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Biomedical subjects

R H Bower

Publications and source records attributed to R H Bower.

At least 19 recordsLinked to original sources
PubMed1999

Patterns of morbidity and resource consumption associated with laparoscopic cholecystectomy in a VA medical center.

BACKGROUND: The generally low incidence of morbidity and reduced rate of health care resource consumption commonly associated with laparoscopic cholecystectomy (LC) have been established from studies of patient populations which are distinct from that served by the Department of Veterans Affairs (VA) health care system. We sought to assess the outcomes of this procedure when performed on VA beneficiaries. MATERIALS AND METHODS: Demographic and perioperative data for all patients undergoing attempted LC in our facility were recorded in a prospective database beginning 1 January 1993. The information in this registry was analyzed to determine the demographics of the treated population, the spectrum of biliary tract disease encountered, and patterns of morbidity and resource consumption. RESULTS: LC was attempted in 141 cases. Median patient age was 62 years. The indication for surgery was either acute cholecystitis or biliary pancreatitis in 63 cases (45%). Thirteen patients (9%) developed major complications. These patients were significantly older (mean age 68 vs 59 years) than patients whose course was uncomplicated. Twenty-seven cases (19%) required conversion to an open procedure, most commonly for acute cholecystitis. Progressive cholecystitis was associated with a conversion rate of 64%. Both conversion and the development of a major complication produced significant increases in length of stay. CONCLUSIONS: The population undergoing attempted LC in the VA system is characterized by relatively advanced age and high incidences of comorbid illness and complicated biliary tract disease. These attributes increase the frequency of major morbidity and of conversion to open cholecystectomy, which in turn increase resource consumption. Comparisons between the outcomes of attempted LC in VA centers and "benchmark" results obtained in other settings should be controlled for these factors.

Acute Disease↗
PubMed1997

Implementation of a clinical pathway decreases length of stay and hospital charges for patients undergoing total colectomy and ileal pouch/anal anastomosis.

BACKGROUND: Clinical pathways are increasingly being used by hospitals to improve efficiency in the care of certain patient populations; however, little prospective data are available to support their use. This study examined whether using a clinical pathway for patients undergoing ileal pouch/anal anastomosis, a complex procedure in which we had extensive practical experience, affected hospital charges or length of stay (LOS). METHODS: A clinical pathway was developed to serve patients undergoing elective total colectomy and ileal pouch/anal anastomosis. All operations were performed by two attending physicians (J.E.F., M.S.N.). Before implementation, 10 pilot patients were prospectively monitored to ensure that hospital charges were accurately generated. In addition, charge audits were performed by an outside agency to verify the accuracy of the hospital bills. The pathway was then implemented, and 14 patients were prospectively analyzed. RESULTS: In all patients the principal diagnosis was ulcerative colitis, with the exception of three patients with familial polyposis. Mean external audit charges were within 2% of the hospital bills; therefore the hospital bills were used in all calculations. The mean LOS decreased from 10.3 days to 7.5 days (p = 0.046) for patients on the pathway versus pilot patients. Mean hospital charges also decreased significantly, from $21,650 to $17,958 per patient (p = 0.005). CONCLUSIONS: Implementation of a clinical pathway, even for an operation in which the surgeon has much experience, is an effective method for reducing LOS and charges for patients. This is likely the result of interdisciplinary cooperation, elimination of unnecessary interventions, and streamlined involvement of ancillary services. These results support the development of clinical pathways for procedures that involve routine preoperative and postoperative care. In addition, the benefits of clinical pathways should increase proportionally with increasing case volume for a particular procedure.

Adenomatous Polyposis Coli↗
PubMed1995

Early enteral administration of a formula (Impact) supplemented with arginine, nucleotides, and fish oil in intensive care unit patients: results of a multicenter, prospective, randomized, clinical trial.

