Biomedical subjects
Publications and source records attributed to V Velanovich.
Although complications of Meckel's diverticula are relatively common, there has not been a reported case, to our knowledge, of foreign bodies impacted within a Meckel's diverticulum. We report herein a case of a 2-year-old child who had two pennies trapped in a Meckel's diverticulum. This case demonstrates that foreign objects in the right lower quadrant that do not progress may be impacted in a Meckel's diverticulum.
Pseudomembranous colitis and toxic megacolon are rare complications of antineoplastic chemotherapy. Twelve cases of pseudomembranous colitis and four cases of toxic megacolon, both occurring as complications of chemotherapy, have been reported in the medical literature. These diseases occurred as separate and distinct entities. Fulminating pseudomembranous colitis leading to toxic megacolon in the setting of chemotherapy has not been previously reported. We report such a case, emphasizing its atypical presentation and rapid, fulminant course.
Parapneumonic effusions are relatively common sequelae of pneumonias. Occasionally, parapneumonic effusions will lead to empyemas. If these fluid collections are not aggressively drained in a timely manner, they will become loculated, placing the patient at risk for septic complications. Two cases of parapneumonic empyemas with delayed drainage eventually requiring thoracotomy and decortication are presented. These cases illustrate the need for early, complete drainage of parapneumonic empyemas to avoid septic complications and unnecessary surgery.
Debate continues as to what should be the appropriate "negative" appendectomy rate for patients suspected of having acute appendicitis. The controversy centers around balancing the complications of appendectomy for a normal appendix with those for a perforated appendix. By using a decision analysis approach to the probable outcomes of appendectomy for a normal appendix, acute appendicitis, and perforated appendicitis, this study provides one answer to this question. These outcomes are based on a review of the results of over 10,000 appendectomies. There is an inverse relationship between the normal appendectomy rate and perforated appendicitis rate. The overall complication rate in patients suspected of having appendicitis improved when the rate of perforated appendicitis was lowered, even if this meant raising the negative appendectomy rate. The perforation rate seemed to level off at approximately 10 per cent. The quality of surgical care delivered to a given population should not be judged solely on the normal appendectomy rate, but this rate should be interpreted in the light of the perforated appendicitis rate. Quality assurance assessments should focus first on perforated appendicitis and only later on normal appendectomy.
The therapeutic approach to a patient with concomitant abdominal aortic aneurysm and colorectal carcinoma is not clear. Decision analysis helps clarify decision options and quantify therapeutic outcomes. Variables used in decision analysis include life expectancy after resection for colorectal cancer and abdominal aortic aneurysm, rupture rate of abdominal aortic aneurysm, complications of colorectal The results support the concept that the symptomatic lesion should be treated first. When both lesions are asymptomatic and the aneurysm is 4-5 cm in diameter, it should be resected first, if the colorectal cancer has a less than 5% chance of obstruction or perforation, as is found in noncircumferential lesions. When the aneurysm is greater than 5 cm, it should be resected first if the cancer has a less than 22% chance of obstructing or perforating, as with circumferential lesions. Simultaneous resection should be considered for patients with aneurysms greater than 5 cm and cancers with a greater than 75-80% chance of obstruction or perforation, provided the dual procedures can be performed with a less than 10% operative mortality and less than 50% complication rate.
Bayesian analysis is a method by which the reliability of diagnostic tests can be determined. It produces a probability of a patient having the disease given a positive test result (posterior probability). If more than one study of a given test's diagnostic accuracy is done, then how can we determine which of these studies has produced the most reliable posterior probability? Meta-analysis is a method whereby data from different studies can be combined. This paper proposes that meta-analysis more accurately estimates the true Bayesian posterior probability than other methods of data pooling.
Although it is generally agreed that prophylactic antibiotics are necessary for the prevention of postoperative wound infection, the choice of antibiotic regimen is controversial. In an attempt to determine the most effective antibiotic regimen, a meta-analysis of published clinical trials of prophylactic antibiotics for head and neck surgery was undertaken. The meta-analysis revealed a relative difference in infection rates of 43.7 percent in favor of the use of antibiotics versus placebo, of 8.3 percent in favor of multiple antibiotics versus a single antibiotic, of 13.7 percent in favor of multiple antibiotics versus cefazolin, and of 4.1 percent in favor of multiple-day prophylaxis versus single-day prophylaxis. This meta-analysis suggests that a 1-day course of clindamycin may be the most effective prophylactic antibiotic regimen for head and neck surgery.
Damage to the lymphatic vessels may occur after surgery on the greater saphenous vein. We describe the development of a lymphocele in a patient after saphenous vein harvesting for a coronary artery bypass graft. Treatment of these lymphoceles should initially be conservative, but if this approach fails, surgical excision should be performed and special attention paid to identifying and ligating the feeding lymphatic vessel.
The purpose of this study was to evaluate the ability of preoperative laboratory testing to predict postoperative complications. Five hundred twenty patients undergoing elective surgery had their American Society of Anesthesiologists' classification, ponderal index, electrolyte values, glucose levels, blood urea nitrogen/creatinine values, complete blood counts, coagulation studies, total protein/albumin/lymphocyte count, electrocardiogram, chest radiograph, urinalysis, pulmonary function tests, type of anesthesia, and type of operation recorded preoperatively. Patients were followed prospectively after surgery for the development of complications. The data were analyzed by univariate and multivariate methods. Postoperative complications were strongly associated with American Society of Anesthesiologists' classification, type of anesthesia, and type of operation. However, only a few laboratory tests, such as electrocardiogram, chest radiograph, and nutritional status, were associated with postoperative complications. Therefore, in general, preoperative laboratory testing should only be undertaken for specific indications. Recommendations for routine tests are made depending on the age of the patient.
