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Biomedical subjects

W Rappaport

Publications and source records attributed to W Rappaport.

At least 19 recordsLinked to original sources
PubMed1997

Risk factors in patients undergoing major nonvascular abdominal operations that predict perioperative myocardial infarction.

BACKGROUND: Perioperative myocardial infarction (PMI) is an uncommon but serious complication of major abdominal surgery. Identifying the patients at risk may potentially reduce morbidity and mortality. In this study we determined risk factors associated with PMI in patients undergoing abdominal, nonvascular surgery (ANVS). METHODS: The utility of risk factors for PMI using Goldman's criteria and nine other variables were compared in patients diagnosed with PMI after ANVS (group I) and a control group (group II) matched for age, gender, and type of operation. RESULTS: Thirty-four patients, 21 men and 13 women, with a mean age of 70 years were diagnosed with PMI, which was associated with a 41% mortality rate (14 of 34). Risk factors for PMI included poor general condition, congestive heart failure, abnormal cardiac rhythm, smoking, previous myocardial infarction (MI), and emergent operation. CONCLUSION: Although PMI following ANVS is uncommon, the mortality rate remains high. Patients classified as Goldman's class III and IV, or with a history of cigarette smoking, previous MI, or angina merit further evaluation in order to reduce the incidence of this complication.

Abdomen↗
PubMed1997

Contemporary medical therapy for gastroesophageal reflux disease.

Gastroesophageal reflux disease is a chronic disorder that requires long-term therapy in most patients. The appropriate medical therapy should be individualized to the severity of symptoms, the degree of esophagitis and the presence of other acid-reflux complications. Lifestyle changes should form the basis of any therapeutic approach. In patients with mild to moderate disease, initial therapy with histamine H2-receptor antagonists in conventional dosages is suggested. Prokinetic agents are potentially useful in patients with impaired esophageal or gastric motor function, but their efficacy as single agents does not appear to surpass that of standard doses of H2 blockers. Sucralfate, a cytoprotective agent, is an additional therapeutic option. For patients with more severe disease, omeprazole and lansoprazole provide unequaled healing rates and accelerated symptom relief. In most patients, maintenance therapy is vital. Surgery is indicated in patients whose disease is refractory to medical therapy and in those who develop complications not amenable to medical therapy.

Drug Therapy, Combination↗
PubMed1995

Surgical treatment of symptomatic biliary stones in patients with cystic fibrosis.

Patients with cystic fibrosis have a high incidence of cholelithiasis. However, few studies have addressed the operative therapy for cholelithiasis in this group of patients with poor pulmonary function. We reviewed six patients with cystic fibrosis who were treated for symptomatic biliary stones. Five patients underwent cholecystectomy for chronic cholecystitis. One patient with extremely poor pulmonary status presented with choledocholithiasis and cholangitis, which was successfully treated with endoscopic sphincterotomy followed by ursodeoxycholic acid therapy. Five of these six patients had significant relief of their symptoms. One patient never recovered completely from the operation and eventually died from continued pulmonary deterioration. We conclude that in patients with cystic fibrosis and symptomatic biliary stones, careful attention to pulmonary care can afford safe, elective cholecystectomy. More conservative treatment is indicated in patients with marginal pulmonary reserve.

Adolescent↗
PubMed1994

Risk of nonshunt abdominal operation in the patient with cirrhosis.

BACKGROUND: The hazards of operative treatment for variceal hemorrhage and intractable ascites in patients with cirrhosis are well known. Much less information is available on the morbidity and mortality in these patients after abdominal operations not directly related to the sequelae of portal hypertension. STUDY DESIGN: We reviewed the records of 77 consecutive histologically proved cases of cirrhosis in patients undergoing 85 general surgical, abdominal procedures during a ten year period. Logistic regression analysis was done on 32 preoperative and intraoperative variables with relation to postoperative outcome. RESULTS: There were 47 men and 30 women, with a mean age of 61 years (range of 28 to 86 years). The 30-day mortality rate was 18 percent (15 of 77 patients). Emergent operation was associated with a mortality rate of 32 percent (11 of 35 patients) compared with 8 percent (four of 50 patients) after elective procedures (p < 0.05). Extensive complications occurred in 28 percent of patients (24 patients; 14 percent after elective operative treatment and 49 percent after emergent procedures). The mortality rate was greatest after gastric procedures (38 percent). Other factors of statistical significance (p < 0.05) associated with poor postoperative outcome included cachexia, preoperative transfusion of fresh frozen plasma, and intraoperative platelet transfusion. Surprisingly, operative blood loss, presence of ascites, and operative time were not associated with increased complications or death. CONCLUSIONS: We conclude that elective, nonshunt abdominal operations can be performed with acceptable morbidity and mortality rates in selected patients with cirrhosis.

