North Carolina Memorial Hospital Research Articles

Appendiceal Malignancy: The Hidden Risks of Nonoperative Management for Acute Appendicitis

One potential harm of nonoperative management for acute appendicitis is missed appendiceal cancer, a rare and often aggressive malignancy due to the frequency of late stage of diagnosis. Previous studies have reported an increasing incidence of appendiceal neoplasms in the population. This is a retrospective case-control study of 1007 adult patients, who presented to the University of North Carolina-Memorial Hospital (UNC-MH) between 2011 and 2015 with clinical signs and symptoms of appendicitis. We evaluated the incidence of primary appendiceal cancer in this population and determined factors that predict appendiceal cancer diagnosis using multivariate logistic regression analysis. The overall incidence of appendiceal neoplasm for adult patients presenting to UNC-MH with appendicitis from 2011 to 2015 was 2.3 per cent (23/1007). The incidence in patients without appendiceal perforation on pathology was 1.9 per cent (16/832). Age (odds ratio (OR) 1.03), number of days of abdominal pain (OR 1.16), self-reported fever (OR 2.08), appendiceal width (OR 1.95), and appendiceal wall thickness (OR 1.30) were predictors of appendiceal neoplasm diagnosis in patients that present with acute appendicitis. We recommend that an operative approach to acute appendicitis should remain the standard of care because operative management may not only be diagnostic but potentially therapeutic.

Elders Need Thorough Screening for Alcohol Abuse

Elders Need Thorough Screening for Alcohol Abuse

Lithium Use for Bipolar Disorder Post Renal Transplant

Lithium Use for Bipolar Disorder Post Renal Transplant

Ernest Craige, MD (1918–2008)

Ernest Craige, MD, 89, Professor Emeritus of Medicine, University of North Carolina at Chapel Hill (UNC), died on January 24, 2008, at North Carolina Memorial Hospital. Dr Craige served as chief of the Division of Cardiology at the UNC School of Medicine for 26 years and was an internationally renowned expert in echocardiography. Dr Craige was born on June 3, 1918, in El Paso, Texas, the son of Fr Branch Craige and Elsa Kohlberg Craige. He received his BA from UNC in 1939. Dr Craige was a member of the Golden Fleece, Order of Gimghoul, Phi Beta Kappa, and Sigma Nu Fraternity, of which he was chapter president. He was awarded a Rhodes Scholarship in 1939 but did not take up residence in England because of the outbreak of World War II. Instead, he attended Harvard Medical School and graduated with an MD degree in the spring of 1943. After an internship at Massachusetts General Hospital and Army training at Camp Barkley in Texas, Dr Craige participated in the northern European Campaign with the Fifth Auxiliary Surgery …

Endoscopic Sphincterotomy Permits Interval Laparoscopic Cholecystectomy in Patients With Moderately Severe Gallstone Pancreatitis

Patients with moderately severe gallstone pancreatitis with substantial pancreatic and peripancreatic inflammation, but without organ failure, frequently have an open cholecystectomy to prevent recurrent pancreatitis. In these patients, prophylactic endoscopic retrograde cholangiography (ERC) with endoscopic sphincterotomy (ES) may prevent recurrent pancreatitis, permit laparoscopic cholecystectomy, and decrease risks. The medical records of all patients with pancreatitis undergoing cholecystectomy from 1999-2004 at the University of North Carolina Memorial Hospital were reviewed. Data regarding demographics, clinical course, etiology of pancreatitis, operative and endoscopic interventions, and outcome were extracted. Moderately severe gallstone-induced pancreatitis was defined as pancreatitis without organ failure but with extensive local inflammation. Thirty patients with moderately severe gallstone pancreatitis underwent ERC and ES and were discharged before cholecystectomy. Mean interval between ES and cholecystectomy was 102 +/- 17 days. Cholecystectomy was performed laparoscopically in 27 (90%) patients, open in three (10%) patients, and converted to open in two (7%) patients, with a morbidity rate of 7% (two patients). No patient required drainage of a pseudocyst or developed recurrent pancreatitis. Interval complications resulted in hospital readmission in seven (23%) patients. In conclusion, recurrent biliary pancreatitis in patients with moderately severe gallstone pancreatitis is nil after ERC and ES. Hospital discharge of these patients permits interval laparoscopic cholecystectomy, but close follow-up is necessary in these potentially ill patients.

