James Barone - Academia.edu (original) (raw)

Papers by James Barone

New Jersey medicine: the journal of the Medical Society of New Jersey

New England Journal of Medicine, 2002

The attempt of Birkmeyer et al.(April 11 issue) 1 to correlate low procedure-specific hospital vo... more The attempt of Birkmeyer et al.(April 11 issue) 1 to correlate low procedure-specific hospital volume with increased mortality has methodologic and interpretive problems. The investigators used data from the Medicare Provider Analysis and Review (excluding those ...

Journal of Intensive Care Medicine, 2002

Patients undergoing tracheostomy may recover enough to be weaned from mechanical ventilation but ... more Patients undergoing tracheostomy may recover enough to be weaned from mechanical ventilation but continue to need the tracheostomy tube for airway toilet. When feeding a patient with a tracheostomy tube in place, it is unclear if the cuff should be inflated or not. This study was undertaken to determine whether cuff status has any impact on aspiration of feedings. Selected patients with tracheostomies who were weaned from the ventilator underwent fluoroscopic swallowing studies with the tracheostomy cuff inflated and deflated. Patients were fluoroscopically observed swallowing contrast-enhanced thin liquids, thick liquids, pureed food, and solid food. Each patient was to have undergone a total of 8 different swallowing studies. A radiologist blinded to cuff status was present to assess the degree of aspiration, which was graded from 0 (no aspiration) to 4 (aspiration of more than 10% of the ingested material with coughing). The study included 12 patients who had a total of 91 different swallowing studies. The full battery of eight swallowing studies could not be completed on every patient. When the cuff was inflated, the aspiration rate was 2.7 times higher (17.8% versus 6.5%). Logistic regression analysis revealed that cuff status and type of substance ingested were both predictors of aspiration (P = 0.032 and P = 0.025, respectively). Although the sample size was small, the nearly threefold increase in the aspiration rate associated with cuff inflation suggests feeding with the cuff deflated may be the preferred method. Solid foods are the safest. Swallowing studies may be the best method of assessing which substances will be tolerated by an individual patient.

Critical Care Medicine, 1999

The Journal of trauma, 1999

To meet American College of Surgeons criteria, Level I and II trauma centers are required to have... more To meet American College of Surgeons criteria, Level I and II trauma centers are required to have in-house operating room (OR) staff 24 hours per day. According to the number of emergency cases occurring, hospitals may have varying needs for OR staffing during the night shift. Queueing theory, the analysis of historic data to provide optimal service while minimizing waiting, is an objective method of determining staffing needs during any time period. This study was done to determine the need to activate a backup OR team during the night shift at a designated, verified Level II trauma center. The basic queueing theory formula for a single-phase, single-channel system was applied to patients needing the services of the OR. The mean arrival rate was determined by dividing the number of actual cases by 2,920 hours in a year (8 hours per night x 365). The mean service rate is determined by averaging the length of the actual cases during the period studied. Using the mean arrival rate and...

The Journal of Trauma: Injury, Infection, and Critical Care, 1999

Many experts have suggested that blunt splenic trauma in patients older than 55 years should not ... more Many experts have suggested that blunt splenic trauma in patients older than 55 years should not be managed by observation because of supposed increased fragility of the spleen and decreased physiologic reserve in elderly patients. We sought to determine the outcome of nonoperative management of blunt splenic trauma in patients older than 55 years. For the years 1994 through 1996, data for patients with splenic injury older than 55 years from seven trauma centers in a single state were reviewed. Blunt splenic trauma occurred in 41 patients older than 55 years. Eight patients were excluded from further analysis because of death from massive associated injuries within 24 hours of admission. The remaining 33 patients (mean age, 72+/-10 years) were divided into two groups: immediate exploration (10 patients) and observation (23 patients). Observation of blunt splenic injury failed in 4 of 23 patients (17%). No patient deaths were related to the method of management of the splenic injury. Observation of the elderly patient with blunt splenic trauma has an acceptable failure rate of 17%.

