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Biomedical subjects

T V Berne

Publications and source records attributed to T V Berne.

At least 19 recordsLinked to original sources
PubMed1995

The impact of a dedicated trauma program on outcome in severely injured patients.

BACKGROUND: In recent years, many trauma centers have been closing or scaling down their operations because of financial losses and lack of commitment by the relevant authorities. OBJECTIVE: To investigate the effect of commitment to trauma and the establishment of a dedicated trauma program on injury outcome. DESIGN: In 1992, a well-funded dedicated trauma program was implemented at the Los Angeles County--University of Southern California Medical Center, Los Angeles. We analyzed the outcome in severely injured patients (Injury Severity Score [ISS] > 15) before and after implementation of the program (1991 and 1993). SETTING: Large, urban, level 1 trauma center. PATIENTS: Patients with trauma and an ISS higher than 15. RESULTS: There were 737 patients with an ISS higher than 15 in 1991 and 812 patients with an ISS higher than 15 in 1993. The overall mortality rate was 30% in 1991 and 24.5% in 1993 (P = .018), which is a reduction by 18.3%. In patients with blunt trauma and an ISS higher than 15, mortality was reduced by 33% (mortality rate of 31.1% in 1991 vs 20.8% in 1993) (P < .002). Mortality in patients with penetrating trauma and an ISS higher than 30 was reduced by 42.7% (mortality rate of 59.3% in 1991 vs 34% in 1993) (P = .019). There was also a trend toward lower permanent disabilities among survivors with an ISS higher than 15 (14.7% in 1991 vs 11.3% in 1993). CONCLUSION: Commitment of financial and human resources for the establishment of a dedicated trauma program is a sound investment in terms of improved survival and fewer permanent disabilities in critically injured patients.

Accidents, Traffic↗
PubMed1995

Timing of laparoscopic surgery in gallstone pancreatitis.

OBJECTIVE: To study the effect of the timing of laparoscopic cholecystectomy following acute gallstone pancreatitis. SETTING: University-based county teaching hospital. DESIGN: Retrospective case series. PATIENTS: One hundred forty-two patients with gallstone pancreatitis treated by laparoscopic cholecystectomy between April 1991 and September 1993. There were 16 men and 126 women, with a mean age of 39.5 years. The mean serum amylase level at admission was 1616 U/L. All patients were operated on more than 48 hours after admission, after clinical and biochemical resolution of pancreatitis. Preoperative endoscopic retrograde cholangiopancreatography was performed in 25 patients (more than 48 hours after admission), with common bile duct stones being identified and removed in 10. RESULTS: Twenty patients had three or more Ranson's criteria. Of these, nine had laparoscopic cholecystectomy attempted within the first week of admission. Six (67%) of these patients required conversion to open procedures (two for common bile duct exploration, one for repair of a common hepatic duct injury, and three for anatomic distortion due to inflammation). The mean postoperative stay of the nine patients was 5.4 days. The other 11 patients with three or more Ranson's criteria were operated on after 1 week, and only two required conversion to open cholecystectomy (18%). The mean postoperative stay in these 11 patients was 2.3 days. The difference in conversion rate approached but did not reach statistical significance (P = .08). The postoperative stay, however, was significantly shorter in the group of patients who underwent late operations (P = .03). There were 122 patients with fewer than three Ranson's criteria. In this group, there was no difference in length of postoperative stay between patients operated on earlier and those operated on later (2.4 vs 3.9 days; P = .49; n = 74 and n = 48, respectively). Of these 122 procedures, eight were converted to open procedures (6.6%). There was no significant difference in conversion rates in these patients regardless of whether they were operated on earlier or later. CONCLUSIONS: Based on these data, we believe, first, that laparoscopic cholecystectomy is safe in patients recovering from gallstone pancreatitis (mortality rate, 0%; bile duct injury, 0.7%). Furthermore, early operation can safely be recommended in patients with mild pancreatitis. However, in patients with three or more Ranson's criteria, operation during the first week following admission is associated with an increase in operative complications, an increased rate of conversion, and longer postoperative stays.

Acute Disease↗
PubMed1995

Penetrating injuries of the neck in patients in stable condition. Physical examination, angiography, or color flow Doppler imaging.