Abdomen↗
PubMed1993

Age- and gender-related differences in 24-hour esophageal pH monitoring of normal subjects.

Twenty-four-hour esophageal pH monitoring is currently the most sensitive test for diagnosing gastroesophageal reflux. Little is known, however, about the effect of aging and gender on esophageal acid exposure in asymptomatic individuals. Thirty asymptomatic volunteers underwent 24-hr esophageal pH monitoring. Fifteen were < 65 years (eight female, seven male) and 15 were > or = 65 years (seven female, eight male). In this asymptomatic group no significant difference was seen by age, while males were found to have significantly more esophageal acid exposure than females. The need for sex-specific normal 24-hr pH monitoring values is suggested. Thirty percent of these asymptomatic subjects were abnormal by conventional 24-pH criteria. The clinical importance of these "silent refluxers" is unknown.

Adult↗
PubMed1993

Education about death and dying during the clinical years of medical school.

BACKGROUND: Although there has been a dramatic increase in education about death and dying in medical school curricula, the physician's interaction with terminally ill patients and their families still causes concern. The purpose of our study was to determine the impact of the third-year clerkship on education of medical students about death and dying. METHODS: From August 1, 1988, to August 1, 1990, a questionnaire concerning the care of terminally ill patients was distributed to all students completing the third-year clinical clerkship at our medical school. RESULTS: One hundred and eighty questionnaires were distributed, of which 106 were returned, yielding a response rate of 59%. All students had cared for a terminally ill patient during their third year. Forty-four (41%) students responding had never been present when an attending physician talked with a dying patient, and 37 (35%) had never discussed with an attending physician how to deal with a terminally ill patient. During the surgical clerkship 77 (73%) students had never been present when a surgeon had to tell the family of a patient bad news after surgery, and 90 (85%) had never been present when an attending surgeon had informed a family that their relative had died. Despite the fact that the curriculum addresses the stages of death and dying, almost half of the students could not remember these. When they were discharging a terminally ill patient home, one third of students could not identify problems that would be encountered by the family in caring for the patient. CONCLUSIONS: Fifty-seven (54%) felt that they were poorly equipped to deal with terminally ill patients on graduation from medical school, and 91% welcomed the opportunity to be educated in this area during the clinical years.

Adult↗
PubMed1993

The failure of conventional methods to promote spontaneous transpyloric feeding tube passage and the safety of intragastric feeding in the critically ill ventilated patient.

Nasoenteral tube feedings are often recommended in critically ill patients when gastrointestinal tract function is intact. Conventional methods of placement include turning the patient on the right side and the use of drugs that stimulate peristalsis to promote transpyloric passage. A prospective study was initially performed to assess the success of conventional methods used to promote transpyloric feeding tube placement in patients requiring assisted ventilation admitted to the Surgical Intensive Care Unit (SICU) (Part I of the study). In 68 critically ill ventilated patients, placement of nasoduodenal feeding tubes was attempted. Successful transpyloric placement was achieved in only ten patients. There was no correlation between age, gender, admitting diagnosis, time of tube placement and successful placement. The second part of the study was initiated to assess the safety of nasogastric feeding in critically ill ventilated patients. Forty-two patients admitted to the SICU were considered candidates for gastrointestinal tract feeding and were fed through the gastric route. Twenty-five patients reached enteral feeding goal rate within 72 hours, while 34 patients achieved goal rate by five days. Eight patients required total parenteral nutrition to meet nutritional needs because of an inability to achieve adequate nutritional support enterally. There were 11 complications noted in ten patients, including one episode of aspiration pneumonia. The presence of complications was not related to age, gender, admitting diagnosis, infusion method or type of formula used. Duodenal intubation using conventional methods in critically ill ventilated patients is unsuccessful in most patients. Nasogastric feeding in this group of patients can be safely administered in selected instances.