Controversy exists over optimal treatment of stage I floor-of-mouth cancers, with advocation of either primary radiotherapy or surgical resection with or with-out a neck dissection. A decision analysis was undertaken to determine the outcomes of these treatment options. The quality-adjusted life expectancies were determined using best estimates from the literature of survival, recurrence, short-term morbidity, and quality of life for radiotherapy and surgical resection. The quality-adjusted life expectancies were as follows: for surgical resection with neck dissection, 18.50 years; for surgical resection without neck dissection, 14.48 years; and for primary radiotherapy, 7.95 years. Sensitivity analysis showed that these results varied with quality of life assumptions and survival data. Therefore, each institution needs to review its own survival data and question patients about quality of life to determine how treatment options fit into the decision analysis.
Ischemic ulcers remain difficult to treat. We describe a patient with bilateral ischemic leg ulcers treated preoperatively with pentoxifylline. She had a successful skin graft with no rejection of the graft. The theoretical advantage of treatment with pentoxifylline is discussed, with emphasis not only on its hemorheological properties, but also on its actions on the prostaglandin pathway, platelet aggregation, and thrombosis. We suggest that preoperative pentoxifylline treatment may be a useful adjunct in the closure of ischemic ulcers.
Thirty-six thousand two hundred fifty abdominal hernia repairs were performed in U.S. Army medical treatment facilities during a five-year period. This study presents data about the type of hernia, incidence of complications by obstruction or strangulation, age, sex, and mortality. Hernias occurring with intestinal obstruction or gangrene (strangulation) are referred to as complicated hernias. Inguinal hernias in children less than two years of age, femoral hernias, and unusual (such as internal or obturator) hernias were found to have an increased incidence of complications. Surgical repair of ventral, umbilical, and femoral hernias was done with a low surgical risk and the presence of complications did not significantly increase this risk. An increased risk of mortality is associated with the repair of complicated unusual hernias and complicated inguinal hernias in patients more than 60 years of age.
Four hundred sixty-eight patients undergoing elective surgery were prospectively followed for the development of postoperative complications. There was a trend toward increasing complication rate with a lower ponderal index. However, lower ponderal indices were associated with increasing rates of diabetes mellitus and hypertension. Of these patients, forty cases with postoperative complications were matched to 40 control cases for sex, age, concomitant illness and operation performed. The cases of postoperative complications had a statistically significantly lower ponderal index than the controls (11.98 versus 12.43). The increased risk of postoperative complications in those patients with a ponderal index of less than 11 was 3.36, and less than 13 was 3.44. Surgeons who treated patients with lower ponderal indices need to have a high index of suspicion for the development of postoperative complications in these patients.
The popular methods of reporting the reliability of a test--sensitivity and specificity--do not tell the practicing physician what the chance is that a patient has the disease if the results from the particular test for that disease are positive or negative. Bayesian analysis, however, does answer this question. In this study, the data from 29 studies of peritoneal lavage were analyzed using the Bayesian method. The probability of an intra-abdominal injury being present if findings from lavage were positive ranged from 0.448 to 1.0. The probability of an intra-abdominal injury being present if findings from lavage were negative ranged from zero to 0.286. These probabilities varied with the criteria for positivity, technique used and type of trauma. In general, results of Bayesian analysis showed that findings from peritoneal lavage were most reliable in diagnosing the patient with blunt trauma when the standard positive criteria and open technique were used.
The increasing incidence of illicit intravenous drug abuse has reached epidemic proportions in western society. Although the accompanying infectious complications such as hepatitis and acquired immunodeficiency syndrome receive the most notoriety, injection injuries are causing an increasing number of problems. A retrospective review of patients requiring admission for acute or chronic drug injection injuries of the upper extremities was made at the Detroit Receiving Hospital from 1980 through 1985. The demographical, historical, physical, microbiological, and follow-up data were analyzed. The majority of the injuries involved subcutaneous injections into the hand with accompanying inflammatory or infectious complications. The bacteriological data revealed unique characteristics and did not reflect patterns expected from inoculation of normal skin flora. A treatment regimen based on the data is proposed.
Controversy persists over the best choice of fluid to use for resuscitation. A number of published articles promote the use of either colloid or crystalloid fluids. Most of the arguments for use of one fluid or the other are based on cardiopulmonary data collected during and after fluid resuscitation. Although many studies report the mortality rate of patients treated with both fluids, none have critically analyzed this most important aspect of therapy. Meta-analysis is a relatively new statistical method whereby data from a number of clinical trials can be pooled to produce more reliable data. In this study meta-analysis was used to pool mortality data from reports of eight previously published, randomized, clinical trials, in which the efficacy of crystalloid and colloid fluid resuscitation was compared. The overall treatment effect when the data from all the clinical trials were pooled showed a 5.7% relative difference in mortality rate in favor of crystalloid therapy. When the data from only those studies using trauma patients were pooled, the overall treatment effect showed a 12.3% difference in mortality rate in favor of crystalloid therapy. However, when data from studies that used nontrauma patients were pooled, there was a 7.8% difference in mortality rate in favor of colloid treatment. In patients with trauma who are septic and in whom the capillary leak syndrome leads to adult respiratory distress syndrome, it may be assumed that colloid resuscitation would be no better than crystalloid resuscitation. In this study the meta-analysis of published data showed that this form of treatment is deleterious. In patients who are nonseptic or having elective surgery, however, the basement membrane is intact, and meta-analysis of data in this setting showed that treatment with colloids would be efficacious.
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