BACKGROUND: The initial assessment of penetrating injuries of the neck is controversial, with angiography remaining the gold standard for identifying vascular injuries. Recent reports suggest that physical examination might be an accurate way to evaluate these injuries. Color flow Doppler imaging has been used with promising results to assess extremity injuries, but the role of color flow Doppler imaging in neck injuries has not been studied. OBJECTIVE: To evaluate and compare the roles of physical examination, color flow Doppler imaging, and angiography in the identification and management of penetrating neck injuries. STUDY DESIGN: A prospective study of patients in stable condition with penetrating injuries of the neck. All study patients were examined according to a written clinical protocol and subsequently underwent angiography and color flow Doppler imaging. The sensitivity and specificity of physical examination and color flow Doppler imaging were compared with those of angiography. RESULTS: Eighty-two patients fulfilled the criteria for inclusion in the study. Angiography demonstrated vascular lesions in 11 patients (13.4%), but only two (2.4%) of them required treatment. Serious injuries were detected or suspected during physical examination, but six lesions not requiring treatment were missed. When injuries not requiring treatment were excluded, the sensitivity was 100% and the specificity was 91%. With color flow Doppler imaging, 10 of the 11 injuries were identified, for a sensitivity of 91% and a specificity of 98.6%. The sensitivity and specificity were 100% for clinically important lesions. CONCLUSION: The combination of a careful physical examination and color flow Doppler imaging provides a reliable way to assess penetrating neck trauma and may be a safe alternative to routine contrast angiography.

Adolescent↗
PubMed1995

Gunshot wounds to the thoracic aorta in the '90s: only prevention will make a difference.

The clinical experience with gunshot injuries to the thoracic aorta at a large urban trauma center was reviewed. Of 1961 patients admitted with gunshot wounds to the chest, 20 sustained injuries to the thoracic aorta. Mortality occurred in 17 patients (85%), all of whom were hypotensive or moribund upon admission. The three patients (15%) presenting with a systolic blood pressure above 100 mm Hg survived; only one of these underwent surgery during the acute period. Only two patients were stable enough for aortography. Advances in the management of critically injured patients have not improved the outcome with this lethal injury.

Adolescent↗
PubMed1992

Tissue concentrations of cefepime in acute cholecystitis patients.

Cefepime is a new broad-spectrum cephalosporin with activity against Staphylococcus, Streptococcus, Pseudomonas, and the Enterobacteriaceae. The purpose of this study was to measure cefepime concentrations in plasma, peritoneal fluid, bile fluid and appendix tissue in patients undergoing elective cholecystectomy. Patients were randomly assigned to receive either cefepime, 2 g intravenously in phosphate buffer (IVPB) q 12 h or gentamicin 1.5 mg/kg IVPB q 8 h plus mezlocillin 4 g IVPB q 6 h. During surgery, gall bladder tissue, plasma, peritoneal fluid, and bile fluid samples were obtained at approximately the same time. Thirty-three patients had data acceptable for analysis. Values are given as mean +/- standard deviation. The mean delta time (defined as the time between the administration of cefepime and the time the samples were obtained) was 8.58 +/- 3.53 h. The values for plasma, peritoneal fluid, bile fluid, and gall bladder tissue concentrations were 7.63 +/- 14.17 micrograms/ml, 5.66 +/- 6.80 micrograms/ml, 15.51 +/- 16.94 micrograms/ml, and 5.36 +/- 6.57 micrograms/gm, respectively. The peritoneal fluid/plasma ratio was 2.10 +/- 2.33, the bile fluid/plasma ratio was 14.44 +/- 31.99, and the gall bladder tissue/plasma ratio was 1.44 +/- 1.82. There was a significant correlation between peritoneal fluid and plasma concentration (r = 0.91, p less than 0.0005), and gall bladder tissue and plasma concentration (r = 0.90, p less than 0.0005). There was no correlation between bile fluid and plasma cefepime concentrations. The minimum inhibitory concentration (MIC) data from previous in vitro studies indicate that cefepime concentrations achieved in this patient population would be adequate against typical biliary tract pathogens.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗
PubMed1992

Prospective evaluation of a double-lumen subclavian dialysis catheter for acute vascular access.

The safety and efficacy of a parallel, double-lumen hemodialysis catheter used to achieve acute, temporary vascular access were evaluated prospectively in 134 hospitalized adult patients in whom 162 catheters were placed. The arterial flow rates and venous resistance were such that 84 per cent of the catheters provided satisfactory access for dialysis. Minor manipulations of the catheter were frequently required to maximize function. Three serious complications occurred, including one instance each of pneumothorax, hemorrhage, and nonfatal pericardial tamponade.