Endovascular Repair of Nontraumatic Ruptured Thoracic Aortic Pathologies

Endovascular repair of ruptured infrarenal abdominal aortic aneurysms (AAA) is receiving increased attention as the number of experienced users increases. Development of thoracic aortic stent grafts has lagged behind infrarenal advancements because of the reported prevalence of disease. In a few centers, however, the experience in performing thoracic stent graft procedures is quite substantial, such that endovascular therapy has been applied to ruptured thoracic aortic pathologies even though data remain limited and this novel therapy remains controversial. We report our combined experience with endovascular repair of ruptured thoracic aneurysms (RTA) and ruptured thoracic dissections (RTD). One hundred eighty-four thoracic stent graft procedures at the University of North Carolina (UNC) and Union Memorial Hospital (UMH) were reviewed and those patients undergoing RTA or RTD repair from January 1, 2000 to December 31, 2003 identified. Patients having procedures for elective repair or aortic transections were excluded from the analysis. Patient presentation, preoperative condition, procedural variables, mortality, and morbidity were examined. Seventy-four percent of the collective procedures were undertaken in high-risk patients (UNC, 38 of 40; UMH, 99 of 144). Twenty-two patients (8.7%; UNC, n = 6; UMH, n = 16) underwent treatment for either an RTA (n = 11) or an RTD (n = 11). The average age of this cohort was 66.5 ± 15.6 years and the average aneurysm diameter was 73.1 ± 31.4 mm. The mean duration of symptoms prior to repair was 103.1 ± 122 hr, influenced primarily by transport times and device availability. Stent graft exclusion was accomplished in 100% of patients with a procedural mortality of 0%. Commercial Talent devices were used in 19 patients (86.4%) and AneuRx device was used in 1 patient (4.5%). In the remaining two (9.1%) patients handmade devices constructed of Gianturco stents and Dacron fabric were used because of active hemorrhage and lack of appropriate device sizes. Operative time was 135.5 ± 48.5 min and was associated with an average blood loss of 242.0 ± 232.4 cc. Thirty-day mortality was 45.5% (RTA, 27.3%; RTD, 63.6%; p = 0.099). Length of stay in the intensive care unit was 6.1 ± 7.9 days and the mean hospital stay was 11.7 ± 10.6 days. Major complications were present in 54.5% of RTA (cardiac, 1; pulmonary, 3; cardiovascular accident, 2; spinal cord ischemia, 2; pulmonary embolism, 1), and 81.2% of RTD (multisystem organ failure, 7; pulmonary, 1; common femoral artery injury, 1) but not statistically different between groups. There were only two late complications (cardiac death, endoleak-Ia, 1) that occurred during the mean follow-up of 12.5 ± 11.3 (range, 1-32) months. These results indicate that endovascular repair of ruptured thoracic pathologies can be accomplished with an acceptable morbidity and mortality. There were no immediate procedural mortalities and complete exclusion was accomplished in all patients. Most postoperative complications arose from preexisting medical conditions and were not procedure related. The benefit of endovascular repair of ruptured thoracic aortic pathologies is promising.