Critical Illness↗
PubMed1992

Influence of spousal opinions on residency selection.

Fourth-year medical students face the difficult task of choosing a residency consistent with their career goals. Our study investigates the input of the spouse on the residency selection. From July 1, 1988, to July 1, 1990, questionnaires were sent to all 69 spouses of fourth-year medical students at the University of Arizona Medical Center. Fifty-six were returned for a response rate of 81%. Of the 16 women and 40 men who responded (mean age: 27 years), 55 (98%) spouse stated that there had been family discussions on the choice of a residency program, and 41 (73%) respondents thought that they had significant input. When asked to rank the items that most influenced their support for a particular training program, career goals of the medical student (68%) and lifestyle (21%) were most important, whereas prestige, earning capacity, and program length were ranked lowest. Specific concerns expressed by spouses on the selection of a surgical residency included time commitment as the most commonly cited (79%), followed by fatigue (48%). A statistically significant correlation existed between those spouses actively discouraging the choice of general surgery and those objecting to the time commitment during residency (p less than 0.05). We conclude that spouses have significant preferences regarding the choice of a training program following medical school. Career goals and lifestyle appear to be the most important factors; however, despite concern about the time commitment, the majority of spouses are supportive of the selection of a surgical residency.

Adult↗
PubMed1992

A new method of diagnosing diaphragmatic injury using intraperitoneal technetium: case report.

The diagnosis of diaphragmatic laceration following blunt or penetrating trauma is often difficult to establish. Delay in recognition of this injury can be life threatening, resulting in herniation of abdominal viscera with possible strangulation or respiratory embarrassment. Previous animal studies from our institution have documented that intra-abdominal instillation of technetium sulfur colloid is a sensitive method to diagnose diaphragmatic disruption. We now present a case of diaphragmatic injury where the preoperative diagnosis was accurately made using this method when other imaging studies were inconclusive.

Adult↗
PubMed1992

Control of nonhepatic intra-abdominal hemorrhage with temporary packing.

The use of temporary packing to obtain hemostasis has long been an adjunct for surgical procedures in the pelvic area and has recently become an acceptable approach to control hemorrhage resulting from hepatic injuries. In an unstable patient with coagulopathy and diffuse capillary bleeding, packing may be the easiest way to control intra-abdominal bleeding through the simple effect of tamponade. The patient can be re-explored after a period of stabilization, when a more definitive control of hemostasis can be undertaken. Herein, we report six patients with severe underlying disease states that contributed to massive intra-abdominal bleeding refractory to control by conventional means when temporary packing was used to control hemorrhage.

Abscess↗
PubMed1992

The role of early tracheostomy in blunt, multiple organ trauma.

During a 9-year period, 101 patients sustaining blunt, multiple organ injury underwent tracheostomy. Group I consisted of 32 patients who underwent tracheostomy within the first 4 days of injury (early tracheostomy) and Group II comprised 69 patients who underwent tracheostomy more than 4 days after surgery (late tracheostomy). There was no statistical difference between the two groups in terms of age, Injury Severity Score, Glasgow Coma Score, and associated injuries. The mean time of mechanical ventilatory support was 6.0 +/- 3.4 days in Group I as compared to 20.6 +/- 12.2 days in Group II (P less than 0.001). Early weaning from the ventilator was accomplished in 32 (100%) patients who underwent early tracheostomy versus 43 (62%) of those who underwent late tracheostomy (P less than 0.001). Finally, the incidence of nosocomial pneumonias was also significantly less in patients undergoing early tracheostomy. There were three nonlethal complications associated with tracheostomy. The authors conclude that early tracheostomy helps in early weaning from the ventilator and reduces the incidence of nosocomial pneumonias and time of mechanical ventilatory support in patients with blunt, multiple organ injury.

Academic Medical Centers↗
PubMed1991

Does the retrocecal position of the vermiform appendix alter the clinical course of acute appendicitis? A prospective analysis.

