Detroit General Hospital Research Articles

Prevalence of clinically occult cardiomyopathy in chronic alcoholism

The mean absolute heart weight and mean heart weight to body weight ratio of a group of 43 alcoholics, screened from 1,970 consectuive autopsy reports at the Detroit General Hospital by selecting alcoholics with only ethyl alcohol abuse as an etiology of heart disease, are compared to those of a group of similarly selected age-matched nonalcoholic controls. None of the alcoholics was clinically suspected of having had cardiomyopathy. The statistically significant increased mean absolute heart weight and heart weight to body weight ratio of the alcoholic group reflected the presence of subclinical alcoholic cardiomyopathy. In addition, several of the patients in the alcoholic group displayed gross and microscopic cardiac pathologic changes consistent with alcoholic cardiomyopathy occurring in the absence of cardiomegaly.

Complications of nasotracheal intubation

For a two-month period, 71 nasotracheal intubations done in the emergency department or inpatient units at Detroit General Hospital were studied. Sixty-five of 71 intubations, or 91%, were successful. Mild or moderate complications occurred in 15 of 71 patients, and consisted of mild or moderate bleeding. Moderate to severe complications occurred in seven of 71 patients, and consisted of severe bleeding and retropharyngeal perforation. Retropharyngeal perforation may be a more common complication of nasotracheal intubation than realized. The major technical error is failure to appreciate that loss of flow of air from the tube, once the tube has passed the turbinates, means that the lumen of the tube is abutting the pharyngeal mucosa. Even slight pressure at this point can lead to retropharyngeal perforation.

Transthoracic pacing during CPR

Twenty-seven patients had transthoracic pacemakers inserted by the subxiphoid approach during advanced cardiopulmonary resuscitation (CPR) in the emergency department of Detroit General Hospital between May 1977 and March 1979. Twenty-one charts were available for detailed review. Pacemaker indications in these 21 cases included electromechanical dissociation in four cases, asystole in 10 cases, pulseless idioventricular rhythm in five cases, and 3 degree heart block in two cases. All patients had failed to respond to conventional chronotropic and inotropic agents prior to pacemaker insertion. Good pacemaker capture was obtained in eight of the 21 patients. Two of the patients with good capture had pulses for about 15 min after capture. One of these two patients rearrested, with signs of pericardial tamponade which was confirmed during emergency thoractomy. Neither of the two patients who had pulses after pacemaker insertion and capture could be stabilized, and both died within 30 min post-insertion. Transthoracic pacemaker insertion during advanced CPR in the emergency department probably does not improve outcome in bradyasystolic arrests if there has been poor response to standard advanced cardiac life support management.

Multiple primary malignant tumors of the head and neck

Multiple primary malignant tumors associated with an index cancer in the head and neck are gaining attention as more patients survive their initial primary disease, the longevity of the population at large increases, health care delivery becomes more readily available, and sophisticated diagnostic technology is developed. Forty-four patients with multiple primary cancer in whom the index neoplasm was inthe head and neck are reported. This group comprises 17 per cent of the patients with head and neck cancer treated at the Detroit General Hospital in the last 10 years. Forty-seven per cent of the cancers occurred simultaneously, 10 per cent were synchronous (discovered within six months), and 43 per cent were metachronous (discovered later than six months). Eighty-six per cent of the patients are dead; 75 per cent died within one year after the diagnosis of the secondary primary cancer. Patients with simultaneously occurring malignant tumors appeared to have a somewhat poorer prognosis than those with metachronously occurring tumors. Although the highest incidence of multiple primary malignant tumors occurs in the first year, a consistent high incidence puts the patient with a solitary neoplasm at risk well beyond the three to five years of survival usually considered as "cure." Although no factor other than coincidence has been proved to be involved in the pattern of occurrence of multiple primary neoplasms of different tissues or organs, this study does corroborate other reported data that emphasize that patients with head and neck cancer are at greater risk of developing a second primary malignant tumor in the multicentric vicinity of the original lesion, and in the esophagus and lung than the general population. A program of management and post-treatment surveillance is presented. The potential for new primary malignant neoplasms to develop in the multicentric vicinity of the original lesion and in remote organs cannot be approached with detached curiosity.

Complications of heroin injections of the neck.

The purpose of this paper is to emphasize the importance of heroin injections in the neck as an etiology of superficial and deep neck infections and to familiarize the otolaryngologist with the problems in the diagnosis and management of such infections. This study represents the first series to be reported in the world literature of patients with neck infections secondary to heroin injections. Fifty-seven patients with neck infections related to injection of heroin in the neck (main-lining) were studied. These patients were admitted to Detroit General Hospital during the three-year period between January 1974 and December 1976. The clinical signs and symptoms, location of the abscesses, soft tissue radiographs of the neck, arteriograms and ultrasound examinations of the neck are discussed. The diagnostic evaluation and the treatment of the heroin addict who presents with an inflammatory neck mass are outlined, emphasizing the difficulty and the importance of differentiating between cellulitis, abscess, and pseudoaneurysms of the carotid and subclavian arteries.