Alcohol Consumption During Pregnancy and Preeclampsia

ABSTRACT Objective: To determine if preeclampsia was associated with alcohol consumption during pregnancy. Design: A case-control study. Setting: North Carolina Memorial Hospital during January 1984 through March 1987. Patients: 110 Caucasian and African-American primiparous preeclamptic women and 115 Caucasian and African-American primiparous healthy women. Main Outcome Measures: Self-reported history of alcohol during lifetime and pregnancy; type of alcohol consumed. Results: Alcohol consumption was not significantly associated with preeclampsia, although there was a suggestion of a protective effect while simultaneously adjusting for a family history of preeclampsia; maternal smoking, medication, and recreational drug use during pregnancy; working during pregnancy; and choice of a contraceptive method (barrier versus nonbarrier) with the partner before the index pregnancy (OR = 0.50, 95% CI: 0.17–1.50). The odds ratio remained unchanged when lifetime smokers (OR = 0.36, 95% CI: 0.08–1.67) or smokers du...

American Burkitt's lymphoma: A 10-year review and case study

Burkitt's lymphoma is a malignancy of B-lymphocyte origin that was initially described in African children with jaw tumors. These tumors often spread to involve abdominal viscera and other sites, have rapid growth kinetics, and are principally responsive to chemotherapy. Prolonged survival is predicted by site and extent of tumor, with bone marrow and central nervous system involvement being indicators of a poor prognosis. The dental practitioner plays an important role in diagnosis of jaw lesions and treatment throughout the course of the disease. An examination of 17 cases of Burkitt's lymphoma diagnosed at The North Carolina Memorial Hospital, University of North Carolina at Chapel Hill, North Carolina, over a 10-year period is undertaken and an illustrative case study is presented to demonstrate the challenge of caring for the patient with Burkitt's lymphoma.

Pediatric Thyroid Cancer

A review was undertaken of the clinical, gross, and microscopic features of thyroid carcinoma in all patients younger than 21 years of age seen at North Carolina Memorial Hospital from 1952 to 1987 (N = 32). These patients had papillary carcinoma, well-differentiated follicular carcinoma with Hürthle cell change, medullary carcinoma, and an unclassifiable aggressive malignancy. In spite of the presence of lymph node metastases at diagnosis in more half the patients with papillary carcinoma, the prognosis of pediatric papillary thyroid carcinoma appears to be excellent with treatment by surgical debulking and hormonal thyroid suppression. Flow cytometric study of 26 cases showed tumor aneuploidy in 8 of 21 papillary carcinomas and 2 of 3 follicular carcinomas. Aneuploidy did not, however, correlate with clinical outcome in this group of pediatric patients, who were followed for 1 to 29 years. Analysis of multiple tissue blocks of tumor does appear to increase the probability of identifying aneuploid populations.

An Epidemiologic Study of Contraception and Preeclampsia

The primary hypothesis of this study was that contraceptive methods that prevent exposure to sperm and seminal fluid (condoms, diaphragms, spermicides, withdrawal) are associated with an increased risk of developing preeclampsia during the subsequent pregnancy. A case-control study was conducted comparing the contraceptive and reproductive histories of 110 primiparous women with preeclampsia with 115 pregnant women without preeclampsia, aged 15 to 35 years, who gave birth at North Carolina Memorial Hospital, Chapel Hill, between 1984 and 1987. Controls were frequency matched to cases by age, race, and distance from the hospital. Unconditional logistic regression analysis indicated a 2.37-fold (95% confidence interval, 1.01 to 5.58) increased risk of preeclampsia for users of contraceptives that prevent exposure to sperm. A dose-response gradient was observed, with increasing risk of preeclampsia for those with fewer episodes of sperm exposure. These results were supportive of the hypothesis that birth control methods that prevent sperm exposure may play a role in the etiology of preeclampsia.

