Biomedical subjects

Thomas Wasser

Publications and source records attributed to Thomas Wasser.

8 recordsLinked to original sources

PubMed2006

Impact of cirrhosis on outcomes in trauma.

BACKGROUND: Cirrhosis as an independent predictor of poor outcomes in trauma patients was identified in 1990. We hypothesized that the degree of preinjury hepatic dysfunction is, by itself, an independent predictor of mortality. STUDY DESIGN: The trauma registry at our Level I trauma center was queried for all ICD-9 codes for liver disease from 1999 to 2003, and patients were categorized as having Child-Turcotte-Pugh (CTP) class A, B, or C cirrhosis. Data analyzed included age, mechanism of injury, Abbreviated Injury Score (AIS), Injury Severity Score (ISS), Glasgow Coma Score (GCS), hospital length of stay, ventilator days, procedures performed, transfusion of blood products, admission lactate, base deficit, and mortality. Trauma Related Injury Severity Score (TRISS) methodology was used to calculate the probability of survival. Outcomes data were analyzed, and statistical comparison was performed using group t-test. RESULTS: Of the 50 patients meeting study criteria, 31 had alcohol-related cirrhosis, 18 had a history of hepatitis C, and 1 had cryptogenic cirrhosis. Twenty (40%) met CTP A classification, 16 (32%) met CTP B criteria, and 14 (28%) had CTP class C cirrhosis. One death occurred in the CTP A and B groups. Comparison between the five survivors and nine nonsurvivors from CTP class C showed no statistical significance in terms of age, ISS, TRISS, or GCS. CONCLUSIONS: The mortality rate for class C cirrhotic patients posttrauma continues to be higher than that predicted by TRISS, although patients with less severe hepatic dysfunction do not appear to have significantly lower than predicted survival. The degree of hepatic dysfunction remains an independent predictor of mortality and CTP C criteria must be considered when determining outcomes for patients posttrauma.

Adult↗

PubMed2006

Integrating palliative medicine and critical care in a community hospital.

Our objective was to describe the rationale and implementation of educational, environmental, clinical, and communication interventions designed to maximize indicators of improved palliative care in a community hospital intensive care unit. Surveys were used to develop educational content and methods for all levels of clinical staff and medical education. All clinical staff expressed confidence in clinical palliative processes but not in communication and psycho-spiritual issues shared with patient/families. An ambassador program and expanded visiting hours turned the waiting room into part of the therapeutic environment. New palliative order sets and practice guidelines were introduced. Interdisciplinary care planning was guided by a family communication record. Communication with families was enhanced by the use of the ambassadors, comprehensive care planning and sharing with the family within 24-48 hrs of admission, and ongoing meetings triggered by care plan changes. Quality indicators for intensive care unit-based palliative care proposed by experts provided a benchmark for evaluating the completeness of our intervention. Although not easily measured or demonstrated, it is our implicit assertion that this set of process and education interventions changed the daily nature of discourse in the intensive care unit among staff and between the staff, patients, and families.

Communication↗

PubMed2006

Radiographic comparison of standing medial cuneiform arch height in adults with and without acquired flatfoot deformity.

BACKGROUND: Adult acquired flatfoot (AAF) is characterized by decreased arch height, talar depression, medial arch depression and elongation, and forefoot abduction. We have measured standing arch height in AAF patients and in a control group of patients using the standing lateral medial cuneiform arch height radiographic measurement. METHODS: Fifteen (25 feet) patients were selected with the clinical diagnosis of symptomatic AAF with no secondary diagnoses. A control group consisted of 36 (72 feet) patients with no foot deformities or prior foot surgeries. Arch height was measured in millimeters using the standing medial cuneiform height on the lateral radiographic view. RESULTS: The mean standing medial cuneiform arch height in the control group was 18.38 mm. The mean arch height in the AAF group was 11.04 mm (p < 0.001). There were no differences between right and left feet in the control group or symptomatic and contralateral feet in the AAF group. Body mass index (BMI) in the control group was 26.17 and in the AAF 33.74. (p = 0.007). CONCLUSION: These data provide a control value for the arch height using the medial cuneiform as reference. The decrease in arch height is a strong indicator of AAF. A study with larger numbers of patients is necessary.

