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Biomedical subjects

S E Morris

Publications and source records attributed to S E Morris.

At least 19 recordsLinked to original sources
PubMed2001

Burn center management of necrotizing soft-tissue surgical infections in unburned patients.

BACKGROUND: Patients with necrotizing soft-tissue infections present great challenges in management from initial presentation through definitive care. Because burn centers concentrate expertise in critical care, wound management, and rehabilitation, we examined the effectiveness of burn center care for patients with necrotizing infections. METHODS: We reviewed our burn center's experience with all patients admitted from 1990 through 1999 with a primary diagnosis of necrotizing fasciitis (NF) or Fournier's gangrene (FG). RESULTS: Fifty-seven patients were identified, 18 with FG and 39 with NF. Patients had a high incidence of preexisting medical problems, including diabetes (37%), obesity defined as greater than 20% above ideal body weight (33%), and hypertension (33%). Seven of 57 (12%) patients died. Patients required a mean of 4.1 operative procedures (range 1 to 15) for definitive wound closure. The mean length of stay (survivors only) was 28.5 days, (range 3 to 70). Although costs increased throughout this period, a formal program of cost-containment resulted in no increase in actual charges per day, from a mean of $4,735 in 1991 to $5,202 in 1999. CONCLUSIONS: Burn centers can provide successful and cost-effective acute care, definitive wound closure, and rehabilitation for patients with NF and FG.

Burn Units↗
PubMed2001

Assessment of tissue viability in complex extremity injuries: utility of the pyrophosphate nuclear scan.

BACKGROUND: Extensive extremity injuries often require difficult decisions regarding the necessity for amputation or radical debridement. During the past decade, we have used technetium-99 pyrophosphate (PyP) scanning as an adjunct in this setting. This study was performed to assess the accuracy of PyP scan in predicting the need for amputation in relation to clinical, operative, and pathologic findings. METHODS: Review of our computerized registry identified 11 patients (10 men, age 36.1 +/- 14.9 years) admitted from 1990 to 1999 who underwent PyP scan. Using operative and pathologic findings, accuracy of the PyP scan was graded as supporting or refuting the clinical assessment of the need for amputation. RESULTS: Eight patients suffered high-voltage electrical injuries, one had severe frostbite, and two suffered soft-tissue infections. In most cases, PyP scan showed clear demarcation of viable and nonviable tissue, verifying the need for amputation (positive); those that demonstrated viable distal tissues confirmed at operation were considered negative. PyP scan had a sensitivity of 94%, a specificity of 100%, and an accuracy of 96% in this setting. CONCLUSION: Technetium-99 PyP scanning is a useful adjunct in predicting the need for amputation in extremities damaged by electrical injury, frostbite, or invasive infection. In addition, by providing an objective "picture" of extremity perfusion, PyP scans can be helpful in convincing patients of the need for amputation.

Adolescent↗
PubMed2001

Mutational analysis of branching in pea. Evidence that Rms1 and Rms5 regulate the same novel signal.

The fifth increased branching ramosus (rms) mutant, rms5, from pea (Pisum sativum), is described here for phenotype and grafting responses with four other rms mutants. Xylem sap zeatin riboside concentration and shoot auxin levels in rms5 plants have also been compared with rms1 and wild type (WT). Rms1 and Rms5 appear to act closely at the biochemical or cellular level to control branching, because branching was inhibited in reciprocal epicotyl grafts between rms5 or rms1 and WT plants, but not inhibited in reciprocal grafts between rms5 and rms1 seedlings. The weakly transgressive or slightly additive phenotype of the rms1 rms5 double mutant provides further evidence for this interaction. Like rms1, rms5 rootstocks have reduced xylem sap cytokinin concentrations, and rms5 shoots do not appear deficient in indole-3-acetic acid or 4-chloroindole-3-acetic acid. Rms1 and Rms5 are similar in their interaction with other Rms genes. Reciprocal grafting studies with rms1, rms2, and rms5, together with the fact that root xylem sap cytokinin concentrations are reduced in rms1 and rms5 and elevated in rms2 plants, indicates that Rms1 and Rms5 may control a different pathway than that controlled by Rms2. Our studies indicate that Rms1 and Rms5 may regulate a novel graft-transmissible signal involved in the control of branching.