Congenital Muscular Torticollis: A Spectrum of Pathology

Congenital muscular torticollis (CMT) is a disorder characterized by a shortening of at least one of the cervical muscles and tilting of the head to the opposite side. The most commonly affected muscle is the sternocleidomastoid (SCM) muscle. An unusual case is presented here: a CMT patient with involvement of the trapezius muscle in addition to the SCM muscle who has recently been treated at North Carolina Memorial Hospital. This patient still has a slight residual deformity despite two surgical procedures, physical therapy, and splinting. A review of 41 CMT patients who presented to this institution from 1952 to the present demonstrates that the disorder is extremely variable in terms of severity of deformity and response to various types of therapy. The condition will resolve spontaneously in the majority of patients by the age of 1 year, and if the condition has not resolved by then, it is unlikely to do so without surgery. We therefore believe that surgery should be postponed until after 1 year of age. Most of the patients requiring surgery are effectively treated by division of the involved muscle in at least one area with or without lengthening of the SCM muscle. Splinting and physical therapy are recommended postoperatively. A few patients such as the unusual one with involvement of the trapezius muscle resist our most aggressive therapeutic efforts.

Multiple nosocomial infections. An incidence study.

Prospective surveillance for nosocomial infections was performed for a five-year admission cohort (1980-1984) at North Carolina Memorial Hospital. One or more nosocomial infections developed in 2,662 patients (2.6%) from 102,206 patients at risk; greater than or equal to 2 nosocomial infections developed in 775 of these 2,662 patients (29.1%), and greater than or equal to 3 nosocomial infections in 304 of 775 patients with greater than or equal to 2 infections (39.2%). Hospital stay was significantly prolonged for infected compared with never-infected patients (38.1 vs. 7.9 days, p less than 0.0001) and for multiply-infected versus once-infected patients (57.9 vs. 30.0 days, p less than 0.0001). Total nosocomial infections numbered 4,031 with 2,144 multiple infections (53%); the average number of nosocomial infections per infected patient was 1.5 (4,031 infections in 2,662 patients). Among all nosocomial infections, 64% of bacteremias, 55% of respiratory infections, 55% of surgical wound infections, and 40% of urinary tract infections occurred in patients with multiple nosocomial infections. Surgical patients had 56% of multiple infections. Intensive care unit patients had significantly more multiple infections than non-intensive care unit patients. Nosocomial infections in intensive care unit patients were 71% multiple nosocomial infections. The probability of developing multiple infections was 11 times greater after the first infection occurred. This emphasizes the need to prevent initial nosocomial infections and to identify risk factors for multiple nosocomial infections. Determining risk factors for multiple nosocomial infections could focus infection control efforts on a subpopulation of patients who acquire over 50% of all nosocomial infections and who have significantly prolonged and costly hospital stays.

Clinical Significance of Bacillus Species Isolated From Blood Cultures

To determine the clinical significance of blood isolates of Bacillus, we reviewed all blood cultures obtained at North Carolina Memorial Hospital between 1981 and 1985. Over the five-year study period the number of patients (incidence per 10,000 hospital admissions) from whom Bacillus was isolated increased from 4.97 in 1981 to 12.5 in 1985. The incidence per 1,000 blood cultures also increased from 1.12 in 1981 to 2.33 in 1985. Review of the medical records of 78 of the 95 patients (82%) with positive cultures allowed retrospective classification of five isolates (6.4%) as clinically significant, 33 isolates (42.3%) as possibly significant, and 40 isolates (51.3%) as nonsignificant. Underlying diseases in patients with clinically significant Bacillus bacteremia included burn trauma in two, leukemia in one, carcinoma in one, and gastrointestinal hemorrhage in one. All isolates judged to be clinically significant and the majority of possibly significant isolates were B cereus. We conclude that the isolation of Bacillus species from blood cultures is clinically significant in 5% to 10% of cases, that the incidence of Bacillus bacteremia is increasing, and that burn trauma should be added to the list of conditions known to predispose to clinically significant Bacillus bacteremia.