The American surgeon, 2005

Sentinel lymph node biopsy (SLNB) has not been examined using the principles of evidence-based me... more Sentinel lymph node biopsy (SLNB) has not been examined using the principles of evidence-based medicine (EBM). Specifically, likelihood ratios have not been used to assess the validity of SLNB. The Surveillance, Epidemiology, and End Results (SEER) public database of the National Cancer Institute was used to establish the baseline or pretest probability of finding a positive lymph axillary node for each stage of breast cancer. Rates of false negative results of SLNB for all breast cancer stages were determined from the surgical literature. Positive and negative likelihood ratios (LR) were calculated. For each stage of breast cancer, the Bayesian nomogram was used to find the post-test probability of missing a metastatic axillary node when the SLN was negative. The SEER database of 213,292 female patients with breast cancer yielded the following rates of positivity of axillary lymph nodes for each breast tumor size: T1a, 7.8 per cent; T1b, 13.3 per cent; T1c, 28.5 per cent; T2, 50.2 ...

The American Journal of Surgery, 2003

Based on a study at our hospital in 1994, we established a practice guideline for appendicitis pa... more Based on a study at our hospital in 1994, we established a practice guideline for appendicitis patients. The practice guideline was followed well except for an increased number of preoperative computed tomography (CT) scans. Data collected from the previous study of 100 patients were compared with data from consecutive patients, 118 total, seen over a similar time period in the year 2000. The percentage of CT scans ordered for the diagnosis of patients who underwent appendectomy markedly increased from 11% in 1994 to 48.3% in 2000. (P <0.001) The percentage of normal appendixes removed did not change significantly from 12% in 1994 to 17.8% in 2000 (P = 0.317). Patients who had a CT scan were no less likely to have a normal appendix at surgery (P = 0.386) and a significant increase in preoperative Emergency Department length of stay (P <0.001). CT was accurate 80% of the time in 2000 and 81% of the time in 1994. Only 14 of 57 CT scans were ordered by surgeons. The use of preoperative abdominal CT scanning has not improved the accuracy of the diagnosis of appendicitis at our institution. It has resulted in a significant increase in Emergency Department preoperative length of stay and the finding of a normal appendix at surgery. As nonsurgeons ordered the majority of preoperative CT scans, earlier input by surgeons might increase the rate of accurate clinical diagnosis and decrease the number of CT scans ordered.

The American Journal of Surgery, 1999

Several anecdotal papers suggest that laparoscopic cholecystectomy can be done safely in pregnant... more Several anecdotal papers suggest that laparoscopic cholecystectomy can be done safely in pregnant patients, but few patients are reported and other patients such as those who underwent laparoscopic appendectomy are often included. A larger series would help clarify the situation. The Connecticut Laparoscopic Cholecystectomy Registry and data from the Connecticut Hospital Association (CHA) were combined to search for all cholecystectomies performed in pregnant patients from 1992 through 1996. Information on outcomes for both mother and infant was obtained through the cooperation of most of the CHA hospitals. Complete data were available for 46 patients, 20 laparoscopic and 26 open cases. The groups were comparable in all demographic respects except for the timing of cholecystectomy, which was performed at a mean of 18.4 +/- 6.7 weeks (range 9 to 32) of gestation for the laparoscopic and 24.8 +/- 4.7 weeks (range 14 to 35) for the open patients (P = 0.01). A maternal-fetal mortality due to intra-abdominal hemorrhage occurred in the laparoscopic group 2 weeks postoperatively. In the open group, a fetal demise occurred at 21 weeks gestation, 5 weeks postcholecystectomy. The open patients experienced 8 episodes of premature contractions compared with one one such event in the laparoscopic group (P = 0.057). This represents the largest reported series of laparoscopic cholecystectomy in pregnant patients. Laparoscopic cholecystectomy does not lead to increased numbers of fetal complications. Premature uterine contractions tend to occur more frequently after open cholecystectomy and when the procedure is performed later in gestation.