Genes, Plant↗
PubMed2000

Is immediate chest radiograph necessary after central venous catheter placement in a surgical intensive care unit?

BACKGROUND: Current standard of care dictates that central venous catheter (CVC) insertion should be followed by an immediate chest radiograph to confirm appropriate position and rule out complications. We hypothesized that a subset of monitored intensive care unit patients exists that is at low risk for complications and might safely have radiographic evaluation of line placement deferred until the next scheduled radiograph. METHODS: Data regarding patient and procedural characteristics were obtained prospectively for 184 CVC placed between March 1, 1998, and June 30, 1999. Retrospective data regarding complications were obtained by chart review for an additional 174 CVC placed during the study period but for which data sheets were not completed. All procedures were followed by chest radiography. RESULTS: We documented a complication rate of 9% with the vast majority (25 of 31, 81%) of complications consisting of incorrect positioning. The number of needle passes was greater in the group suffering pneumothorax and arterial puncture than the uncomplicated group (5.6 versus 1.9, P = 0.008). "Straightforward" operator gestalt (P = 0.04) and number of needle passes <3 (P = 0.03) were factors correlating with the absence of complications. These factors had negative predictive values of 94% and 96%, respectively. CONCLUSION: Placement of CVC is safe in experienced hands. In monitored intensive care unit patients who undergo a "straightforward" procedure with <3 needle passes, chest radiograph can be safely deferred until the next scheduled examination.

Catheterization, Central Venous↗
PubMed2000

Point-source modelling using matched case-control data.

We describe an extension to matched case-control studies of the parametric modelling framework developed by Diggle (1990) and Diggle and Rowlingson (1994) to investigate raised risk around putative sources of environmental pollution. We use a conditional likelihood approach for the family of risk functions considered in Diggle and Rowlingson (1994). We show that the likelihood surface that results from these models may be highly irregular, and provide a Bayesian analysis in which we investigate the posterior distribution using Markov chain Monte Carlo. An analysis of one-one matched data that were collected to investigate the relationship between respiratory disease and distance to roads in East London is presented.

Journal Article↗
PubMed2000

Situational trust and co-operative partnerships between physicians and their patients: a theoretical explanation transferable from business practice.

A model to explain interpersonal trust development, and its consequences for co-operative behaviour in doctor/patient partnerships derived from the context of business relationships is applied to patient/physician relationships. Threshold barriers exist against all human behaviours or actions and trust is the process by which barriers to co-operation and compliance are overcome. Dispositional trust (a psychological trait to be trusting) is dominant in the early stages of a relationship and contributes to the weight of subsequent trust development. Co-operative behaviour or compliance ultimately requires a secure situational trust emerging from consultations, which is carried forward as learnt trust and modified in each subsequent consultation. The model comprises three types of situational trust (calculus-based, knowledge-based, and identification trust) and five co-operation criteria from which to determine an individual's tendency for co- operative behaviour. These model components can be identified and mapped from a range of qualitative data, with the aim of enhancing co-operative behaviour and efficiently achieving optimal patient compliance.

Clinical Competence↗
PubMed2000

Still hungry in hospital: identifying malnutrition in acute hospital admissions.

We assessed the prevalence, methods for recognition and clinical management of malnutrition in acute admissions in a large academic inner-city hospital. Of a total of 337 patients, it was possible to measure both height and weight in 219 patients (65% of admissions). As an alternative for bed-bound patients, mid-upper arm circumference was not very reliable in predicting BMI (sensitivity 98%; specificity 65%), and waist circumference even less so. Of these, 13% were malnourished (body mass index BMI <18.5 kg/m(2) or BMI 18.5-20 kg/m(2) with reported weight loss >3 kg in the last 3 months). Six patients (31% of those with BMI <18.5 kg/m(2)) and one with BMI 18.5-20 kg/m(2) were recognized as suffering from malnutrition and referred to the dietitian. Review of case records could not establish if the diagnosis was missed in the remainder, or if a conscious decision was taken not to manage malnutrition actively. Malnutrition in acute hospital admissions goes apparently unrecognized and unmanaged in 70% of cases. Since there are serious consequences, and effective simple treatment is readily available, increased awareness is required, with routine assessment of nutritional status in all patients.