OBJECTIVE: To determine if early enteral feeding, in an intensive care unit (ICU) patient population, using a formula supplemented with arginine, dietary nucleotides, and fish oil (Impact), results in a shorter hospital stay and a reduced frequency of infectious complications, when compared with feeding a common use enteral formula (Osmolite.HN). DESIGN: A prospective, randomized, double-blind, multicenter trial. SETTING: ICUs in eight different hospitals. PATIENTS: Of 326 patients enrolled in the study, 296 patients were eligible for analysis. They were admitted to the ICU after an event such as trauma, surgery, or sepsis, and met a risk assessment screen (Acute Physiology and Chronic Health Evaluation II [APACHE II] score of > or = 10, or a Therapeutic Intervention Scoring System score of > or = 20) and study eligibility requirements. Patients were stratified by age (< 60 or > or = 60 yrs of age) and disease (septic or systemic inflammatory response syndrome). INTERVENTIONS: Patients were enrolled and full-strength tube feedings were initiated within 48 hrs of the study entry event. Enteral feedings were advanced to a target volume of 60 mL/hr by 96 hrs of the event. One hundred sixty-eight patients were randomized to receive the experimental formula, and 158 patients were randomized to receive the common use control formula. MEASUREMENTS AND MAIN RESULTS: Both groups tolerated early enteral feeding well, and the frequency of tube feeding-related complications was low. There were no significant differences in nitrogen balance between groups on study days 4 and 7. Patients receiving the experimental formula had a significant (p = .0001) increase in plasma arginine and ornithine concentrations by study day 7. Plasma fatty acid profiles demonstrated higher concentrations of linoleic acid (p < .01) in the patients receiving the common use formula and higher concentrations of eicosapentaenoic and docosahexaenoic acid (p < .01) in the patients receiving the experimental formula. The mortality rate was not different between the groups and was significantly (p < .001) lower than predicted by the admission severity scores in both feeding groups. In patients who received at least 821 mL/day of the experimental formula, the hospital median length of stay was reduced by 8 days (p < .05). In patients stratified as septic, the median length of hospital stay was reduced by 10 days (p < .05), along with a major reduction in the frequency of acquired infections (p < .01) in the patients who received the experimental formula. In the septic subgroup fed at least 821 mL/day, the median length of stay was reduced by 11.5 days, along with a major reduction in acquired infections (both p < .05) in the patients who received the experimental formula. CONCLUSIONS: Early enteral feeding of the experimental formula was safe and well tolerated in ICU patients. In patients who received the experimental formula, particularly if they were septic on admission to the study, a substantial reduction in hospital length of stay was observed, along with a significant reduction in the frequency of acquired infections.

APACHE↗
PubMed1994

The effect of thrombocytosis on serum potassium and phosphorus concentrations.

Thrombocytosis is a cause of falsely elevated serum potassium concentrations, and phosphorus concentrations may be similarly distorted. Because plasma concentrations are not affected, the difference between the serum and plasma concentrations detects spurious elevations. The authors, in this study, sought to determine the degree of correlation between thrombocytosis and false elevations in serum potassium and phosphorus concentrations. Ninety-one general, medical/surgical patients with elevated platelet counts were identified by laboratory reports. Subjects were stratified into blocks by platelet count. Samples were obtained simultaneously for serum and plasma potassium and phosphorus concentrations and complete blood counts. The serum minus plasma concentrations for potassium (Kdiff) and phosphorus (Pdiff) were calculated and analyzed against each other and the platelet count by linear regression. A control group of 20 subjects with normal platelet counts was used to verify laboratory results with literature values. The Kdiff and Pdiff values in the control group very closely approximated literature values of 0.4 mmol/L and 0.08 mmol/L, respectively. Platelet count was a moderate predictor of Kdiff, r2 = 0.55 (p = 0.00001). Kdiff exceeded the upper limit of control at a platelet count of approximately 600 x 10(9)/L. Platelet count also correlated with Pdiff, r2 = 0.31 (p = 0.00001). Additionally, Kdiff correlated with Pdiff, r2 = 0.39 (p = 0.00001). Thrombocytosis is associated with false elevations in measured serum potassium and phosphorus concentrations. Additionally, the magnitude of elevations in potassium and phosphorus concentrations appear to be related.