Obstetrical & Gynecological Survey, 1993

Rupture of a splenic artery aneurysm during pregnancy or delivery is an unusual event. Only 98 pr... more Rupture of a splenic artery aneurysm during pregnancy or delivery is an unusual event. Only 98 previous cases have been reported. The survival of both mother and fetus is even more uncommon. This paper describes the tenth case of maternal-fetal survival after splenic artery aneurysm rupture. The literature is reviewed in detail with emphasis on the epidemiology, etiology, clinical presentation, and treatment of this problem. A high index of suspicion and an awareness of the management options are necessary to achieve a successful outcome.

The Journal of Trauma: Injury, Infection, and Critical Care, 1993

Recent papers from established trauma centers reported average elapsed times from emergency depar... more Recent papers from established trauma centers reported average elapsed times from emergency department (ED) admission to the operating room (OR) of greater than 100 minutes for patients judged to be in immediate need of surgery. This study was undertaken to determine whether patients treated at an institution desiring level II trauma center designation in a geographic area with a low incidence of penetrating trauma suffered any adverse effects because of lack of a 24-hour in-house OR staff. Trauma registry data at The Stamford Hospital, a suburban community teaching hospital without OR nursing staff in-house at night, were reviewed and compared with data from three affiliated level I trauma centers and with established national standards using TRISS methodology. Of 659 major trauma patients, 86 (44 blunt, 42 penetrating) underwent surgery within 12 hours of admission. Patients' injuries were similar in severity to those seen at the affiliated trauma centers and to the Major Trauma Outcome Study population. Mortality rates were also similar. No statistically significant differences were seen in elapsed times from ED arrival to OR arrival even in the subgroup of patients with systolic blood pressure values of < or = 90 mm Hg. No unexpected adverse outcomes could be ascribed to the lack of 24-hour OR staffing in this setting. The estimated cost of providing additional OR staffing is $145,000 per year. Since times to the OR and outcomes were similar to those at level I centers, this expense may not be warranted.

The Journal of Trauma: Injury, Infection, and Critical Care, 2002

Abdominal computed tomographic (CT) scan is accepted as the primary diagnostic modality in stable... more Abdominal computed tomographic (CT) scan is accepted as the primary diagnostic modality in stable patients with blunt abdominal trauma. A recent survey of 328 trauma surgeons demonstrated marked variation in the management of patients with head injuries and the finding of free intra-abdominal fluid without solid organ injury on CT scan. This study was undertaken to attempt to determine what to do when free fluid without solid organ injury is seen on abdominal CT scan in patients with blunt trauma. Articles concerning the incidence and significance of free intra-abdominal fluid on CT scan of blunt trauma patients without solid organ injury were systematically reviewed. A MEDLINE search was performed using terms such as tomography-x-ray computed, wounds-nonpenetrating, small intestine/injuries, time factors, and abdominal trauma and diagnostic tests. Bibliographies of pertinent articles were reviewed. Appropriate articles were evaluated for quality and data were combined to reach a conclusion. Meta-analysis could not be performed because no randomized, prospective, controlled trials could be found. Forty-one articles were excluded from the analysis because they looked at only patients with known injuries to intestine, diaphragm, or pancreas and the investigation of the CT scan findings did not include negative scans. Ten articles, which described CT scan results for all patients presenting with blunt abdominal trauma for a defined period of time, formed the basis of this study. Isolated free fluid was seen in 463 (2.8%) of over 16,000 blunt trauma patients scanned. A therapeutic laparotomy was performed in only 122 (27%) of these patients. The isolated finding of free intra-abdominal fluid on CT scan in patients with blunt trauma and no solid organ injury does not warrant laparotomy. Alert patients may be followed with physical examination. Patients with altered mental status should undergo diagnostic peritoneal lavage.