Thoracolumbar-Sacral Flaps in the Treatment of Sacral Pressure Sores

The treatment of pressure sores is a challenging problem. A new flap is described to be added to the armamentarium of surgeons looking after these patients. This procedure is not presented as a panacea for the sacral pressure sores but as an additional technique that could be used in very large sacral pressure sores, particularly recurrent pressure sores following conventional procedures.

Incidence, etiology, and outcome of pulseless idioventricular rhythm treated with dexamethasone during advanced CPR

The cardiac resuscitation records of 458 patients who received advanced cardiac life support at Detroit General Hospital during the last two years were reviewed to identify patients who had pulseless idioventricular rhythm (PIVR) recognized and treated with dexamethasone. Twenty-five cases were identified. The initial successful resuscitation rate of 52% in these patients contrasts sharply with other published data indicating 100% failure with the use of conventional chronotropic drugs. The most common etiology of cardiac arrest in our patients who display PIVR during resuscitation is hypoperfusion shock. Dexamethasone may counteract the lethal arrhythmia by causing the release of aditional adenosine triphosphate into the cytoplasm from the mitochondria.

Ivor David Harris, M.D., F.A.C.R.

Dr. Ivor David Harris, 65, of Grosse Pointe Farms, Michigan, died Saturday, the 9th of September 1978. He had been a practicing radiologist in the Detroit area for more than 36 years. Dr. Harris was born Feb. 9, 1913 to the late Mr. and Mrs. Ivor Harris.of New Philadelphia, Ohio. He was a direct descendant of Nicholas Neighbor, a revolutionary soldier associated with General RufusPutnamand the founderof Newcomerstown, Ohio. His grandfather, Dr. Daniel Conrad Gentsch, and his four great uncles were all distinguished physicians who, after completing their postgraduate studies in Vienna, practiced in Ohio and Michigan. Dr. Harris was a graduate of the University of Virginia School of Medicine and a past president of the Virginia Medical Alumni Advisory Board. A former instructor of radiology at both the University of Virginia and Wayne State University, he was the former chief of radiology at old Detroit General Hospital, old Delray Hospital, Wayne University, Doctors Hospital (past president of staff), Wyandotte General Hospital (past president of staff), Oakwood Hospital, and Heritage Hospital. He was a member of the Executive Committee of all the above hospitals. Dr. Harris was the founding member of the medical firm of Drs. Harris, Birkhill, Wang, Songe and Associates. On April 20, 1978, Wyandotte General Hospital and Public Welfare Commission dedicated a room to Dr. Harris in appreciation of his leadership and commitment to quality patient care demonstrated during more than thirty years as director of radiology at that hospital. Dr. Harris was a past president of the Michigan Radiological Society. He was a member of the AMA, the Wayne County Medical Society, the Michigan and Virginia Medical Societies, the North American Radiological Society. the American Geriatric Society, the American Society of Railway Surgeons, The Pan American Medical Association, and a Federal Examiner for the National Institute of Occupational Safety and Health. In 1974 he was elevated to Fellow of the American College of Radiology. He was a member of the Board of Directors of the Michigan Cancer Society and a lecturer throughout the country on the radiology of trauma as well as a lecturer to the Michigan Bar Association. Among his civic activities Dr. Harris included the Detroit and American Historical Societies, the Detroit Symphony Society, the National Trust for Historic Preservation, and the Founders Society of the Detroit Institute of Arts. He was a member of the Country Club of Detroit. Ivor David Harris, M.D.

Anterior Urethral Injuries: Four Years of Experience at the Detroit General Hospital

Among 19 patients with trauma of the anterior urethra 16 were treated by urinary diversion without primary repair of the injured area. Of these patients 15 recovered with excellent results. Since most traumatic injuries to the anterior urethra are partial disruptions we believe that urinary diversion may be the only treatment needed.

High Priests with Low Profiles

From the Department of Surgery, Wayne State University School of Medicine, Detroit, Michigan. Supported by Detroit General Hospital Research Corporation.

Drug injection injuries of the hands: evaluation and treatment.

Twenty-six patients with hand infections caused by drug injection were seen at Detroit General Hospital between 1974 and 1976 and were followed up. The duration of drug abuse was 2 to 25 years. The time before the patient sought medical help ranged from three days to 20 weeks. Among the 26 patients were three webspace infections, three finger abscesses, four gangrene of distal phalanx, nine cellulitis and abscess, one ulceration of the thenar eminence, and two ulcerations of the volar aspect. Follow-up was difficult due to unreliability of drug addicts.

