J. Gary Maxwell

A statewide analysis of level I and II trauma centers for patients with major injuries.

BACKGROUND This study examines statewide outcomes and resource use in Level I and II trauma centers for patients with major injuries. METHODS This study analyzed trauma registry data on patients admitted to North Carolina Level I and II trauma centers from January 1995 to December 1996 with one of four major injuries: thoracic aortic disruption, liver injury, pelvic fracture, or pulmonary contusion. RESULTS There were 59 thoracic aortic disruptions, 109 liver injuries, 153 pelvic fractures, and 962 pulmonary contusions identified among 26,030 admissions. Case fatality was not significantly different (Level I, 16.8%; Level II, 14.9%). Hospital charges were significantly higher in Level I centers (Level I,

Cholecystectomy in Patients aged 80 and older

47,366; Level II,

Indium-111 labeled leukocytes in the evaluation of suspected abdominal abscesses

35,490), but this difference was confined to transferred patients. Controlling for Revised Trauma Score, Injury Severity Score, age, gender, and race, multivariable regression confirmed findings regarding hospital charges, and multiple logistic regression confirmed findings regarding case fatality. CONCLUSION Case fatality was similar in Level I and Level II trauma centers in North Carolina, and hospital charges were comparable in patients with comparable injuries not requiring transfer. This suggests that patients with major injuries may be optimally cared for in both Level I and Level II trauma centers.

Carotid endarterectomy in the community hospital in patients age 80 and older.

BACKGROUND We assessed whether the increase in performance of laparoscopic cholecystectomy has affected patients aged 80 and older and if outcomes of a laparoscopic approach in this population would show improvement over those for open surgery. METHODS We analyzed an 11-state discharge database obtained from the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project. Release 1 contains a 20% sample of United States hospitals for the period 1988 to 1992. Diagnosis-related group (DRG) codes 197 and 198 were searched, and demographics, type of surgery, and outcome measures were analyzed. RESULTS In 5 years, 350,451 patients underwent cholecystectomy with the DRG codes listed. Of those, 18,500 patients were aged 80 to 105. The total number of cholecystectomies increased each year. Performance of laparoscopic cholecystectomy rose rapidly and that of open cholecystectomy decreased. Overall mortality with laparoscopic cholecystectomy was 1.8%, was lower than that of open cholecystectomy, was lower in women, and decreased with time. CONCLUSIONS Patients aged 80 and older have participated in the increased performance of cholecystectomy and the switch to laparoscopic cholecystectomy. This has a low mortality, low length of stay, and higher proportion of patients being discharged to home compared with patients having open cholecystectomy.

Hospital Resources Used To Treat the Injured Elderly at North Carolina Trauma Centers

Sixty-eight indium-111-labeled leukocyte imaging studies were performed in 53 patients with suspected abdominal abscesses. Twenty-nine studies gave abnoramal results. Nine wound infections were demonstrated, and 14 abscesses were correctly identified. Four studied demonstrated colonic accumulation, one of which remains unexplained, and two accessory spleens were identified. Indium-111 leukocyte imaging is a sensitive and specific study in evaluating patients with suspected abdominal abscess. Differentiation of abscess from other causes of inflammation has not been a problem. The exact role of leukocyte imaging compared with gallium-67 citrate imaging, ultrasound and computerized tomography remains to be determined.

Deriving the indications for laparoscopic appendectomy from a comparison of the outcomes of laparoscopic and open appendectomy

OBJECTIVE To determine whether the rates of death and complications of carotid endarterectomy (CE) were different in the octogenarian population than in patients younger than age 80. SUMMARY BACKGROUND DATA The utility of CE depends on the ability of the surgeon and hospital to attain low rates of death and complications, including all subgroups of the patient population. In the past 30 years, the number of people age 85 and older has increased 274%. METHODS Detailed chart review was carried out on all CE procedures done from 1979 through 1998. Descriptive demographic data, risk factors, surgical details, length of stay, deaths, and complications were recorded. RESULTS A total of 2,398 CEs were performed in 1,970 patients; 2,180 procedures were performed in 1,783 patients younger than 80, and 218 CEs were performed in 187 patients age 80 and older. Sixty-five percent of the octogenarians and 67% of patients younger than age 80 had neurologic symptoms. Among asymptomatic patients, 89% had stenosis of 75% or more. There were 62 strokes in the 2,180 procedures in the younger group, for a stroke rate of 2.8%, and 7 strokes in the 218 procedures in the older group, for a stroke rate of 3.2%. The death rates were 0.9% for the octogenarians and 1.4% for the younger group. CONCLUSIONS Carotid endarterectomy can be safely performed in a community hospital in patients age 80 and older. Outcomes in octogenarians were not significantly different than those of younger patients and were within the range required for CE to be considered beneficial in the prevention of stroke.