Diseases of the Colon & Rectum, 1990

Over a period of seven years, 474 patients with acquired immune deficiency syndrome (AIDS) or AID... more Over a period of seven years, 474 patients with acquired immune deficiency syndrome (AIDS) or AIDS-related complex were admitted on 782 occasions to the St. Francis Medical Center, Trenton, New Jersey. Abdominal surgery was performed on 16 (3.4 percent) patients, 14 (88 percent) of whom were heterosexual intravenous drug users. Anorectal surgery was performed on 20 (4.2 percent), 14 (70 percent) of whom were intravenous drug users. Intravenous drug users undergoing abdominal surgery had the same types of surgical abdominal conditions that occur in the general population. None required surgery for complications secondary to cytomegalovirus, visceral lymphoma, or visceral Kaposi's sarcoma. The postoperative morbidity rate was 72 percent. The postoperative mortality rate (30 day) was 0 percent. No intravenous drug users who underwent anorectal surgery had associated anorectal malignancies or infectious diseases. Five of six homosexual patients had either an anorectal malignancy or an associated anorectal infectious disease. Anorectal wounds did not heal within one month in one third of the intravenous drug users. The rate of wound healing was inversely related to the white blood cell count. One third of the intravenous drug users undergoing anorectal surgery were dead within six months.

Critical Care Medicine, 1991

Critical Care Medicine, 1992

Annals of Surgery, 1976

ABSTRACT

Annals of Emergency Medicine, 1987

The patient with acquired immune deficiency syndrome (AIDS) and abdominal pain presents the surge... more The patient with acquired immune deficiency syndrome (AIDS) and abdominal pain presents the surgeon with a difficult challenge. The pain may be due to an opportunistic infection, ileus, organomegaly, or a true surgical emergency. The hospital records of 235 patients with AIDS were reviewed. Of the 29 patients with abdominal pain, 12 had infectious diarrhea, eight were diagnosed as having ileus or organomegaly, and nine had miscellaneous causes for their pain. Only five patients underwent laparotomy. Two patients were operated on for pain associated with bleeding (Meckel's diverticulum and intestinal Kaposi's sarcoma); one had a perforated duodenal ulcer and one had severe ileitis. One patient was electively operated on for Burkitt's lymphoma. Laparotomy for abdominal pain is not usually necessary in patients with AIDS. Specific recommendations for evaluation and management of these patients are offered.

Annals of Emergency Medicine, 1986

The value of endotracheal intubation and internal stabilization in severe chest injuries is well ... more The value of endotracheal intubation and internal stabilization in severe chest injuries is well known. Recent reports have proposed that many such patients can be managed without intubation. To determine which patients need intubation we reviewed 140 patients with three or more rib fractures who presented to our hospitals from 1 January 1979 through 31 December 1983: 119 nonintubated patients (Group A); 13 patients intubated on admission (Group B); five patients intubated after hospital day 1 (Group C); and three patients intubated questionably on admission (Group D). The purpose of this report was to identify the factors which indicated severe pulmonary injury necessitating intubation. The need for intubation was correlated with five risk factors: 1) initial respiratory rate of over 25 min; 2) pulse greater than 100 min; 3) systolic blood pressure less than 100 mm Hg; 4) poor initial arterial blood gas; 5) the presence of other injuries. There was no correlation between severity of pulmonary injury and number of fractures, bilateral and/or segmental fractures, flail chest, contusion of lung, or age of patient. There was a greater percentage of complications and deaths in intubated patients (Groups B, C, and D). Group C patients all had poor initial blood gases and were erroneously not intubated early, even though 60% of them had three or more risk factors, as did Group B patients. Only 4% of patients who did not need intubation (Group A) had three or more risk factors. Group D patients were intubated without apparent indication. They had good initial blood gas levels and only one risk factor.(ABSTRACT TRUNCATED AT 250 WORDS)

Annals of Vascular Surgery, 2010

We describe a case of innovative endovascular techniques to repair traumatic bilateral axillary a... more We describe a case of innovative endovascular techniques to repair traumatic bilateral axillary artery disruption. A 36-year-old male construction worker fell eight stories from a scaffold and sustained bilateral axillary artery injuries. The injuries between the brachial and axillary arteries were bridged using long bare self-expanding stents (Zilver). To the best of our knowledge, this is a novel case report from a level-one trauma center where endovascular techniques were employed to repair bilateral axillary arteries with long-term follow-up.