Gunshot Wounds of the Ureter: 5 Years of Experience

During 5 consecutive years 20 patients with ureteral gunshot wounds were treated at the Detroit General Hospital. Among the 19 patients treated surgically 4 unrelated deaths occurred and 3 patients underwent a second exploration. No kidney was lost. Our surgical technique involving a tension-free, watertight anastomosis and diversion is emphasized. We believe that better results are obtained with stented repairs.

Shock and acute respiratory failure after chest trauma.

Shock or acute respiratory failure developing soon after chest trauma are associated with extremely high mortality and morbidity rates. In a study of 1,136 patients with chest trauma admitted to Detroit General Hospital during a 2-year period (1974-1975), it was found that 218 (19%) had shock or acute respiratory failure when first seen in the Emergency Department. Of these patients, 36% (78/218) died and the survivors had a complication rate of 63% (88/140). Shock was associated with a mortality rate of 7.3% (7/96) but the combination of shock and respiratory failure was particularly lethal, with a mortality rate of 73.1% (57/78)overall. No patient over 45 years of age survived this combination. Efforts to improve results following chest trauma must be directed toward earlier and more aggressive management of both these problems

Gentamicin/amikacin-resistant gram-negative bacilli at Detroit General Hospital, 1975–1976

During a consecutive 10 month period from November 1975 through August 1976, all gram-negative bacilli isolated at Detroit General Hospital were tested for gentamicin and amikacin resistance on Mueller-Hinton agar using 10 μg discs utilizing Bauer-Kirby methods. Amikacin-resistant strains (and many gentamicin-resistant bacilli) were similarly tested using tube dilutions in Mueller-Hinton broth. The two methods correlated well for gentamicin but did so imperfectly with amikacin. In analyses for amikacin susceptibilities, values for minimal inhibitory concentration(s) and minimal bactericidal concentrations obtained in broth were subsequently employed. In this survey, 4,640 gram-negative bacilli were isolated; 1,199 strains (26 per cent) and 37 strains (0.8 per cent) were resistant to gentamicin and amikacin, respectively. Thirty-six of the strains had combined gentamicin/amikacin resistance, and they represented 3.1 per cent of all of the gentamicin-resistant isolates. Gentamicin/amikacin-resistant gram-negative bacilli were widely spread throughout medical and surgical services of the hospital. These organisms clustered in the adjacent intensive and respiratory care units. Amikacin-resistant bacilli were recovered from sputum (15 times), wounds (12 times), urine (five times) and blood (five times). Pseudomonas aeruginosa was isolated six times, Ps. cepacia 13 times and Serratia marcescens six times. These strains were usually susceptible to chloramphenicol, tetracycline and trimethoprimsulfamethoxazole but were regularly resistant to amikacin, gentamicin, tobramycin, kanamycin, streptomycin, carbenicillin and cefoxitin.

Urologic Injuries

We have reviewed our experience in 311 cases of urologic trauma seen at Detroit General Hospital. A properly organized emergency surgery team is necessary to handle these types of injures effectively. We feel that, whenever possible, evaluation of any patient suspected of genitourinary trauma should be accomplished by a urologist before the patient enters the operating room. We approach renal injuries with a conservative viewpoint, trying to preserve as much renal tissue as possible, yet realizing that at time an aggressive approach to renal injuries is necessary to accomplish this and to save the patient's life. The injuries of the renal pelvis and ureter should be treated by debridement and a water-tight anastomosis with a fine absorbable material. It is our impression that patients suffering from gunshot wounds, because an ideal anastomosis is not possible, do better with a stented anastomosis. Ruptures of the bladder are simple to repair and attention is focused on the diagnosis and exploration of associated ureteral injuries. The prostatomembranous disruptions are without question one of the most difficult injuries in urology. Although we attempt to stent the urethra in order to align the ends, we condemn a vigorous attempt with interlocking sounds or other instruments since they may lead to iatrogenic injuries of the urogenital diaphragm. In these cases suprapubic cystostomy drainage and secondary repair is indicated. Our results with a group of patients with injuries of the anterior urethra showed that the overwhelming majority of these patients did well with a suprapubic cystostomy and drainage with no immediate repair.

