University-affiliated General Hospital Research Articles

Long-term Follow-up on the Effect of Silastic Ring Vertical Gastroplasty on Weight and Co-Morbidities

Silastic ring vertical gastroplasty (SRVG) is a simple, effective and reproducible restrictive operation for the treatment of morbid obesity. Over the last years, it has lost its popularity due to the development of adjustable gastric banding systems performed laparoscopically. In order to evaluate the long-term effect of SRVG on weight loss and co-morbidities, we reviewed the results of SRVG operations in our institution. We reviewed SRVG operations performed in our University-affiliated General Hospital. Data was collected from the patients' in-patient records, their outpatient-clinic files, and from a telephone interview. Between 1989 and 2001, 162 patients were operated upon. Complete follow-up was obtained of 115 patients (71%). The mean follow-up was 7.1 +/- 3 years (range 4 to 16 years). Mean preoperative BMI was 47 kg/m2 (range 34 to 69 kg/m2). Maximal weight loss was obtained within 1 year to a mean BMI of 29 kg/m2, with a mean excess BMI loss of 67%. Subsequently, there was a small increase in BMI, which stabilized at 34 kg/m2 up to 15 years after the operation. A rapid, significant improvement in obesity-related co-morbidities was observed regarding hypertension (81%), diabetes (100%), sleep disorders (90%), osteoarthritis (83%) and ischemic heart disease (75%). There was no peri-operative mortality. Early complication rate was 10%. Late complications included postoperative ventral hernia (18%), esophagitis (31%), ring stricture (19%), ring erosion (2 patients), failure of staple line (8%) and obstruction of the pouch with food (19%). 35 patients (30%) required another procedure, 8 of them were eventually converted to other bariatric operations, and 2 patients had the ring removed and refused another bariatric procedure. The overall satisfaction rate was 86%. SRVG is a simple, safe and effective bariatric operation in selected patients with morbid obesity. It results in a rapid, excellent effect on obesity-related co-morbidities and good long-term effect in weight loss, which compares positively with other, more complicated bariatric operations.

Fecal impaction in children: report of 53 cases of rectal seed bezoars

Background Rectal seed bezoars in children seem to present an uncommon problem that necessitates some operative intervention. Purpose Our objective is to determine the occurrence and clinical characteristics of rectal seed bezoars in children with fecal impaction. Methods A retrospective review of hospital records of children with discharge diagnosis of fecal impaction was conducted from 1996 to 2005 in a university-affiliated general hospital Results The study group is composed 59 children. A total of 53 had rectal seed bezoars: watermelon seeds in 43 children, prickly pear seeds in 6, sunflower seeds in 3, and pumpkinseeds in 1. Six children had seedless fecal impaction. All the children with seed bezoars were of Arab origin. Fifty children were treated under general anesthesia. Of the remaining 9 children, 5 underwent digital disimpaction without general anesthesia: 3 with seedless feces and 2 with rectal seed bezoars. Four children with rectal seed bezoars evacuated spontaneously without digital disimpaction. There was summer seasonal preference for watermelon and prickly pear seed bezoars, whereas sunflower seed bezoars occurred in the spring. Conclusions Fecal impaction owing to rectal seed bezoars is more common than previously believed. Its occurrence among Arab children alone in this study might indicate a high proportion of fecal seed bezoars throughout the Middle East. We propose that the preferred treatment should include disimpaction and irrigation of the rectal content under anesthesia. Greater awareness by primary care practitioners and parents might be beneficial in its prevention in the future.

Resolution of Residual Pleural Disease According to Time Course in Tuberculous Pleurisy During and After the Termination of Antituberculosis Medication