New Jersey medicine: the journal of the Medical Society of New Jersey

New England Journal of Medicine, 2002

The attempt of Birkmeyer et al.(April 11 issue) 1 to correlate low procedure-specific hospital vo... more The attempt of Birkmeyer et al.(April 11 issue) 1 to correlate low procedure-specific hospital volume with increased mortality has methodologic and interpretive problems. The investigators used data from the Medicare Provider Analysis and Review (excluding those ...

Journal of Intensive Care Medicine, 2002

Patients undergoing tracheostomy may recover enough to be weaned from mechanical ventilation but ... more Patients undergoing tracheostomy may recover enough to be weaned from mechanical ventilation but continue to need the tracheostomy tube for airway toilet. When feeding a patient with a tracheostomy tube in place, it is unclear if the cuff should be inflated or not. This study was undertaken to determine whether cuff status has any impact on aspiration of feedings. Selected patients with tracheostomies who were weaned from the ventilator underwent fluoroscopic swallowing studies with the tracheostomy cuff inflated and deflated. Patients were fluoroscopically observed swallowing contrast-enhanced thin liquids, thick liquids, pureed food, and solid food. Each patient was to have undergone a total of 8 different swallowing studies. A radiologist blinded to cuff status was present to assess the degree of aspiration, which was graded from 0 (no aspiration) to 4 (aspiration of more than 10% of the ingested material with coughing). The study included 12 patients who had a total of 91 different swallowing studies. The full battery of eight swallowing studies could not be completed on every patient. When the cuff was inflated, the aspiration rate was 2.7 times higher (17.8% versus 6.5%). Logistic regression analysis revealed that cuff status and type of substance ingested were both predictors of aspiration (P = 0.032 and P = 0.025, respectively). Although the sample size was small, the nearly threefold increase in the aspiration rate associated with cuff inflation suggests feeding with the cuff deflated may be the preferred method. Solid foods are the safest. Swallowing studies may be the best method of assessing which substances will be tolerated by an individual patient.

Critical Care Medicine, 1999

The Journal of trauma, 1999

To meet American College of Surgeons criteria, Level I and II trauma centers are required to have... more To meet American College of Surgeons criteria, Level I and II trauma centers are required to have in-house operating room (OR) staff 24 hours per day. According to the number of emergency cases occurring, hospitals may have varying needs for OR staffing during the night shift. Queueing theory, the analysis of historic data to provide optimal service while minimizing waiting, is an objective method of determining staffing needs during any time period. This study was done to determine the need to activate a backup OR team during the night shift at a designated, verified Level II trauma center. The basic queueing theory formula for a single-phase, single-channel system was applied to patients needing the services of the OR. The mean arrival rate was determined by dividing the number of actual cases by 2,920 hours in a year (8 hours per night x 365). The mean service rate is determined by averaging the length of the actual cases during the period studied. Using the mean arrival rate and...

The Journal of Trauma: Injury, Infection, and Critical Care, 1999

Many experts have suggested that blunt splenic trauma in patients older than 55 years should not ... more Many experts have suggested that blunt splenic trauma in patients older than 55 years should not be managed by observation because of supposed increased fragility of the spleen and decreased physiologic reserve in elderly patients. We sought to determine the outcome of nonoperative management of blunt splenic trauma in patients older than 55 years. For the years 1994 through 1996, data for patients with splenic injury older than 55 years from seven trauma centers in a single state were reviewed. Blunt splenic trauma occurred in 41 patients older than 55 years. Eight patients were excluded from further analysis because of death from massive associated injuries within 24 hours of admission. The remaining 33 patients (mean age, 72+/-10 years) were divided into two groups: immediate exploration (10 patients) and observation (23 patients). Observation of blunt splenic injury failed in 4 of 23 patients (17%). No patient deaths were related to the method of management of the splenic injury. Observation of the elderly patient with blunt splenic trauma has an acceptable failure rate of 17%.