Angiography in Lower Gastrointestinal Bleeding-Reply

In Reply .–The prime objective of thisbrief clinical notewas to reaffirm the principle that, once surgical intervention is decided on, total abdominal colectomy with ileoproctostomy is the only procedure that precludes rebleeding; a secondary objective was to discourage time-consuming angiography, since identifying and resecting a portion of the colon containing the bleeding site will not prevent later rebleeding from another site. Identification of the active bleeding site, therefore, is not entirely pertinent to our disagreement, which centers around the success in controlling diverticular bleeding with intraarterial vasopressin infusion. My own experience at Detroit General Hospital has been less than satisfactory with this technique. Reasons for failure have included inability to cannulate either the superior mesenteric artery or the inferior mesenteric artery in patients with diffuse, occlusive disease, lack of response to a standard vasopressin infusion, and rebleeding after initial success either during or following a vasopressin infusion. Comparable

Prospective evaluation of hemostatic techniques for liver injuries.

The methods of hemostasis used for liver injuries were evaluated prospectively in 637 patients treated at Detroit General Hospital during a 5-year period. Variables evaluated included severity of injury, presence or absence of bleeding, and methods of hemostasis, The liver injury was either not bleeding or was controlled by temporary pack compression during laparotomy in 325 patients: none of these patients, including the 284 in whom no hemostatic procedure was used, rebled postoperatively. Active bleeding at laparotomy was directly related to the severity of liver injury, and required some hemostatic procedure in 312 patients. The methods of hemostasis were liver sutures (244 patients), nonanatomic resection (30 patients), anatomic resection (21 patients), hepatic artery ligation (nine patients), hepatotomy with intraparenchymal vascular control (five patients), and temporary internal pack with later re-operation (three patients). Rebleeding occurred in eight of the 243 patients who survived (seven after liver sutures and one after nonanatomic resection) and four required re-operation for control of bleeding. Sixty-nine patients with active bleeding died. Death on the table in 38 patients was related primarily to uncontrolled bleeding from liver and major vessel injury. Postoperative rebleeding from the liver occurred in 14 of 31 patients who died after surgery: following initial control by liver sutures (seven patients); anatomic resection (four patients); and hepatic artery ligation (three patients). There was no apparent relationship between any hemostatic procedure and the subsequent appearance of the hepatic ischemia or parahepatic abscess. Based on this experience, the merits and detriments of individual hemostatic procedures are presented.

Characteristics of bacterial endocarditis in heroin addicts in Detroit.

Over 24 months (January 1972-December 1973) 48 intravenous heroin users were admitted to Detroit General Hospital with 50 episodes of bacterial endocarditis (B.E.). Staphylococcus aureus (25 cases), enterococci (13 cases), and Pseudomonas aeruginosa (5 cases) were the usual pathogens, accounting for 86 per cent of these illnesses. Occasional episodes were due to other streptococci or diphtheroids which were susceptible to penicillin G. Staphylococcal and pseudomonas endocarditis usually involved the tricuspid valve, while enterococci affected aortic or mitral valves. Pre-existing valvular heart disease was not the sole determinant of the site of infection.

Management of Trauma: Pitfalls and Practice

For this comprehensive volume on the management of trauma, Doctors Walt and Wilson and 41 of their colleagues on the faculty of Wayne State University have drawn on extensive experience with injured patients, largely at the Detroit General (Receiving) Hospital, where trauma is endemic and often epidemic. In the management of injured patients, as the authors note in their preface, "recurrent pitfalls tend to be ignored or forgotten and need to have mental `flags' placed around them." To emphasize the traps for the unwary physician who must care for the injured patients, often in large numbers, the authors have identified many pitfalls, stated them concisely, and bracketed them in bold print throughout the text. This useful device should be of great practical help to those who must deal with these often urgent problems. The book is divided into six sections. The first discusses preparation and planning for emergencies in trauma,

Factors influencing outcome after blunt duodenal injury.

Thirty-six patients with blunt duodenal injury have been treated at Detroit General Hospital since 1960. The majority of the patients were driving an automobile under the influence of alcohol and none were wearing seat restraints. Diagnosis was often delayed due to a failure to recognize the significant, but subtle, physical and roentgenographic findings of retro-peritoneal injury. Morbidity and mortality were related to a delay in operative intervention, the severity of duodenal injury, the presence and degree of associated pancreatic injury, and the choice of operative therapy. Patients with intramural hematoma or complete duodenal perforation without pancreatic injury did well with simple closure or evacuation of the hematoma. Patients with duodenal perforation and minor pancreatic injury did best after primary closure and pancreatic drainage if operation was performed within 24 hours; delay beyond 24 hours resulted in a high incidence of duodenal fistula after simple closure, and therefore is an indication for a bypass procedure, such as a distal gastrectomy, vagotomy, tube duodenostomy, and gastrojejunostomy. Patients with combined duodenal and major pancreatic disruption did best after a bypass procedure when the main pancreatic ductal system was intact, whereas pancreaticoduodenectomy was the best procedure when the main pancreatic duct was disrupted.