Adult↗
PubMed1991

Intramuscular imipenem as adjuvant therapy for acute cholecystitis and perforated or gangrenous appendicitis.

An open-label prospective study was performed employing intramuscularly administered imipenem as an adjunct to surgery in 20 patients with acute cholecystitis and 24 patients with perforated or gangrenous appendicitis. Three (12.5%) septic failures occurred in appendicitis patients and 2 (10%) failures in cholecystitis patients. There were no deaths. Adverse effects were minor, and there was no toxicity. Although failures were not associated with in vitro resistance, Pseudomonas spp. were recovered from 2 of 3 appendicitis failures. Intramuscular imipenem appeared to be an effective single-drug antimicrobial when used as an adjunct to surgery in patients with acute cholecystitis or perforated appendicitis. It should be a more cost-effective alternative to the current multiple-drug therapy frequently employed in patients with intra-abdominal sepsis.

Adult↗
PubMed1991

Analysis of cefepime tissue penetration into human appendix.

Cefepime is a new extended-spectrum cephalosporin with gram-positive and gram-negative coverage including Staphylococcus aureus and Pseudomonas aeruginosa. We evaluated the drug's plasma, peritoneal fluid, and appendix tissue concentrations in patients with a postoperative diagnosis of perforated or gangrenous appendicitis. Patients 18 years of age or older were randomly assigned to receive either cefepime 2 g every 12 hours plus metronidazole 500 mg every 6 hours intravenously, or gentamicin 1.5 mg/kg plus clindamycin 900 mg every 8 hours intravenously. During surgery, appendix tissue, plasma, and peritoneal fluid samples were obtained, and frozen at -70 degrees C for high-pressure liquid chromatographic analysis. Thirty-five patients with perforated (26) or gangrenous (9) appendicitis had concentrations acceptable for analysis. The mean time between the administration of cefepime and the time of sampling (referred to as delta time) was 5.99 +/- 3.75 hours (mean +/- SD). The values for plasma (n = 34), tissue (n = 33), and peritoneal fluid (n = 25) concentrations were 16.27 +/- 21.87 micrograms/ml, 4.84 +/- 6.15 micrograms/g, and 14.4 +/- 22.84 micrograms/ml, respectively. The appendix tissue:plasma ratio was 0.66 +/- 0.52 and the peritoneal fluid:plasma ratio was 0.66 +/- 0.51. Spearman rank correlations indicated statistically significant correlations between plasma concentration (r = -0.889; p less than 0.0001), peritoneal fluid concentration (r = -0.783; p = 0.0002), and appendix tissue concentration (r = -0.704; p = 0.0016) versus delta time.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1991

Wound infection in patients with traumatic small intestinal injuries.

Delayed closure has been the traditional management of wounds in patients with traumatic colon injury, whereas small bowel injury has generally been treated with primary wound closure. Sixty-seven patients with traumatic hollow viscus injury isolated to jejunum and ileum were reviewed to determine the incidence of septic wound complications. Fifty-eight patients underwent primary wound closure with 15 (26%) developing wound infections. Nine patients had their wounds left open because of major intraperitoneal contamination with no resulting wound infection. In patients with primary closure of their wounds, there was no difference between these developing wound infections and those without with regard to the presence of hypotension, amount of spill, type of repair, site of injury, or antibiotic given. Significant difference was present regarding time between injury and surgery (8.6 vs 17.7, P = .025). Results suggest that delayed wound closure should be performed in patients with traumatic small bowel injury.

Abscess↗
PubMed1990

Management of penetrating back trauma.

The best management plan for patients with stab wounds of the posterior abdomen who have no obvious indication for operation is a selective one. Repeated physical examination is the mainstay of treatment, as indicated by many authors. Other special studies, such as DPL, angiography, intravenous pyelography, and contrast CT scanning, are indicated on a case-by-case basis, but as yet lack convincing justification for routine use.

Abdominal Injuries↗
PubMed1990

Intraoperative concentrations of ofloxacin in serum, bile fluid, and gallbladder wall tissue.