The American surgeon, 2005

Sentinel lymph node biopsy (SLNB) has not been examined using the principles of evidence-based me... more Sentinel lymph node biopsy (SLNB) has not been examined using the principles of evidence-based medicine (EBM). Specifically, likelihood ratios have not been used to assess the validity of SLNB. The Surveillance, Epidemiology, and End Results (SEER) public database of the National Cancer Institute was used to establish the baseline or pretest probability of finding a positive lymph axillary node for each stage of breast cancer. Rates of false negative results of SLNB for all breast cancer stages were determined from the surgical literature. Positive and negative likelihood ratios (LR) were calculated. For each stage of breast cancer, the Bayesian nomogram was used to find the post-test probability of missing a metastatic axillary node when the SLN was negative. The SEER database of 213,292 female patients with breast cancer yielded the following rates of positivity of axillary lymph nodes for each breast tumor size: T1a, 7.8 per cent; T1b, 13.3 per cent; T1c, 28.5 per cent; T2, 50.2 ...

The American Journal of Surgery, 2003

Based on a study at our hospital in 1994, we established a practice guideline for appendicitis pa... more Based on a study at our hospital in 1994, we established a practice guideline for appendicitis patients. The practice guideline was followed well except for an increased number of preoperative computed tomography (CT) scans. Data collected from the previous study of 100 patients were compared with data from consecutive patients, 118 total, seen over a similar time period in the year 2000. The percentage of CT scans ordered for the diagnosis of patients who underwent appendectomy markedly increased from 11% in 1994 to 48.3% in 2000. (P <0.001) The percentage of normal appendixes removed did not change significantly from 12% in 1994 to 17.8% in 2000 (P = 0.317). Patients who had a CT scan were no less likely to have a normal appendix at surgery (P = 0.386) and a significant increase in preoperative Emergency Department length of stay (P <0.001). CT was accurate 80% of the time in 2000 and 81% of the time in 1994. Only 14 of 57 CT scans were ordered by surgeons. The use of preoperative abdominal CT scanning has not improved the accuracy of the diagnosis of appendicitis at our institution. It has resulted in a significant increase in Emergency Department preoperative length of stay and the finding of a normal appendix at surgery. As nonsurgeons ordered the majority of preoperative CT scans, earlier input by surgeons might increase the rate of accurate clinical diagnosis and decrease the number of CT scans ordered.

The American Journal of Surgery, 1999

Several anecdotal papers suggest that laparoscopic cholecystectomy can be done safely in pregnant... more Several anecdotal papers suggest that laparoscopic cholecystectomy can be done safely in pregnant patients, but few patients are reported and other patients such as those who underwent laparoscopic appendectomy are often included. A larger series would help clarify the situation. The Connecticut Laparoscopic Cholecystectomy Registry and data from the Connecticut Hospital Association (CHA) were combined to search for all cholecystectomies performed in pregnant patients from 1992 through 1996. Information on outcomes for both mother and infant was obtained through the cooperation of most of the CHA hospitals. Complete data were available for 46 patients, 20 laparoscopic and 26 open cases. The groups were comparable in all demographic respects except for the timing of cholecystectomy, which was performed at a mean of 18.4 +/- 6.7 weeks (range 9 to 32) of gestation for the laparoscopic and 24.8 +/- 4.7 weeks (range 14 to 35) for the open patients (P = 0.01). A maternal-fetal mortality due to intra-abdominal hemorrhage occurred in the laparoscopic group 2 weeks postoperatively. In the open group, a fetal demise occurred at 21 weeks gestation, 5 weeks postcholecystectomy. The open patients experienced 8 episodes of premature contractions compared with one one such event in the laparoscopic group (P = 0.057). This represents the largest reported series of laparoscopic cholecystectomy in pregnant patients. Laparoscopic cholecystectomy does not lead to increased numbers of fetal complications. Premature uterine contractions tend to occur more frequently after open cholecystectomy and when the procedure is performed later in gestation.

