treat ventilator-associated pneumonia in a trauma-burn intensive care unit?

BACKGROUND: Recent literature supports the notion that bronchoalveolar lavage (BAL) in ventilated trauma patients may improve our ability to diagnose and treat ventilator-associated pneumonia (VAP). We hypothesized that BAL would decrease the number of cases of VAP diagnosed and impact our antibiotic use and ventilator days. METHODS: Prospective data on all infectious complications were collected for patients admitted to the trauma-burn service for the year 2001. All VAPs between January 1, 2001, through June 30, 2001, were diagnosed without BAL (No BAL group) using clinical signs of fever, sputum production, leukocytosis, chest radiographs, and sputum culture. After July 1, 2001, VAP was diagnosed with the use of BAL. RESULTS: There were 37 cases of VAP in the No BAL group (11%) and 29 cases of VAP (8%) in the BAL group. There were no statistical differences in Injury Severity Score, hospital length of stay, ventilator days, or mortality between the two groups. The time to initial treatment of VAP was shorter for the BAL group, but did not reach significance. The number of patients who had their VAP pathogens correctly treated with empiric antibiotics was also the same between the two groups. There was no difference in the rate of recurrent pneumonias. The antibiotic costs and respiratory therapy/ventilator costs were not statistically different between the groups for trauma patients, although antibiotic costs were higher for burn patients. CONCLUSION: The routine use of BAL to diagnose VAP in our mixed trauma-burn population did not impact on clinical outcomes or antibiotic use. Our results do not justify the additional costs and potential risks of BAL for all patients. The means of VAP diagnosis may not be as important as choosing the appropriate antibiotics for common VAP organisms in any given intensive care unit.

Adult↗
PubMed2003

Liberal use of CT scanning helps to diagnose appendicitis in adults.

Appendicitis can be difficult to diagnose as patients get older and the incidence of other intra-abdominal processes increases. We hypothesize that with the use of helical computed tomography (CT), we will be better at diagnosing appendicitis in adults. We reviewed all the medical records of patients 18 years and older who were admitted to our service with the diagnosis of appendicitis (ICD-9: 540.0, 540.1, 540.9, and 541) from January 1999 through October 2002. In addition to demographics, we collected pathology results, if CTs were done, and CT results. This study was approved by the Institutional Review Board (IRB) of the University of Michigan. Three hundred thirty patients with the diagnosis of appendicitis were admitted to our service. We found the negative appendectomy rate in all patients to be 12.1 per cent. In all patients who had CT scans, the negative appendectomy rate was 7.3 per cent. In patients > or = 45 years, patients without CT had 5.6 per cent negative appendectomy rate versus 5 per cent (P = 0.02) with CT scanning. There were no mortalities. Our negative appendectomy rate in adult patients is lower than previously published reports. We believe our high rate of CT scanning helped in making the correct diagnosis. We recommend liberal use of CT scanning to help diagnose appendicitis in adults.

Adolescent↗
PubMed2002

Antiplatelet therapy: an alternative to heparin for blunt carotid injury.

BACKGROUND: Blunt carotid injuries (BCIs) are uncommon. Most single-center studies are small and highlight the use of anticoagulation for treatment. In a retrospective review, we identified 22 patients who presented with BCI and assessed neurologic and survival outcomes on the basis of injury grade and treatment with anticoagulation or antiplatelet therapy. METHODS: Patient demographics were identified using the trauma registry at a single Level I trauma center. Chart reviews assessed neurologic function, modalities used for diagnosis, and treatment. Neurologic outcomes were graded good (minimal to no deficit), fair (moderate deficit needing some assistance), poor (requiring institutionalization), and dead. RESULTS: Twenty-two adult trauma patients were diagnosed with BCI, for an incidence of 0.45% in the 8-year study period. All BCI patients underwent head computed tomography and four-vessel cerebral arteriography. Eight patients were not anticoagulated, five because of intracranial injuries, two who had surgical CCA repairs, and one with an aortic injury. Full anticoagulation with heparin was attempted in seven patients, with four major bleeding complications requiring cessation of heparin and blood transfusions. Seven patients received antiplatelet therapy. No difference in neurologic outcome was observed between those receiving anticoagulation and those receiving antiplatelet therapy. Bleeding complications from full anticoagulation were higher than with antiplatelet agents (p = 0.05). CONCLUSION: Contrary to previous reports, we did not observe improved outcomes with full anticoagulation compared with antiplatelet therapy. Anticoagulation was associated with increased extracranial bleeding complications. The risks and possible benefits, as well as timing, of anticoagulation or antiplatelet therapy for BCI should be carefully weighed by the major care providers of the patient with multiple injuries.