Carcinoma of the cervix: Analysis of bladder and rectal radiation dose and complications

From April 1969 through December 1980, 527 patients with epidermoid carcinoma of the cervix received radical radiation therapy at North Carolina Memorial Hospital (NCMH). The treatment was designed to deliver a combined dose (external beam plus intracavitary) of 7000–8000 cGy to Point A and 5000–6500 cGy to the pelvic lymph nodes depending upon the stage of the disease. The maximum dose to the bladder and to the rectum were calculated from the orthogonal intracavitary placement films with contrast material in these organs. Thirty-three cases of cystitis and fifty-eight cases of proctitis were recorded. The mean bladder dose for the group of patients with cystitis was higher, 6661 ± 1309 cGy, than that for the patients without cystitis, 6298 ± 1305 cGy, p = .19. The risk of cystitis increased as a function of bladder dose ranging from 3% for patients receiving ≤5000 cGy to the bladder to 12% for patients receiving ≥8001 cGy to the bladder. A similar correlation was also found for rectal dose and proctitis. The mean rectal dose for the group of patients with proctitis was higher, 6907 ± 981 cGy, than that for the patients without proctitis, 6381 ± 1290 cGy, p = .003. The risk of proctitis increased as a function of rectal dose ranging from 2% for patients receiving ≤5000 cGy to the rectum to 18% for patients receiving ≥8001 cGy to the rectum. A study of the severity of the cystitis as a function of bladder dose revealed a relationship between bladder dose and the severity of the complication (Grade I cystitis = 6600 ± 1318 cGy vs Grade III cystitis = 6856 ± 853 cGy). A dose-response relationship was found between the rectal dose and the severity of the complication (Grade I proctitis = 6810 ± 906 cGy vs Grade III proctitis = 6997 ± 1137 cGy). This relationship was statistically significant, p = .003. While there was no difference in the frequency of cystitis as a function of dose to the whole pelvis, the risk of proctitis did increase with increasing doses of external beam to the whole pelvis. It ranged from 3% for patients who received 2000 cGy or less to the whole pelvis to 14% for patients who received >4000 cGy to the whole pelvis, p = .02.

Needle Localization Biopsy of Occult Lesions of the Breast: Experience in 199 Cases

From January 1980 through June 1986, 199 percutaneous needle localizations for clinically occult breast lesions were performed at North Carolina Memorial Hospital. A retrospective analysis of the medical records, mammograms, operative notes, and pathology reports was undertaken to evaluate the success of this procedure. In our series, biopsy was prompted by abnormal calcifications in 27.1% of lesions, occult masses in 37.2%, and by a combination of occult masses and microcalcification in 35.7%. Overall, we had a yield of positive biopsies for cancer of 16.3%, with the yield improving from 12.3% in the earlier years of our study, to 18.7% in the latter years. Of the cancer cases detected, 89.7% were stage I. The localization procedure was successful in 95.9% of the cases. Analysis of our eight failures, along with a review of the literature, shows the major reasons for failure to be incomplete removal of areas with multiple calcifications, dislodgement of the needle, and problems resulting from lack of communication between the radiologist and surgeon. We conclude that the failure rate is low, the yield good, and needle localization a worthwhile procedure for localizing nonpalpable occult lesions.

Adenomas of the large bowel after cholecystectomy. A case-control study.

Cholecystectomy has been reported to be more common in patients with colon cancer. Since adenomas are believed to be precursors of colon cancer, we evaluated the association of cholecystectomy and adenomas in a case-control study. Cases were 244 patients with one or more adenomas who underwent colonoscopy at the North Carolina Memorial Hospital between May 1983 and August 1985. Controls were 281 patients without adenomas. Overall, cholecystectomy was found in 11.9% of cases and 10.3% of controls. White women with adenomas, however, were more likely to have had previous cholecystectomy than controls [odds ratio (OR) 2.5, 95% confidence interval (CI) 1.1-5.6]. Although women with adenomas were older and heavier than controls, the elevated odds ratio persisted after adjustment for these factors (OR 1.8; 95% CI 0.8-4.2). No association was observed for men or for nonwhite women. Cholecystectomy may predispose to colon adenomas and to colon cancer in some patients. Alternatively, common risk factors for gallstones, cholecystectomy, and colon cancer may explain the apparent risk of colon cancer or adenomas after cholecystectomy.