Obstetrical & Gynecological Survey, 1993

Rupture of a splenic artery aneurysm during pregnancy or delivery is an unusual event. Only 98 pr... more Rupture of a splenic artery aneurysm during pregnancy or delivery is an unusual event. Only 98 previous cases have been reported. The survival of both mother and fetus is even more uncommon. This paper describes the tenth case of maternal-fetal survival after splenic artery aneurysm rupture. The literature is reviewed in detail with emphasis on the epidemiology, etiology, clinical presentation, and treatment of this problem. A high index of suspicion and an awareness of the management options are necessary to achieve a successful outcome.

The Journal of Trauma: Injury, Infection, and Critical Care, 1993

Recent papers from established trauma centers reported average elapsed times from emergency depar... more Recent papers from established trauma centers reported average elapsed times from emergency department (ED) admission to the operating room (OR) of greater than 100 minutes for patients judged to be in immediate need of surgery. This study was undertaken to determine whether patients treated at an institution desiring level II trauma center designation in a geographic area with a low incidence of penetrating trauma suffered any adverse effects because of lack of a 24-hour in-house OR staff. Trauma registry data at The Stamford Hospital, a suburban community teaching hospital without OR nursing staff in-house at night, were reviewed and compared with data from three affiliated level I trauma centers and with established national standards using TRISS methodology. Of 659 major trauma patients, 86 (44 blunt, 42 penetrating) underwent surgery within 12 hours of admission. Patients' injuries were similar in severity to those seen at the affiliated trauma centers and to the Major Trauma Outcome Study population. Mortality rates were also similar. No statistically significant differences were seen in elapsed times from ED arrival to OR arrival even in the subgroup of patients with systolic blood pressure values of < or = 90 mm Hg. No unexpected adverse outcomes could be ascribed to the lack of 24-hour OR staffing in this setting. The estimated cost of providing additional OR staffing is $145,000 per year. Since times to the OR and outcomes were similar to those at level I centers, this expense may not be warranted.

The Journal of Trauma: Injury, Infection, and Critical Care, 2002

Abdominal computed tomographic (CT) scan is accepted as the primary diagnostic modality in stable... more Abdominal computed tomographic (CT) scan is accepted as the primary diagnostic modality in stable patients with blunt abdominal trauma. A recent survey of 328 trauma surgeons demonstrated marked variation in the management of patients with head injuries and the finding of free intra-abdominal fluid without solid organ injury on CT scan. This study was undertaken to attempt to determine what to do when free fluid without solid organ injury is seen on abdominal CT scan in patients with blunt trauma. Articles concerning the incidence and significance of free intra-abdominal fluid on CT scan of blunt trauma patients without solid organ injury were systematically reviewed. A MEDLINE search was performed using terms such as tomography-x-ray computed, wounds-nonpenetrating, small intestine/injuries, time factors, and abdominal trauma and diagnostic tests. Bibliographies of pertinent articles were reviewed. Appropriate articles were evaluated for quality and data were combined to reach a conclusion. Meta-analysis could not be performed because no randomized, prospective, controlled trials could be found. Forty-one articles were excluded from the analysis because they looked at only patients with known injuries to intestine, diaphragm, or pancreas and the investigation of the CT scan findings did not include negative scans. Ten articles, which described CT scan results for all patients presenting with blunt abdominal trauma for a defined period of time, formed the basis of this study. Isolated free fluid was seen in 463 (2.8%) of over 16,000 blunt trauma patients scanned. A therapeutic laparotomy was performed in only 122 (27%) of these patients. The isolated finding of free intra-abdominal fluid on CT scan in patients with blunt trauma and no solid organ injury does not warrant laparotomy. Alert patients may be followed with physical examination. Patients with altered mental status should undergo diagnostic peritoneal lavage.