To evaluate concentrations of ofloxacin in serum, bile fluid, and gallbladder wall tissue after intravenous administration, patients greater than or equal to 16 years old diagnosed with acute cholecystitis were randomly assigned to receive ofloxacin (400 mg) intravenously every 12 h or ceftazidime (2 g) intravenously every 8 h. Doses of each regimen were given preoperatively. Serum, bile fluid, and gallbladder wall tissue samples of consecutive patients in the ofloxacin group were obtained intraoperatively. The samples were frozen at -70 degrees C until analyzed by high-pressure liquid chromatography. Twenty-three patients (6 males and 17 females) were evaluated. The mean (+/- the standard deviation) ofloxacin concentrations in serum, bile fluid, and gallbladder wall tissue were 2.9 +/- 2.4 and 6.0 +/- 7.9 micrograms/ml and 3.1 +/- 2.9 micrograms/g, respectively. The mean number of doses each patient received before surgery was 5.3 +/- 3.0, and the mean delta time (time elapsed between last antibiotic administration and when intraoperative samples were obtained) was 9.6 +/- 7.5 h. The mean tissue-to-serum ratio was 1.2 +/- 0.5, and the mean bile-to-serum ratio was 2.3 +/- 1.4. The mean serum ofloxacin concentrations were not statistically different from the concentrations in bile (P = 0.1) and tissue (P = 0.7) at the mean delta time. The study revealed that concentrations of ofloxacin in serum, bile fluid, and gallbladder tissue after intravenous dosing were adequate against susceptible organisms found in the biliary tract.

Adult↗
PubMed1990

Ceftazidime/clindamycin versus tobramycin/clindamycin in the treatment of intra-abdominal infections.

In order to assess the efficacy and toxicity of ceftazidime as a substitute for aminoglycosides in the treatment of intra-abdominal sepsis, a prospective randomized trial was conducted. Ninety-four patients (49% trauma) were randomized to receive ceftazidime/clindamycin (CAZ/C) (n = 47) or tobramycin/clindamycin (T/C) (n = 47). CAZ (2.0 gm) and C (0.9 gm) were administered intravenously every 8 hours while T dosage was adjusted to maintain peak (5-8 mg/L) and trough (less than 2 mg/L) concentrations. Age, sex, baseline serum creatinine, and etiology of infection were comparable in the two groups. Clinical cure was similar in culture-positive and culture-negative patients who received CAZ/C (94% vs 88%). The clinical cure rate however was significantly lower in the T/C culture positive (73%) than in the culture negative patients (100%) (P = 0.016). Pathogenic organisms were eradicated in 100% (30/30) and 76% (13/17) of CAZ/C and T/C patients, respectively (P = 0.0006). Nephrotoxicity Nephrotoxicity or ototoxicity was observed in none of the CAZ/C patients and in one and two T/C patients, respectively. CAZ/C more effectively eradicated the bacteria isolated from these patients and no significant difference in clinical response was observed in culture-positive patients. These findings plus the lack of toxicity suggest that CAZ/C is an effective alternative for treatment of IAI.

Abdomen↗
PubMed1990

Fine needle aspiration of pancreatic fluid collections.

The complications of pancreatitis remain diagnostic and therapeutic challenges. Patients with simple pancreatitis, pancreatic necrosis, pseudocyst, noninfected fluid collection or abscess may all have similar clinical pictures. During the last decade computerized tomography (CT)-guided needle aspiration of peripancreatic fluid collections has been increasingly used as a diagnostic tool for pancreatic abscesses. This study reviewed the effectiveness of CT-guided needle aspiration of peripancreatic fluid collections at our institution in terms of diagnostic accuracy, correlation with eventual outcome, and safety. Charts of patients who underwent needle aspiration of de novo peripancreatic fluid collections over the past 2 years were reviewed. Thirty-five patients underwent 50 aspirations. Eleven patients (31%) had a positive aspirate culture; seven of these had a positive Gram's stain. There were no false positive Gram's stains but four false negatives. Twenty-four (69%) patients had negative aspirate Gram's stains and cultures. Patients with positive aspirate cultures were treated with antibiotics only (2), CT-guided drain placement (7), or surgical drainage (3). The mortality related to each of these therapeutic modalities was 50 per cent, 0 per cent, and 33 per cent, respectively. Of the 24 patients with negative aspirate cultures, five had no further treatment, 12 received antibiotics, and six underwent CT drain placement. All these patients survived. There was one false negative aspirate culture. This patient underwent delayed surgical drainage but expired. There were no major complications from CT-guided aspiration. CT-guided aspiration appears to be a safe and reliable method of diagnosing infection in peripancreatic fluid collections.(ABSTRACT TRUNCATED AT 250 WORDS)

Abscess↗
PubMed1990

Controlled comparison of cefmetazole with cefoxitin for prophylaxis in elective cholecystectomy.