Adolescent↗
PubMed2000

The demand and supply of nutritional advice and guidance in Scottish family planning services.

Recent changes to the health services have led to an increased provision of clinical care in family planning clinics. While some women may only require contraceptive services, others may demand advice on a breadth of lifestyle issues, including diet and nutrition. Obesity affects 17% of women of childbearing age in Scotland and being overweight during pregnancy has significant health risks. A postal survey of 227 nurses identified as working in family planning clinics in Scotland was conducted in 1998. After a mail shot and one reminder, a net response rate of 64% (n = 145) was achieved. Overall, it was found that obesity was perceived as the most extensive problem in women of childbearing age. Seventy nurses (48%) reported that, in addition to offering family planning services, they gave dietary advice 'frequently' or 'always' to their clients without being asked. There were differences in nutrition-related activities in consultations between nurses offering family planning services only and those who routinely offered nutritional advice. Over half (61%) of the nurses reported that they would give advice regarding weight management even if the patients were not seeking help, although there was no significant difference between the two comparison groups. In some cases, the nutritional advice offered to clients highlighted a deficit in training. Most nutrition education came from diploma and/or training courses and scientific literature, followed by 'experience'. Those nurses already embracing a nutritional advice and guidance role were more interested in further nutrition training (p = 0.018) than the other nurses. However, overall, 67% of the nurses wished to train further in nutrition and weight management. The findings suggest that family planning nurses should be supported to develop nutritional advice and guidance skills, and that there is a pressing need for training in public health nutrition and weight management for nurses working in family planning services.

Adult↗
PubMed1999

Plasmapheresis as an adjunct treatment in toxic epidermal necrolysis.

BACKGROUND: Toxic epidermal necrolysis (TEN) is a severe, progressive disease characterized by the sudden onset of skin necrosis. It is frequently associated with systemic involvement and has a high rate of morbidity and mortality. Standard therapy includes meticulous wound care, fluid replacement, and nutritional support in an intensive care setting. OBJECTIVE: We evaluated the outcomes of patients treated in a burn unit for TEN over a 9-year period and compared the outcomes of a subset of patients treated with plasmapheresis with those managed by conventional means. METHODS: The records of 16 patients with a diagnosis of TEN obtained from a computerized database were reviewed. Parameters recorded included extent of body surface area involvement and number of mucous membranes involved at admission, complications such as sepsis or need for mechanical ventilation, length of stay, and disposition. RESULTS: Sixteen patients were included in this study. Ten were treated with conventional support measures alone. Six were treated with plasmapheresis. The average age was 42.4 years; the male/female ratio was 1:2.2. Sulfamethoxazole/trimethoprim was implicated in causation in 6 patients. The average extent of involvement on admission in all patients was 51.5% total body surface area. The average length of stay in all patients was 14.8 days. Eight patients (50%) were discharged home, 4 (25%) were discharged to a rehabilitation facility, and 4 (25%) died (2 of sepsis, 2 of cardiopulmonary arrest). None of the plasmapheresis-treated patients died. CONCLUSION: Plasmapheresis is a safe intervention in extremely ill TEN patients and may reduce the mortality in this severe disease. Prospective studies are needed to further define its usefulness.

Adolescent↗
PubMed1999

Who gets what treatment for obesity? A survey of GPs in Scotland.