Clinicopathologic factors and patient perceptions associated with surgical breast-conserving treatment

Objective: The purpose of this paper is to compare the hospital resources used by elderly, adult, and pediatric patients treated in hospitals reporting to the North Carolina Trauma Registry (NCTR).

Abdominal aortic aneurysm infected with Campylobacter fetus subspecies fetus

BACKGROUND Indications for laparoscopic appendectomy (LA) remain controversial and poorly defined. We sought to identify indications for LA through a comparison of LA and open appendectomies (OA). METHODS We reviewed demographics, coexisting medical conditions, radiology and pathology data, hospital course, and complications from charts on all LA patients and a comparison group of OA done from 1991 to 1998. RESULTS The following were significantly associated with LA: female sex, higher mean body mass index (BMI), coexisting medical problems, private insurance, and daytime surgery. The OA group was significantly more likely to have: a radiology report suggesting the diagnosis of acute appendicitis, perforation of the appendix, intensive care unit admission, and complications in their hospital course. Forty-one percent of the LA patients did not have appendicitis, compared with 20% of the OA patients. CONCLUSIONS Daytime surgery, women, private insurance, coexisting medical problems, prior abdominal surgery, higher BMI, and less severe disease appear to be used by surgeons as indicators for LA. The threshold for surgical exploration appears to be lower for LA.

Breast conservation surgery for breast cancer at a regional medical center.

AbstractBackground: Clinical studies have shown equivalent survival rates between breast-conserving surgery (BCS) and mastectomy in early breast cancer; however, rates for BCS remain low. The purpose of this study was to determine (a) the prevalence of BCS in a regional medical center, (b) clinicopathologic factors associated with BCS, and (c) patient perceptions of the treatment decision-making process. Methods: We retrospectively reviewed 251 consecutive breast cancer cases during January 1990–December 1991; 77 patients were ineligible for BCS because of unfavorable pathology. We then interviewed 118 of the 160 women available for interview. Results: BCS was performed in 31 of the eligible patients (18%). Multivariate analysis revealed that tumor size <10 mm (p=0.03) was the only significant predictive variable for BCS. Patient interviews revealed that 93% said their surgeon was the primary source of information regarding treatment options. Among 69% of the women whose surgeons reportedly recommended a particular option, 89% recommended mastectomy with 93% compliance, and 11% recommended BCS with 89% compliance. The BCS group more often obtained a second opinion (p=0.04) and 60% said they made the decision themselves compared with only 37% of the mastectomy group (p=0.05). Conclusion: Limiting BCS to women whose tumor size is <10 mm is too restrictive; this excludes a large number of women who are clinically eligible for BCS. The surgical decision-making process for early-stage breast cancer is very much surgeon-driven, with a high degree of patient compliance.

Segmental absence of intestinal musculature: An unusual cause of intestinal obstruction in the neonate

We report a survivor of Campylobacter fetus septicemia from an infected abdominal aortic aneurysm who was successfully treated with an anatomic graft reconstruction and antibiotics. According to a survey of the English-language medical literature this was the fourth such patient successfully treated. C. fetus sepsis associated with an abdominal aortic aneurysm was first reported in 1971. The first patient to survive reconstruction of an aortic tube graft aneurysm infected with C. fetus was reported in 1983. Because the natural history of an aneurysm infected by C. fetus appears to be rapid progression to rupture, patients should be operated on promptly. All patients reported in the literature who were operated on before rupture survived. Survival was independent of the type of reconstruction. When the aneurysm ruptured all patients died. Whereas extraanatomic bypass is generally considered the procedure of choice for an infected abdominal aneurysm, the aneurysms of our patient and three other patients cited in the literature were reconstructed with anatomically placed prosthetic grafts. In the absence of other contraindications such as a grossly evident purulent infection, an abdominal aortic aneurysm infected by C. fetus may represent a subset of infected aneurysms that can be treated successfully with an anatomically placed prosthetic graft and antibiotics.