Michael A. Goldfarb

Tracking respiratory therapy in the trauma patient

The respiratory index (RI), P(AaDO2)/PaO2, was investigated in a retrospective study of 177 intubated patients treated at the Maryland Institute for Emergency Medicine. An RI of 0.1 to 0.37 is normal. Patients with an RI of 2 or greater were intubated. Those patients who reached an RI of 6 or more had an associated 12 per cent probability of survival. The RI reflects the presence of pulmonary shunting in a variety of circumstances including atelectasis, pulmonary contusion, and pulmonary emboli. A nomogram that allows the course of the patient with respiratory problems to be followed is described. Movement along the same isobars or between isobars can be followed by plotting the PaO2 against the FI0-2. Thus, the rationale and effect of respiratory therapeutic manipulations may be recorded graphically.

Oncologic and aesthetic results following breast-conserving therapy with 0.5 cm margins in 100 consecutive patients.

Abstract:  The purpose of this study was to evaluate the oncologic and aesthetic results of patients undergoing breast‐conserving therapy with 0.5 cm surgical margins and determine the factors that influence the need for reconstruction. One hundred consecutive patients who underwent breast‐conserving surgery with 0.5 cm surgical margins followed by radiotherapy for invasive cancer and ductal carcinoma in situ (DCIS) were followed prospectively and evaluated for recurrence and aesthetic result. Thirteen patients underwent reexcision to achieve a 0.5 cm margin. Factors including breast size, location of the tumor, specimen size and volume, tumor size and volume, and TNM stage, if axillary dissection or reexcision were required, were included in the analysis. Aesthetic evaluation consisted of both patient rating and an independent observer rating on a 10‐point scale that assessed volume, shape, symmetry, areola/nipple, and scar. Of the 100 patients that underwent breast‐conserving therapy, the overall aesthetic results revealed that 8% of the patients scored themselves seven or less, another 8% were scored seven or less by the independent observer, and another 7% were scored seven or less by both the patient and the observer. Of these patients, only one proceeded to have a reconstructive procedure. Analysis of variance revealed a significant correlation between tumor size (cm2) and an aesthetic score of seven or less (p = 0.023), and specimen volume (cm3) and an aesthetic score of seven or less (p = 0.039). Chi‐squared analysis revealed a significant difference (χ2 = 4.39, p < 0.5) in the aesthetic result in patients with stage IIA disease. Other independent factors such as age, breast size, location of the tumor, axillary dissection, and reexcision did not influence the overall aesthetic result. A Pearson correlation of patient and independent observer ratings showed a positive correlation (r = 0.4; 95% confidence interval [CI] 0.19–0.57) between the two groups. There were zero local recurrences of breast cancer during the study period. Our results demonstrate that following breast‐conserving therapy with a minimum of 0.5 cm resection margins, it is possible to achieve excellent oncologic and aesthetic results. Patients with large tumors that require a large volume of resection or with stage IIA disease should be considered for reconstructive evaluation.

Ten-year review of groin laparoscopy in 1001 pediatric patients with clinical unilateral inguinal hernia: an improved technique with transhernia multiple-channel scope.

PURPOSE The purpose of this 10-year review of data is to verify the effectiveness, safety, and appropriate age group for using a multichannel scope during inguinal herniorrhaphy in pediatric patients with clinical unilateral inguinal hernia to evaluate for contralateral patent processus vaginalis (CPPV). METHODS The data evaluated are age, sex, negative findings, positive findings, false positives, false negatives, recurrences, date of recurrence, and complications. Patients who clinically had bilateral hernias or were born prematurely were excluded. A 5-mm, 30° multichannel scope was used through the ipsilateral open hernia sac to explore the contralateral internal ring. A Fogarty catheter was used through one of the channels of the scope to probe the contralateral side in instances of questionable patent processus vaginalis. RESULTS One thousand one patients were studied, and a total of 237 CPPVs (23%) were identified. The highest incidence of CPPV was found in those patients younger than 1 year (44%). Contralateral patent processus vaginalis was identified and ligated in 34% of patients younger than 2 years, 20% in patients 2 to 8 years old, and 17% of patients 9 to 18 years old. There were no false positives and 6 false negatives (0.6%) of the contralateral side. There were 3 (0.3%) recurrent inguinal hernias of the ipsilateral side and no complications. CONCLUSIONS The use of a multichannel scope through the ipsilateral open hernia sac during inguinal herniorrhaphy in pediatric patients with clinical unilateral inguinal hernia to evaluate for CPPV proved to be effective, cost-effective, and safe. Our procedure eliminated any additional scars and the cost of trocars and permitted us to probe the contralateral internal ring. Unnecessary open exploration was spared in 56% of children younger than 1 year and proved to be useful in all pediatric patients up to the age of 18 years.