Ninety-four adult patients undergoing appendectomy for acute appendicitis were prospectively studied during a 2-year period. Patients were divided into retrocecal (group 1; n = 27 [29%]) and anterior (group 2; n = 67 [71%]) groups according to the position of the appendix. There was no statistical difference between the two groups in duration of symptoms, presenting signs and symptoms, and initial white blood cell count. Furthermore, retrocecal appendicitis was not associated with a higher rate of perforation or increased morbidity. We conclude that the retrocecal position of the appendix does not alter the presentation of appendicitis.

Acute Disease↗
PubMed1991

A model for the assessment of students' physician-patient interaction skills on the surgical clerkship.

Physician-patient interaction skills are predominantly taught by successful role modeling but are rarely evaluated formally and systematically. This study describes a new model for the assessment of student physician-patient interaction skills and reports results of use in 78 third-year medical students on clerkships at two institutions. A single nurse instructor at each institution evaluated these skills using an 18-item checklist during student performance of wound care and dressing changes. Students were focused on the evaluation of their technical skills and were unaware of the evaluation of their interaction skills. Immediate feedback on performance was provided. The mean percentage score for the interaction skills was 35%, and no improvement was noted with greater clinical experience (later rotations). We conclude that there is a striking deficiency in physician-patient interaction skills among third-year students. The model described is effective for both evaluation and feedback.

Clinical Clerkship↗
PubMed1991

Value of lymph node biopsy in the treatment of patients with the human immunodeficiency virus.

The indications and value of lymph node biopsy in patients infected with the human immunodeficiency virus (HIV) are not clearly defined. We reviewed 29 consecutive lymph node biopsies performed on 24 patients with the HIV over a 4-year period. Indications for biopsy included: (1) new or worsening medical symptoms with no detectable etiology in patients with lymphadenopathy, (2) disproportionately larger or enlarging lymph node in patients with generalized adenopathy, and (3) exclusion of concomitant disease in patients with previously defined infectious or neoplastic processes. The biopsy samples exhibited a diversity of histologic appearances including atypical and reactive hyperplasia, malignancy, and infection. Nineteen biopsies (64%) resulted in the institution or alteration of treatment. The absolute number of T-helper cells prior to biopsy was significantly lower in patients with a diagnosis of malignancy or infection (p < 0.05), as well as in those who eventually died (p < 0.05). Four (14%) minor complications resulted from lymph node biopsy. Based on our results, we conclude that lymph node biopsy is indicated in the above three subsets of HIV-infected patients. Biopsy can be performed with minimal morbidity and significantly alters therapy in the majority of patients.

AIDS-Related Complex↗
PubMed1991

A technique for repair of recurrent indirect inguinal hernias.

The repair of a recurrent inguinal hernia can be a technically demanding operation. Due to scar tissue from prior surgery, injury to the spermatic cord or compromise of the testicular blood supply is possible. A technique for repair of recurrent indirect inguinal hernia that allows minimal dissection of the spermatic cord structures is described.

Hernia, Inguinal↗
PubMed1991

Teaching mechanical ventilation.

Participants have stated that having actually experienced the modes of the ventilator and the components of weaning parameters, they are better able to understand and manage ventilated patients, as opposed to trying to memorize them as in the past. They also have a much greater appreciation for the discomfort experienced by the ventilated patient. (Most students cannot tolerate a PEEP of 10 centimeters of H2O for more than a few minutes). Many remarked that they are much more tolerant with their agitated, intubated patients because they can now understand their agitation. The session has proved to be an effective teaching tool. It is cost effective, does not take long and is enthusiastically received by the participants who believe they have gained a better understanding of how to properly care for their anxious, intubated patients.

Education, Medical↗
PubMed1991

Preoperative screening for perioperative cardiac risk.

Preoperative screening for potential cardiac complications is crucial in making rational decisions about surgery. A number of classification schemes are available to aid the primary care physician in assessing a patient's perioperative cardiac risk. In general, these schemes enable the physician to place patients in low-risk, moderate-risk and high-risk categories. Patients at low risk can often be safely referred for surgery with minimal preoperative evaluation, while those at potentially high risk frequently need further assessment and medical or surgical treatment of cardiac disease prior to surgery. The classification schemes are most accurate in identifying patients at high risk for perioperative cardiac complications. However, patients with silent underlying cardiac disease are often underclassified with respect to potential risk. For those patients, accurate prediction of perioperative cardiac complications can be challenging.

Health Status↗