Adult↗

PubMed2006

The use of standing lateral tibial-calcaneal angle as a quantitative measurement of Achilles tendon contracture in adult acquired flatfoot.

BACKGROUND: To quantitate the association of Achilles tendon contracture (ATC) with adult acquired flatfoot, the authors hypothesized that the standing lateral tibial-calcaneal angle increases because of ATC. METHODS: The standing lateral tibial-calcaneal angle, talo-first metatarsal angle, lateral talocalcaneal angle, lateral standing medial cuneiform, arch height, and anteroposterior talonavicular coverage angle were measured in 21 patients (25 feet) with clinical diagnoses of ATC and adult acquired flatfoot (AAF) and compared to the same measurements in a control group of 15 patients (30 feet) with no foot deformities or previous foot surgeries. RESULTS: The mean lateral tibial-calcaneal angle in the control group was 64.43 degrees and in the AAF group 71.24 degrees (p < 0.001). The mean lateral talo-first metatarsal angle in the control group was 11.77 degrees, and in the AAF group with ATC it was 25.80 degrees (p < 0.001). The mean arch height in the control group was 17.90 mm and in the AAF group, 8.48 mm (p < 0.001). In the ATC and AAF group an increasing standing lateral tibial-calcaneal angle was correlated with a decreasing lateral talo-calcaneal angle (p = 0.044), and a decreasing arch height was correlated to an increasing lateral talo-first metatarsal angle (p < 0.001). CONCLUSION: Adults with flatfeet and Achilles tendon contracture may have a statistically significant increase in the standing lateral tibial-calcaneal angle. This angle may be a reproducible measure of ATC. An increase in the standing lateral tibial-calcaneal angle may confirm and quantitate the clinical diagnosis of Achilles tendon contracture. Further studies with more patients are needed.

Achilles Tendon↗

PubMed2005

How do medical student self-assessments compare with their final clerkship grades?

The purpose of this study was to determine how a medical student's self-assessment at the completion of the third-year Ob/gyn clerkship compares with the institution's final grades at Lehigh Valley Hospital. From November 2002 to November 2003 at completion of each six-week Ob/gyn clerkship rotation, 47 medical students assessed themselves on the following parameters: fund of knowledge, personal attitude, clinical problem-solving skills, written/verbal skills, and technical skills. Additionally, they were asked to predict their performance on the NBME Shelf Exam. Their assessments were then compared with their final clerkship grades in each of the above parameters. Chi-squared and Kendall-tau tests were used to analyse the data for degree of agreement and association, respectively. There was a statistically significant weak to moderate, positive correlation between students' self-assessment and final clerkship grade for written/verbal skills (p = 0.002, r = 0.390). A statistically significant agreement between raters was also revealed for written/verbal skills (p = 0.003). Weak, non-statistically significant, positive relationships were revealed for fund of knowledge, clinical problem-solving and technical skills. A weak, negative, non-significant relationship was revealed for personal attitudes, and there was no statistically significant relationship between students' prediction of NBME score and categorized true score (p = 0.717, r = 0.49). At the end of their Ob/gyn clerkship, third-year medical students are better at assessing their technical and written/verbal skills than their global fund of knowledge and personal attitudes. These results may suggest that students are not aware of their own personal attitudes and communication skills and how they can affect their effectiveness as a physician.

Clinical Clerkship↗

PubMed2005

The effect of body mass index on patient outcomes in a medical ICU.