Adult↗
PubMed1994

Clinical benefits of an immune-enhancing diet for early postinjury enteral feeding.

In this multicenter prospective controlled trial, 98 evaluable patients sustaining major torso trauma were randomized to receive early enteral nutrition with a new "immune-enhancing" diet (study: n = 51) or a standard stress enteral formula (control: n = 47). At baseline, both groups had comparable demographics and Injury Severity Scores. After 7 days of feeding, the groups had equivalent increases in serum total protein, albumin, and transferrin concentrations. Patients receiving the "immune-enhancing" diet, however, experienced significantly greater increases in total lymphocyte (p = 0.014), T lymphocyte (p = 0.04), and T-helper (p = 0.004) cell numbers. Additionally, these patients had significantly fewer intraabdominal abscesses (study, 0% vs. control, 11%; p = 0.023) and significantly less multiple organ failure (study, 0% vs. control, 11%; p = 0.023). In conclusion, this multicenter trial suggests this "immune-enhancing" enteral diet offers clinical benefits in stressed surgical patients.

Abdominal Injuries↗
PubMed1993

Nutrition during critical illness and sepsis.

The requirements for nutrient substrates are altered in patients with infection and critical illness. Parenteral and enteral nutritional support are indicated in septic patients to preserve lean body mass and support metabolic processes while appropriate anti-infective therapy is administered. In general, such patients require greater amounts of protein and fewer calories than normal patients. Enteral nutrition in septic patients has been demonstrated to be safe and well tolerated if begun immediately after the onset of infection or after injury. The salutary effect of enteral nutrition on the gastrointestinal tract has been shown to enable severely injured patients to have a lower frequency of infectious complications than similar patients fed parenterally. A new enteral formula fortified with arginine, nucleotides, and fish oil has been demonstrated to reduce hospital stay and to reduce complications in patients who are fed for > or = 7 days when compared with conventional formula. The increased use of early enteral nutrition and special nutrient formulas has the potential to reduce hospital length of stay, complications, and the cost of care if used appropriately.

Anti-Bacterial Agents↗
PubMed1991

Lipid-free total parenteral nutrition and macrophage function in rats.

Certain lipids are immunosuppressive when used for nutritional support, while other lipids and nutritional additives may enhance immunologic function. We hypothesized that total parenteral nutrition (TPN) may be immunosuppressive irrespective of lipids. Twenty-four rats underwent central vein catheterization and received either intravenous saline solution and oral chow or TPN alone. At 7 or 14 days, the animals were killed. Splenic and bone marrow macrophages were isolated and cultured in either M199 medium alone or were stimulated with Escherichia coli lipopolysaccharide. The supernatants were tested for prostaglandin E2 and C3. The splenic prostaglandin E2 levels were significantly higher in the TPN group following lipopolysaccharide stimulation at 7 days but not at 14 days. Administration of TPN to rats, even without lipids, may be immunosuppressive through the release of prostaglandin E2 from splenic macrophages following a septic challenge. This effect appears to be abolished after 14 days of TPN infusion.

Animals↗
PubMed1990

Study of surgical resident working hours and time utilization.

Recently, changes have been suggested in resident working hours and conditions. Few objective data exist, however, as to how many hours surgical residents work or how they utilize their time. Surgical residents on four every-third-night general surgery services (two services in the University Hospital and two in the Veterans Hospital) kept a log of their activities divided into 15-min intervals 24 hr a day for 4 weeks. Activity for each 15-min interval was entered into one of nine predesignated categories. Residents spent an average of 95.8 hr per week in the hospital, working 85.8 hr and sleeping 10 hr. Overall, residents slept an average of 5.9 hr per night, 4.2 hr on on-call nights and 6.2 hr on off-call nights. Operating and direct patient care activities consumed 8.7 hr per day (10.25 hr Monday to Friday). Patient care activities which residents believed could be performed by nonphysicians accounted for 1.5 hr per day. An average of 1.8 hr per day was spent in conferences or independent study. This survey provided objective data regarding working hours and time utilization for our residency. Both residents and faculty found that time spent in various activities differed from preconceived notions. We suggest that program directors may find a formal survey of this type useful in assessing the structure of their own residency and in providing objective data to compare to or determine compliance with externally generated guidelines.