Diseases of the Colon & Rectum, 1990

Over a period of seven years, 474 patients with acquired immune deficiency syndrome (AIDS) or AID... more Over a period of seven years, 474 patients with acquired immune deficiency syndrome (AIDS) or AIDS-related complex were admitted on 782 occasions to the St. Francis Medical Center, Trenton, New Jersey. Abdominal surgery was performed on 16 (3.4 percent) patients, 14 (88 percent) of whom were heterosexual intravenous drug users. Anorectal surgery was performed on 20 (4.2 percent), 14 (70 percent) of whom were intravenous drug users. Intravenous drug users undergoing abdominal surgery had the same types of surgical abdominal conditions that occur in the general population. None required surgery for complications secondary to cytomegalovirus, visceral lymphoma, or visceral Kaposi's sarcoma. The postoperative morbidity rate was 72 percent. The postoperative mortality rate (30 day) was 0 percent. No intravenous drug users who underwent anorectal surgery had associated anorectal malignancies or infectious diseases. Five of six homosexual patients had either an anorectal malignancy or an associated anorectal infectious disease. Anorectal wounds did not heal within one month in one third of the intravenous drug users. The rate of wound healing was inversely related to the white blood cell count. One third of the intravenous drug users undergoing anorectal surgery were dead within six months.

Critical Care Medicine, 1991

Critical Care Medicine, 1992

Annals of Surgery, 1976

ABSTRACT

Annals of Emergency Medicine, 1987

The patient with acquired immune deficiency syndrome (AIDS) and abdominal pain presents the surge... more The patient with acquired immune deficiency syndrome (AIDS) and abdominal pain presents the surgeon with a difficult challenge. The pain may be due to an opportunistic infection, ileus, organomegaly, or a true surgical emergency. The hospital records of 235 patients with AIDS were reviewed. Of the 29 patients with abdominal pain, 12 had infectious diarrhea, eight were diagnosed as having ileus or organomegaly, and nine had miscellaneous causes for their pain. Only five patients underwent laparotomy. Two patients were operated on for pain associated with bleeding (Meckel's diverticulum and intestinal Kaposi's sarcoma); one had a perforated duodenal ulcer and one had severe ileitis. One patient was electively operated on for Burkitt's lymphoma. Laparotomy for abdominal pain is not usually necessary in patients with AIDS. Specific recommendations for evaluation and management of these patients are offered.

Annals of Emergency Medicine, 1986

The value of endotracheal intubation and internal stabilization in severe chest injuries is well ... more The value of endotracheal intubation and internal stabilization in severe chest injuries is well known. Recent reports have proposed that many such patients can be managed without intubation. To determine which patients need intubation we reviewed 140 patients with three or more rib fractures who presented to our hospitals from 1 January 1979 through 31 December 1983: 119 nonintubated patients (Group A); 13 patients intubated on admission (Group B); five patients intubated after hospital day 1 (Group C); and three patients intubated questionably on admission (Group D). The purpose of this report was to identify the factors which indicated severe pulmonary injury necessitating intubation. The need for intubation was correlated with five risk factors: 1) initial respiratory rate of over 25 min; 2) pulse greater than 100 min; 3) systolic blood pressure less than 100 mm Hg; 4) poor initial arterial blood gas; 5) the presence of other injuries. There was no correlation between severity of pulmonary injury and number of fractures, bilateral and/or segmental fractures, flail chest, contusion of lung, or age of patient. There was a greater percentage of complications and deaths in intubated patients (Groups B, C, and D). Group C patients all had poor initial blood gases and were erroneously not intubated early, even though 60% of them had three or more risk factors, as did Group B patients. Only 4% of patients who did not need intubation (Group A) had three or more risk factors. Group D patients were intubated without apparent indication. They had good initial blood gas levels and only one risk factor.(ABSTRACT TRUNCATED AT 250 WORDS)

Annals of Vascular Surgery, 2010

We describe a case of innovative endovascular techniques to repair traumatic bilateral axillary a... more We describe a case of innovative endovascular techniques to repair traumatic bilateral axillary artery disruption. A 36-year-old male construction worker fell eight stories from a scaffold and sustained bilateral axillary artery injuries. The injuries between the brachial and axillary arteries were bridged using long bare self-expanding stents (Zilver). To the best of our knowledge, this is a novel case report from a level-one trauma center where endovascular techniques were employed to repair bilateral axillary arteries with long-term follow-up.