Adult↗
PubMed2002

The need for early angiographic embolization in blunt liver injuries.

BACKGROUND: Although nonoperative management of blunt liver injury (BLI) has become standard practice, adjuncts to nonoperative therapy, such as angiographic embolization, have not been well characterized. METHODS: Patients with BLI were retrospectively identified at our American College of Surgeons-verified Level I trauma center from January 1997 through February 2001. Patients were stratified into four groups: those who received angiographic embolization (AE) as an early intervention when BLI was initially diagnosed (EARLY-AE); those who underwent AE after liver-related operation or later in the hospital course (LATE-AE); those treated with operation only (OR-ONLY); and nonoperative patients who also did not undergo AE (NO-OR). RESULTS: There were 126 patients with BLI, of whom 94 were NO-OR, 20 were OR-ONLY, 6 had LATE-AE, and 6 had EARLY-AE. The NO-OR group had significantly lower liver Abbreviated Injury Scale scores. Liver Abbreviated Injury Scale scores were not different between the EARLY-AE, LATE-AE, and OR-ONLY groups. Liver-related mortality was not lower for those treated with AE. There was a trend toward lower mortality for just the EARLY-AE group compared with the LATE-AE and OR-ONLY groups (0% vs. 50% and 35%). The number of units of packed red blood cells transfused and the number of liver-related operations were lower in the EARLY-AE compared with the LATE-AE group, but liver-related complications were not different between the EARLY-AE, LATE-AE, or OR-ONLY groups. AE was successful in arresting hemorrhage in 83% of the cases. CONCLUSION: In this small series, we observed similar morbidity and mortality with AE compared with operative therapy. EARLY-AE did decrease blood use and the number of liver-related operations. AE can be performed on severely injured patients with comparable liver-related mortality and complications. Further study of the timing of and outcomes from AE is needed.

Adult↗
PubMed2002

Decreased juvenile arson and firesetting recidivism after implementation of a multidisciplinary prevention program.

OBJECTIVES: In 1999, we developed the multidisciplinary Trauma Burn Outreach Prevention Program (TBOPP), which focuses on the medical and societal consequences of firesetting behavior. The basis for this program development was a 17% increase in pediatric burn admissions. The purpose of this study was to determine the value of this trauma burn center prevention program from a financial, clinical, and recidivism perspective. METHODS: Juveniles (ages 4-17 years) were enrolled into our 1-day program on the basis of referrals from the county court system, fire departments, schools, and parents. The program's interactive content focuses on the medical, financial, legal, and societal impact of firesetting behavior, with emphasis on individual accountability and responsibility. The court system and fire departments tracked all episodes of firesetting behavior within their respective communities. Arson is defined as behavior with the intent to produce damage, whereas firesetting is defined as having no ill intent. The recidivism rate was determined using fire department and court follow-up records. Follow-up was from 8 months to 2.5 years. A random control group that did not receive TBOPP education (noTBOPP group) with identical entry criteria was used for comparison. Institutional review board approval was obtained. RESULTS: There were 132 juveniles in the TBOPP group (66 arsonists and 66 firesetters) and 102 juveniles in the noTBOPP group (33 arsonists and 66 firesetters). Fifty-nine TBOPP participants had a medical history of behavioral disorders. Property damage for arson averaged $4,040, with additional court costs of $1,135 per incident. Family environment was an independent predictor for risk of repeat offense. The odds ratio for risk of repeat offense in foster care was 17.9 (p < 0.05) as compared with two-parent homes. The recidivism rate was 1 of 32 (<1%) for the TBOPP group and 37 of 102 (36%) for the noTBOPP group (adjusted odds ratio, 0.02; p < 0.001). CONCLUSION: When compared with the noTBOPP group, TBOPP participants had essentially no recidivism. The financial impact of arson behavior was over $6,000 per incident. The implementation of a juvenile firesetting prevention program has demonstrable benefits to the participants and to society.

Adolescent↗
PubMed2002

Hospital cost is reduced by motorcycle helmet use.