Leaks occurring after gastric bariatric operations.

A leak from the stomach is the most serious complication that occurs after a gastric bariatric operation. The experience with 19 leaks that occurred after 791 gastric bariatric operations performed at North Carolina Memorial Hospital from 1975 to 1986 is described. The incidence of leaks was higher (8.3%) after a second than after a first gastric bariatric operation (2.0%). Ten leaks were life threatening and nine were not. There were no deaths. The diagnosis was made on the basis of Gastrografin swallow in seven patients, clinical findings in six, oral dye studies in three, barium study, a sinogram, and operation in one patient each. Thirteen of 16 patients were operated on within 4 hours of the diagnosis of a leak. One patient with a life-threatening leak and two with non-life-threatening leaks were managed without operations. Three patients were discharged after uncomplicated courses and readmitted, and the diagnosis of a leak was established. To minimize morbidity and mortality related to a leak, it is imperative to (1) recognize that a leak can occur after any gastric bariatric operation, (2) perform a Gastrografin swallow when a leak is suspected, and (3) operate on the patient if the Gastrografin swallow is positive or if the clinical findings suggest a leak.

Impact and costs of varicella prevention in a university hospital.

Information regarding all patient and staff exposures to varicella-zoster virus (VZV) was prospectively accumulated from 1/1/86 to 12/31/86 at North Carolina Memorial Hospital. During this period of time 37 sources of exposure to VZV were reported: 10 outside and 27 within the hospital. Index cases for nosocomial exposure included: 12 patients with zoster, 9 patients with varicella, two staff with varicella, three visitors with varicella, and one staff with zoster. One hundred and twenty patients received nosocomial exposures; 28 had no history of VZV infection (23 per cent), of whom 11 were serosusceptible (39 per cent). Sources of nosocomial patient exposure included: other patients (85 per cent), staff (14 per cent), and a single visitor (1 per cent). More than 300 employees received nosocomial exposure; 158 had no history of VZV infection, of whom 49 were serosusceptible (31 per cent). Only a single employee and no patients developed clinical varicella as a result of nosocomial exposure. Costs associated with VZV control during 1986 totaled $55,934: $39,658 for work furloughs, $9,800 for serologies, $4,293 for patient isolation, $155 for varicella-zoster immune globulin, and $2,028 for infection control personnel time. These costs should be considered as part of any benefit-cost analysis of varicella immunization of health care personnel.

The influence of exogenous estrogen use on survival after diagnosis of endometrial cancer.

For examination of the effect of prior exogenous estrogen use on survival after diagnosis of endometrial cancer, 244 endometrial cancer cases newly diagnosed at North Carolina Memorial Hospital, Chapel Hill, North Carolina, between 1970 and 1976 were followed until 1982. Estrogen users (n = 46) were younger, had less advanced disease, and were more likely to be nonobese and white than were nonusers (n = 198). The estimated probability of surviving (Kaplan-Meier) five years after diagnosis was 0.89 for users and 0.53 for nonusers. When adjusted for age, grade, stage, obesity, race, and treatment (using the Cox proportional hazards regression model), the survival probabilities throughout the period of observation for estrogen users continued to be higher. The adjusted hazard rate for a nonuser was 2.05 (95% confidence interval (Cl) 0.96-4.39) times that for an estrogen user. The adjusted hazard rate from endometrial cancer only was 4.01 (95% Cl 1.22-13.21) times greater among estrogen nonusers. The more frequent occurrence of endometrial cancer in an earlier stage and grade among estrogen users may not be the sole cause of their lower hazard rate from this disease.

Perimortem Cesarean Delivery

Department of Obstetrics-Gynecology, North Carolina Memorial Hospital, Chapel Hill, North Carolina Obstet. Gynecol. 68: 571, 1986