General Surgery↗
PubMed1990

Nutrition and immune function.

Despite provision of adequate calories and nitrogen, patients receiving current nutrition support formulations often have suppression of immune function. Certain nutrients may act pharmacologically on the immune system. The choice of nutrients appropriate for a given disease state must take into consideration the nutritional status of the subject, presence of infection, injury or hypermetabolism, and the specific immune defect. Nutritional therapy specific for certain disease states is complex and in its infancy but may hold promise for improved patient outcome. Randomized prospective trials to evaluate efficacy are mandatory. Continued research into individual nutrients to elucidate mechanisms of immunomodulation must follow. In the meantime, broad application of products shown to be effective for a specific indication is inappropriate.

Enteral Nutrition↗
PubMed1987

Early total parenteral nutrition in acute pancreatitis: lack of beneficial effects.

To determine the effect of early aggressive parenteral support in pancreatitis, 54 patients with acute pancreatitis were randomized to receive either conventional therapy (control group) or conventional therapy plus the institution of total parenteral nutrition within 24 hours. The two groups were similar demographically. The total parenteral nutrition group had a significantly higher rate of catheter-related sepsis than did an additional group of contemporaneous patients without pancreatitis who received total parental nutrition (10.5 percent and 1.47 percent, respectively; p less than 0.01). There was no advantage to the use of early total parenteral nutrition; that is, there was no difference in the number of days to oral intake, total hospital stay, or number of complications of pancreatitis. Patients with zero or one Ranson's criterion on admission were more likely to be eating by the seventh hospital day than were those with two or more Ranson's criteria (80 percent and 54 percent, respectively; p less than 0.05). The early institution of total parenteral nutrition in patients with acute pancreatitis did not appear to improve the outcome. Its use should be limited to prolonged periods of no oral intake or treatment of a specific complication, such as a pseudocyst.

Acute Disease↗
PubMed1987

The value of hepatobiliary scans in fasted patients receiving total parenteral nutrition.

Hepatobiliary scanning is considered to be a highly accurate method for the diagnosis of acute cholecystitis. False-positive scans (failure to visualize the gallbladder in the absence of cholecystitis) have been reported to occur in fasted patients receiving total parenteral nutrition (TPN). To determine the prevalence of false-positive scans in this patient population and identify factors that might be associated with scan outcome, hepatobiliary imaging was performed in fasted patients receiving TPN and without clinical evidence of acute cholecystitis. Gallbladder nonvisualization occurred in 18 of 50 (36%) patients. In the group whose gallbladders did not visualize, a significantly higher male to female ratio (15:3 versus 17:15; p = 0.016), alkaline phosphatase (346 +/- 84 IU/L versus 212 +/- 32 IU/L, p less than 0.04), total bilirubin (1.7 +/- 0.3 mg/dl versus 1.0 +/- 0.2 mg/dl, p less than 0.02), and lower serum albumin (2.4 +/- 0.01 gm/dl versus 2.8 +/- 0.2 gm/dl, p less than 0.02) levels were noted. In 18 patients, gallbladder ultrasonography was also performed, and the presence of sludge or a thickened gallbladder wall did not correlate with scan outcome. The prevalence of false-positive hepatobiliary scans in fasted patients receiving TPN is significant and does not always correlate with a syndrome of acute gallbladder inflammation. The results of such scans must therefore be interpreted with caution in these patients.

Adult↗
PubMed1986

Postoperative enteral vs parenteral nutrition. A randomized controlled trial.