BACKGROUND: The purpose of this study was to identify the impact of motorcycle helmet use on patient outcomes and cost of hospitalization, in a state with a mandatory helmet law. METHODS: Patients admitted after motorcycle crashes from July 1996 to October 2000 were reviewed, including demographics, Injury Severity Score, length of stay, injuries, outcome, helmet use, hospital cost data, and insurance information. Statistical analysis was performed comparing helmeted to unhelmeted patients using analysis of variance, Student's test, and regression analysis. RESULTS: We admitted 216 patients: 174 wore helmets and 42 did not. Injury Severity Score correlated with both length of stay and cost of hospitalization. Mortality was not significantly different in either group. Failure to wear a helmet significantly increased incidence of head injuries (Student's test, p < 0.02), but not other injuries. Helmet use decreased mean cost of hospitalization by more than $6,000 per patient. CONCLUSION: Failure to wear a helmet adds to the financial burden created by motorcycle-related injuries. Therefore, individuals who do not wear helmets should pay higher insurance premiums.

Accidents, Traffic↗
PubMedDate not supplied

Burn centers should be involved in prevention of occupational electrical injuries.

Electrical injuries are uncommon, comprising 10% of our regional burn center admissions during a 9-year period. The purpose of this study was to determine the incidence, type, and location of occupation-related electrical injuries in an attempt to focus our injury prevention and outreach efforts. We retrospectively reviewed the medical records of patients with electrical injuries admitted to our burn center from January 1992 through March 2000, with focused analysis on those patients admitted with occupation-related electrical injuries. Of the 95 patients admitted for electrical burns, 81% (n = 77) were occupational injuries. This rate of injury suggests that prevention efforts should be directed at work sites and partnerships should be developed between burn centers and businesses to reduce the incidence of injuries.

Accidents, Occupational↗
PubMedDate not supplied

The utility of D-dimer levels in screening for thromboembolic complications in burn patients.

Recent studies confirm that thromboembolic complications in burn patients are higher than previously reported. Swelling, pain, and erythema are not useful indicators of deep venous thrombosis (DVT) in burned extremities. We propose that D-dimer levels may be useful in determining which patients would benefit from further screening for DVT. Thirty adult hospitalized burn patients were screened for DVT with duplex ultrasound on admission and then weekly until discharge. D-dimer levels were measured at the same intervals. Seven patients developed 11 cases of DVT. The mean time to DVT diagnosis was 6.7 days. D-dimer levels were elevated in 86% of DVT patients at week 1, with a negative predictive value of 94%. The evaluation of elevated D-dimer levels at week 1 may be a useful screening tool for detecting DVT in the burn population.

Adult↗
PubMedDate not supplied

Bronchoalveolar lavage in diagnosis of ventilator-associated pneumonia in patients with burns.

Ventilator-associated pneumonia (VAP) remains a major cause of morbidity and mortality for patients with burns. In nonburn populations, bronchoalveolar lavage (BAL) excludes other pathology such as systemic inflammatory response syndrome. We hypothesized that BAL would decrease our false-positive VAP rate. All ventilated patients with burn injury who were admitted to our institution from July 2000 through June 2003 were included. After June 2001, BAL was used to make the diagnosis of VAP, with > or =10(4) organisms considered a positive result. Fifty patients met criteria for VAP, 21 in the pre-BAL period and 29 in the BAL period. Six patients (21%) in the BAL group had quantitative cultures <10(4) and were not treated. The outcomes for these patients were not different than those treated for VAP. There were no differences in age, TBSA size, antibiotic use, or ventilator days for the pre-BAL or BAL groups, although the pneumonia rate was lower for the BAL time period. The use of BAL eliminated the unnecessary antibiotic treatment of 21% of patients in the BAL time period and was associated with a lower rate of VAP.

Adolescent↗
PubMedDate not supplied

Burn support for Operation Iraqi Freedom and related operations, 2003 to 2004.

Thermal injury historically constitutes approximately 5% to 20% of conventional warfare casualties. This article reviews medical planning for burn care during war in Iraq and experience with burns during the war at the US Army Burn Center; aboard the USNS Comfort hospital ship; and at Combat Support Hospitals in Iraq and in Afghanistan. Two burn surgeons were deployed to the military hospital in Landstuhl, Germany, and to the Gulf Region to assist with triage and patient care. During March 2003 to May 2004, 109 burn casualties from the war have been hospitalized at the US Army Burn Center in San Antonio, Texas, and US Army Burn Flight Teams have moved 51 critically ill burn casualties to the Burn Center. Ten Iraqi burn patients underwent surgery and were hospitalized for up to 1 month aboard the Comfort, including six with massive wounds. Eighty-six burn casualties were hospitalized at the 28th Combat Support Hospital for up to 53 days. This experience highlights the importance of anticipating the burn care needs of both combatants and the local civilian population during war.

Burn Units↗