OBJECTIVE: To describe the types and delivery of obesity treatment currently favoured by General Practitioners (GPs) working in Scotland. DESIGN: Representative cross-sectional survey using a postal questionnaire which included case stories as stimuli for questions about the GPs' nutrition guidance to overweight female patients. SUBJECTS: A systematic sample of 1400 general practitioners (GPs) from a total of 3593 GPs working in Scotland in 1997. RESULTS: From 1363 eligible GPs, 609 returned the full questionnaire and a further 132 took part in a telephone mini-interview. Net response was 54.4% (741/1363). Almost half of the GPs (45.6%) reported that they had read the recent national clinical guideline for integrating obesity prevention with weight management (SIGN 1996). The majority of GPs (89.6%) agreed that nutrition has an important role to play in the management of disease and 82.4% agreed that they can offer healthy eating advice to patients. However, only 34.8% of GPs believed that they had been successful in treating overweight patients. Routinely used treatments involve either a dietitian, practice nurse and/or a commercial slimming group and realistic weight loss was considered one criteria of successful treatment by some GPs. Age, year qualified and location of practice were found to have little influence over variations in GP treatment while weak associations between gender of GP and treatment were found. CONCLUSIONS: The readership of the clinical guidelines in Scotland has been moderate so far although a multidisciplinary approach to obesity treatment is recognised. Further investigations of any relationships between nutrition education-obesity treatment are needed.

Adult↗
PubMed1999

Intestinal obstruction secondary to enteral feedings in burn trauma patients.

BACKGROUND: Enteral feeding is preferred for maintaining gut integrity and providing nutrition in trauma patients. Recent reports suggest that use of early enteral feeds is successful and that complications are rare. A recent burn patient, who suffered apparent bowel obstruction and perforation secondary to enteral feedings, led us to review our experience with mechanical complications of tube feedings. METHODS: We searched our registry of patients treated for acute burn trauma injury and identified patients treated for acute bowel obstruction in the past 3 years. RESULTS: Four patients were identified, ages 22 to 44, with burns of 6 to 92% total body surface area. Each required intubation and ventilatory support during initial treatment, complicated by adult respiratory distress syndrome and sepsis. We began enteral feeds 1 to 3 days after admission. At approximately 14 days after admission, each patient deteriorated clinically, which led to emergent abdominal exploration; the tube feedings caused bowel obstruction and associated complications. Each patient improved with laparotomy. CONCLUSION: Bowel obstruction, ischemic necrosis, or both, secondary to early and aggressive nutrition with a fiber supplemented enteral feeding is an uncommon, life-threatening complication. Understanding and early recognition of this potential complication are essential to prevention or successful treatment.

Adult↗
PubMed1998

P50 suppression in recent-onset schizophrenia: clinical correlates and risperidone effects.

Chronic schizophrenic patients often do not suppress the auditory P50 component of the event-related potential to the second of 2 clicks, presented 500 ms apart, suggesting a loss of normal inhibition. This study attempted to replicate the P50 suppression deficit in patients with recent-onset schizophrenia and to examine whether P50 is related to clinical symptoms or is affected by an atypical antipsychotic medication. Data from 22 recent-onset schizophrenia patients and 11 normal controls revealed that disruption in P50 suppression is present during the early stages of illness. In addition, impaired P50 suppression covaried with clinical ratings of anxiety, depression, and anergia; results also suggested that the P50 inhibitory deficit may be related to the degree of patients' attentional impairment. Finally, risperidone, compared with a typical antipsychotic medication, improved inhibition of P50 to the second click. These results support P50 suppression as a measure of disordered neurocognition in schizophrenia.

Adult↗
PubMed1998

Inhaled nitric oxide versus conventional therapy: effect on oxygenation in ARDS.