Twenty patients undergoing major upper-gastrointestinal-tract or pancreaticobiliary surgery were randomized to receive postoperative nutritional support by total parenteral nutrition (TPN) or elemental diet administered by needle-catheter jejunostomy (NCJ). Both routes of administration provided adequate nutritional support. No unexpected complications were encountered. The NCJ group compared favorably with the TPN group at the end of the seven-day trial. The NCJ group provided significant cost efficiency while maintaining adequate nutritional support.

Adult↗
PubMed1986

Branched chain amino acid-enriched solutions in the septic patient. A randomized, prospective trial.

A prospective, randomized trial was undertaken to compare the nutritional efficacy in surgical stress of a standard amino acid solution and two branched chain-enriched amino acid solutions: one enriched primarily with valine, the other with leucine. The study comprised 37 patients in the surgical intensive care unit who received isocaloric, isonitrogenous parenteral nutrition started within 24 hours of the onset of major operation, injury, or sepsis. Nitrogen retention was marginally but statistically significantly better on days 5, 7, and 10 in both groups of patients receiving the branched chain-enriched solutions, but differences in cumulative nitrogen balance were not statistically significant. Amino acid composition appeared to be important in that the group receiving the leucine-enriched solution appeared to maintain hepatic protein synthesis better (as manifest by higher short-turnover plasma protein concentrations) and required less exogenous insulin to maintain euglycemia. Improved outcome was not seen in the groups receiving the branched chain-enriched solutions.

Adolescent↗
PubMed1985

Postoperative enteral versus parenteral nutritional support in gastrointestinal surgery. A matched prospective study.

The effects of an elemental-enteral diet administered by a needle catheter jejunostomy or central total parenteral nutrition were prospectively studied in 15 patients undergoing abdominal operations. Infusions were started 1 day after operation and continued for 7 to 10 days. The two nutrient modalities were matched to deliver equal amounts of nitrogen and calories. Both promoted positive nitrogen balance and preserved body weight and serum proteins (albumin, transferrin, thyroxine-binding prealbumin, and retinol-binding protein). Both enteral and parenteral nitrogen caused a similar increase in plasma insulin levels. Pancreatic glucagon, total glucagon, gastrin, and pancreatic polypeptide were also maintained at similar levels in both groups. Plasma vasoactive intestinal polypeptide levels declined in patients receiving total parenteral nutrition but remained stable in the patients who were fed enterally. Both routes caused modest, inconsequential elevations in liver enzymes, but were otherwise equally safe. Patients tolerated total parenteral nutrition far better in the early postoperative period. Patients whose needs are great are probably better treated by total parenteral nutrition. Needle catheter jejunostomy feeding, however, is much less expensive. These studies do not support the commonly held belief that enteral nutrition is a more efficient route for administration of calories and protein.

Adult↗
PubMed1985

Use of a branched chain amino acid enriched solution in patients under metabolic stress.

The metabolic response to stress results in proteolysis, increased gluconeogenesis, and negative nitrogen balance. Infusion of BCAA has been shown experimentally to decrease protein degradation and stimulate protein synthesis. Such infusion may modify the response of patients to metabolic stress. An amino acid solution containing 45 percent BCAA as a component of central vein parenteral nutrition was infused into 20 moderately to severely stressed postoperative patients in a prospective, nonrandomized fashion. Infusion was begun within 24 hours postoperatively and continued for 7 to 14 days. Patients received 1.6 g protein equivalents per kg body weight daily and 30 kcal/kg body weight daily. Nutritional indexes as measured by albumin and transferrin values were maintained during the study period. Nitrogen balance became increasingly positive over the period of infusion without an increase in the urinary excretion of 3-methylhistidine. There were no serious clinical or biochemical side effects of the BCAA infusion, although a statistically significant increase in alkaline phosphatase was observed. These results suggest that central vein parenteral nutrition utilizing a 45 percent BCAA enriched solution can promote nitrogen retention without serious side effects in moderately to severely stressed patients.

Adolescent↗