Prophylactic antibiotics are given routinely to patients undergoing surgical treatment of the biliary tract to prevent postoperative infection if risk factors for postoperative sepsis are present. Cefmetazole (CM) is a new broad spectrum parenteral cephamycin antibiotic. This drug possesses a spectrum of activity against a wide range of gram-negative and gram-positive bacteria that is similar to cefoxitin (CX), an antibiotic widely used for prophylaxis with operations upon the abdomen. In this study, there was a random selection of two patients to receive CM to every one patient to receive CX. The dose of CM was 1 gram given intravenously every eight hours for three doses beginning 30 minutes before the operation; three doses of CX were given intravenously, 2 grams every six hours. Fifty-two evaluable patients comprised the CM group and 26, the CX group. The risk factors for postoperative infection were acute cholecystitis (CM, seven patients; CX, one patient), evidence from imaging procedure suggesting need for exploration of the common duct (CM, six; CX, one), hyperbilirubinemia (CM, eight; CX, four), hyperamylasemia (CM, 17; CX, seven); age of 60 years or more (CM, six; CX, one), obesity (CM, 36; CX, 14) and diabetes mellitus (CM, four; CX, five). Operative bactibilia and the organisms were comparable in both groups. Postoperative days of fever greater than or equal to 38 degrees C. (oral) (CM, 0.83 +/- 1.20; CX, 0.58 +/- 0.96) and hospitalization (CM, 6.59 +/- 2.20; CX, 5.04 +/- 1.26) were similar. Postoperative septic complications at the operative site occurred in two patients in the CM group (4 per cent) and in none of the patients in the CX group (p = 0.4; N.S., Fischer exact test). These two antibiotics had similar efficiency in preventing postoperative infections.

Adult↗
PubMed1989

Nonoperative treatment of perforated duodenal ulcer.

This report concerns 35 adult patients in whom perforation of a duodenal or prepyloric ulcer was treated nonoperatively between July 1979 and April 1988 at the Los Angeles County--University of Southern California Medical Center, Los Angeles. Each patient had pneumoperitoneum with clinical evidence of peritonitis, and a gastroduodenogram documented a sealed perforation. The ulcer was believed to be acute in 27 patients and chronic in 8. These 35 cases represent 12% of 294 cases of duodenal and prepyloric peptic ulcers with perforation treated during the same period. An intra-abdominal abscess developed in 1 of the 35 patients. Reperforation did not occur. The mortality rate for the 259 cases treated operatively during this period was 6.2%; the mortality rate of the 35 cases treated nonoperatively was 3%. Duodenal ulcer can be safely treated nonoperatively when a gastroduodenogram documents self-sealing.

Adult↗
PubMed1989

Cost analysis of two clindamycin dosing regimens.

A clinical trial of clindamycin 900 mg q8h admixed with gentamicin 1.5 mg/kg (eight-hourly group) versus clindamycin 600 mg q6h with gentamicin 1.5 mg/kg given separately (six-hourly group) was analyzed for relative cost containment. Acquisition costs were significantly higher for the six-hourly group for intravenous supplies ($181.5 +/- 47.8) when compared with the eight-hourly group ($67.6 +/- 21.6) (p less than 0.05). Nursing administration costs were greater for the six-hourly group ($28.6 +/- 7.5) compared with ($10.7 +/- 3.4) for the eight-hourly group (p less than 0.05). Also, significantly higher cost (p less than 0.05) was noted for pharmacist and technician manufacturing cost for the six-hourly group ($15.4 +/- 4.0) compared with the eight-hourly group ($13.3 +/- 4.3). Incorporating all appropriate costs, the mean total drug therapy costs were significantly greater (p less than 0.05) for clindamycin 600 mg q6h ($527.4 +/- 143.0) compared with clindamycin 900 mg q8h ($433.3 +/- 99.2). The dosing of clindamycin 900 mg q8h admixed with gentamicin 1.5 mg/kg is a more cost-effective method of drug delivery with similar efficacy and safety when compared with clindamycin 600 mg q6h with gentamicin given separately.

California↗