A randomized, controlled clinical trial was performed with patients with acute respiratory distress syndrome (ARDS) to compare the effect of conventional therapy or inhaled nitric oxide (iNO) on oxygenation. Patients were randomized to either conventional therapy or conventional therapy plus iNO for 72 h. We tested the following hypotheses: (1) that iNO would improve oxygenation during the 72 h after randomization, as compared with conventional therapy; and (2) that iNO would increase the likelihood that patients would improve to the extent that the FI(O2) could be decreased by > or = 0.15 within 72 h after randomization. There were two major findings. First, That iNO as compared with conventional therapy increased Pa(O2)/FI(O2) at 1 h, 12 h, and possibly 24 h. Beyond 24 h, the two groups had an equivalent improvement in Pa(O2)/FI(O2). Second, that patients treated with iNO therapy were no more likely to improve so that they could be managed with a persistent decrease in FI(O2) > or = 0.15 during the 72 h following randomization (11 of 20 patients with iNO versus 9 of 20 patients with conventional therapy, p = 0.55). In patients with severe ARDS, our results indicate that iNO does not lead to a sustained improvement in oxygenation as compared with conventional therapy.

Administration, Inhalation↗
PubMed1997

Randomized trial of immune-enhancing enteral nutrition in burn patients.

BACKGROUND: "Immune-enhancing" diets (IEDs) are aimed at improving outcomes in patients suffering trauma and infection. This study was conducted to evaluate a popular IED in patients suffering burn injury. METHODS: Fifty burned patients were randomized to receive either Impact (Sandoz Nutrition, Minneapolis, Minn), an IED enhanced with omega-3 fatty acids, arginine, and RNA, or Replete (Clintec, Deerfield, Ill), our standard high-protein diet. Feedings were begun within 48 hours of injury, and continued until patients supported themselves with oral intake. RESULTS: Forty-nine patients completed the study. The two feeding groups did not differ with respect to age, burn size, incidence of inhalation injury, or the quantity of calories and protein received. There were no differences between groups in mortality, length of hospitalization, hospital charges, days of ventilator support, or incidence of complications. Patients with inhalation injuries required more ventilatory support, and had longer lengths of hospitalization and higher costs. CONCLUSIONS: Administration of an IED has no clear advantages over the use of less expensive high-protein enteral nutrition in burn patients.

Adjuvants, Immunologic↗
PubMed1997

Early prediction of prolonged ventilator dependence in thermally injured patients.

BACKGROUND: Recent studies suggest that when prolonged ventilator dependence (PVD) can be predicted in trauma or intensive care unit patients, early tracheostomy may reduce hospital stay and improve utilization of resources. This study was performed to develop criteria predictive of PVD (> 14 days) in burn patients. METHODS: We reviewed burn patients aged > or =16 years admitted between 1990 and 1994 who required ventilator support for > or =3 days. Using the variables full-thickness burn size, age, inhalation injury, and worst PaO2/FiO2 on ventilator day 3, an equation predicting PVD was created using logistic regression. The equation was tested by applying it to 1995 patients. RESULTS: When a probability of >0.5 was considered predictive of PVD, the equation correctly predicted PVD in 82% of 1990 to 1994 patients (n = 110) and 90% of 1995 patients (n = 29). CONCLUSION: PVD in burn patients can be predicted using objective variables in the early postburn period. Predictions can be used to select patients for prospective studies of early tracheostomy.

Adult↗
PubMed1996

Necrotizing group A streptococcal infections associated with streptococcal toxic shock syndrome.

BACKGROUND: Group A streptococci (GAS) cause a variety of life-threatening infectious complications, including necrotizing fasciitis (NF), purpura fulminans (PF), and streptococcal toxic shock syndrome (strepTSS), in which bacteremia is associated with shock and organ failure. METHODS: We reviewed our experience in the management of patients with necrotizing GAS infections from 1991 to 1995. RESULTS: Eight adult patients (6 NF, 2 PF) were identified. Patients presented with fever, leukocytosis, and severe pain, and rapidly developed shock and organ dysfunction. The diagnosis of strepTSS was confirmed in 6 cases. A total of 54 surgical procedures were required, including widespread debridements and amputations. Two patients died (25%). CONCLUSIONS: Recognition of the need for aggressive diagnosis and surgical treatment of this most rapidly progressive surgical infection is necessary for successful management.

Adult↗