STUDY OBJECTIVES: To examine the effect of patient body mass index (BMI) on outcome in intensive care. DESIGN: In a prospective study, the patients were classified into groups based on the calculated BMI, as follows: BMI < 19.0 (n = 350), > or = 19.0 and < 25.0 (n = 663), > or = 25.0 and < 29.9 (n = 585), > or = 30.0 and < 40.0 (n = 396), and > or = 40.0 (n = 154). Groups were compared by age, APACHE (acute physiology and chronic health evaluation) II score, mortality, ICU length of stay (LOS), hospital LOS, number receiving ventilation, and ventilator-days. Adverse events including nosocomial pneumonia, ventilator-days per patient, failed extubations, and line-related complications were recorded. SETTING: The study was conducted in a 9-bed medical ICU of a 650-bed tertiary care hospital. MEASUREMENTS: Height and weight were prospectively recorded for the first ICU admission during a hospital stay. RESULTS: Between January 1, 1997, and August 1, 2001, 2,148 of 2,806 patients admitted to the ICU had height and weight recorded. There were no differences in APACHE II score, mortality, ICU LOS, hospital LOS, number receiving ventilation, ventilator-days, average total cost, or average variable cost among the five groups. However, the severely obese patients were more frequently female and younger than those who were overweight and obese (p < 0.001). Adverse events were infrequent, but there were no differences between the obese/very obese compared with others. CONCLUSION: BMI has minimal effects on ICU outcome after patients are admitted to a critical care unit.

APACHE↗

PubMed2004

Initial head computed tomographic scan characteristics have a linear relationship with initial intracranial pressure after trauma.

BACKGROUND: Despite current recommendations by the Brain Trauma Foundation regarding the placement of intracranial pressure (ICP) monitoring devices, advances in computed tomographic (CT) scan technology have led to the suggestion that increased ICP may be predicted by findings on admission head CT scan and that patients without such findings do not require such monitoring. A linear relationship exists between characteristics of admission head CT scan and initial ICP level, allowing for selective placement of ICP monitoring devices. METHODS: From 1997 to 2001, a retrospective review of patients admitted with a Glasgow Coma Scale (GCS) score < 8 and head CT scan who underwent ventriculostomy placement at our institution, was conducted. Patients undergoing craniotomy with evacuation of mass lesions before ventriculostomy placement were excluded. Age, sex, mechanism of injury, anoxia, osmotic treatment, presence of drugs/alcohol, initial mean arterial pressure, initial GCS score, and initial ICP were recorded. Initial head CT scans were reviewed independently by two neuroradiologists who were blinded to ICP measurements, neurosurgical treatment, patient outcome, and each other's interpretation. Initial CT scans were evaluated and scored on a 1 (normal) to 3 (abnormal) scale with respect to ventricle size, basilar cistern size, sulci size, degree of transfalcine herniation, and gray/white matter differentiation. Initial ICP readings and CT scan findings were compared to determine whether a significant linear relationship existed between the above CT scan findings and ICPs. Logistic and univariate linear regression were used to compare averaged radiologist score versus dichotomized ICP at baseline. RESULTS: Initial head CT scan characteristics show a linear relationship to baseline ICPs. These findings are associative, but are not uniformly predictive. CONCLUSION: Therefore, the current Brain Trauma Foundation recommendation of ICP monitoring in those patients presenting with a GCS score < 8 with an abnormal CT scan or a normal CT scan with age > 40 years, systolic blood pressure < 90 mm Hg, or exhibiting posturing should be followed.

Adolescent↗

PubMedDate not supplied

Evaluation and recommendations from a study of a critical-care waiting room.

The intensive care unit (ICU) waiting room is a dynamic place that influences the satisfaction of families of critically ill patients. Waiting-room comfort and amenities are important, because families often spend a great deal of nonvisiting time there. A quality improvement evaluation of the ICU waiting room at Lehigh Valley Hospital, Allentown, PA, was conducted. Methods included distribution of an 18-item family survey, ethnographic observations, interviews, and assessment of the physical environment. Findings suggest that the role of the receptionist and access to food and other services were important to families and influenced their assessment of the quality of services provided by the ICU.

Academic Medical Centers↗