VATS intraoperative tattooing to facilitate solitary pulmonary nodule resection

IntroductionVideo-assisted thoracic surgery (VATS) has become routine and widely accepted for the removal of solitary pulmonary nodules of unknown etiology. Thoracosopic techniques continue to evolve with better instruments, robotic applications, and increased patient acceptance and awareness.Several techniques have been described to localize peripheral pulmonary nodules, including pre-operative CT-guided tattooing with methylene blue, CT scan guided spiral/hook wire placement, and transthoracic ultrasound.As pulmonary surgeons well know, the lung and visceral pleura may appear featureless on top of a pulmonary nodule.Case descriptionThis paper presents a rapid, direct and inexpensive approach to peripheral lung lesion resection by marking the lung parenchyma on top of the nodule using direct methylene blue injection.MethodsIn two patients with peripherally located lung nodules (n = 3) scheduled for VATS, we used direct methylene blue injection for intraoperative localization of the pulmonary nodule. Our technique was the following: After finger palpation of the lung, a spinal 25 gauge needle was inserted through an existing port and 0.1 ml of methylene blue was used to tattoo the pleura perpendicular to the localized nodule.The methylene blue tattoo immediately marks the lung surface over the nodule. The surgeon avoids repeated finger palpation, while lining up stapler, graspers and camera, because of the visible tattoo. Our technique eliminates regrasping and repalpating the lung once again to identify a non marked lesion.ResultsThree lung nodules were resected in two patients. Once each lesion was palpated it was marked, and the area was resected with security of accurate localization. All lung nodules were resected in totality with normal lung parenchymal margins. Our technique added about one minute to the operative time. The two patients were discharged home on the second postoperative day, with no morbidity.ConclusionVATS with intraoperative tattooing is a safe, easy, and accurate technique to streamline and efficiently resect solitary pulmonary nodules.

Two prognostic indices for the trauma patient

Abstract This paper attempts to further the quest for an acceptable, practical system for measuring and tracking the response to injury in patients. A general trauma index, (the CHOP index) and a respiratory index were used in combination to define prognosis regions based on a retrospective study of 172 consecutive intubated multiple trauma victims. A discussion is included of the planned computer-assisted bed-side use of the indices.

The combined use of proton pump inhibitors and antibiotics as risk factors for Clostridium difficile infection

Abstract Purpose A review of the incidence of Clostridium. difficile infection (CDI) at our hospital was performed due to the morbidity of CDI in its fulminate form, reports of the increased incidence of CDI in the United States and the increased use of medications associated with its onset. Methods The study was retrospective and took place over a 9-month period, from 1 January 2009 through 30 September 2009. Results There were 88 cases of CDI in the course of the review which amounted to 5.1 infections per 1000 patient hospital admissions. The percentage of overall admissions that were prescribed antibiotics and proton pump inhibitors (PPI), PPI alone or antibiotics alone were 17.1%, 15.5% and 24.3%, respectively. Of all cases of CDI, 59.1% of patients were on both a PPI and antibiotic, 9.1% were on a PPI alone and 13.6% were on an antibiotic alone. Patients on both proton pump inhibitors and antibiotics had an odds ratio of 8.30 ( P