To assess the resolution of pleural disease in patients with tuberculous pleurisy (TP) during and after antituberculosis medication. An observational, prospective, longitudinal study. University-affiliated general hospital in Seoul, Korea. Chest radiographs of 85 adult TP patients were followed up prospectively from diagnosis to 24 months after the start of medication. The extent of pleural disease, synonymous with the radiographic term, pleural opacity (PO), was evaluated at regular intervals according to a size scale. Additionally, following completion of 6 months of therapy, residual PO (RPO) was determined by either measurement of the widest width of the opacity, if loculated, or at the superior level of the hemidiaphragm. Seventy-seven patients had a PO graded > or = 2 at the initial presentation. At 6, 9, and 24 months, the number of patients with these grades declined. At these time periods, there were 14, 8, and 7 patients, respectively, remaining with this classification. RPO > 10 mm at 24 months was considered indicative of significant residual pleural disease. During the period after 6 months of antituberculosis medication, the number of patients with RPO > or = 10 mm declined from 43 patients at 6 months to 21 patients at 24 months. The presence of loculation on an initial chest decubitus view was associated with significant RPO at 24 months (p = 0.009). In TP patients, improvement of RPO often occurred even after completion of 6 months of antituberculosis medication up to 24 months. A loculated PO at initial presentation, but not initial PO size, was a predictor of significant RPO at 24 months.

Safe administration of contrast media: what do physicians know?

Radiographic contrast media (RCM) are among the most commonly used materials in medicine. Nevertheless, there seems to be a little agreement between current practice and accepted guidelines regarding their adverse reactions, the indications for premedication, and use of low-osmolar contrast agents (LOCAs). Misconceptions exist regarding the relationship between hypersensitivity to RCM and foods and medications that contain iodine. To evaluate physicians' knowledge, misconceptions, and attitudes regarding the use of RCM and the prevention of their adverse reactions. Physicians from university-affiliated general hospitals were asked to complete an anonymous questionnaire on RCM. A total of 157 physicians (45%), including radiologists, internists, pediatricians, surgeons, and primary family physicians, agreed to participate. All physicians demonstrated limited knowledge regarding adverse effects of RCM and the patients who might be at increased risk of developing them. Most physicians were not familiar with accepted guidelines for using premedication and LOCAs. Misconceptions regarding the association between the use of drugs or foods that contain iodine and adverse effects to RCM were common among all physicians. The level of knowledge about the adverse reactions of RCM among physicians is unsatisfactory, which may result in unwarranted use of expensive LOCAs or premedication in healthy patients. Alternatively, physicians' failure to use these measures when indicated may endanger patients. Despite the lack of association between adverse effects to RCM and safe consumption of iodine-containing substances, physicians continue to harbor these misconceptions. Educational programs that may improve physicians' knowledge are urgently needed.

Prenatal age-specific reference intervals for measuring all five digits of the fetal hand.

To construct prenatal age-specific reference intervals for measurement of five digits in normal fetuses. Prospective cross-sectional study of fetuses assessed at an antenatal ultrasound unit in a university-affiliated general hospital. The study cohort comprised 302 pregnant women attending our clinic for routine fetal biometry or anomaly scan between December 1997 and June 2000. They all fulfilled the study inclusion criteria: singleton fetuses with normal anatomy, accurate gestational age and no medical complications of pregnancy. Each fetus was scanned once only and the finger measurements of one hand were obtained. Electronic calipers were placed on the outer margin of the proximal phalanx to the outer margin of the distal phalanx level. Those measurements and the relevant gestational age were registered in a computerized database. The linear increase of size of each of the five fingers was plotted across the evaluated range of gestation (P < 0.001; r2 between 0.85 and 0.86 for fingers I to V). Tables showing the 5th, 50th and 95th centiles of finger lengths between 14 and 27 weeks' gestation were created based on the reference interval charts. Second-trimester measurement of all five digits of the fetal hand is feasible. This may assist in the evaluation of fetuses that are primarily suspected of having genetic abnormalities that might be expressed by deviation in finger length.

Monopaternal superfecundation of quintuplets after transfer of two embryos in an in vitro fertilization cycle

Objective: To present the first genetically proven identity of quintuplets in an IVF treatment cycle after transferring only two embryos. Design: Case report. Setting: IVF unit and obstetrics department of university-affiliated general hospital. Patient(s): Twenty-five–year-old patient undergoing IVF treatment for unexplained infertility. Intervention(s): In vitro fertilization with intracytoplasmic sperm injection performed on 50% of oocytes, resulting in successful production of nine early-cleavage embryos. Transfer of two embryos on day 3 and freezing of the remaining embryos. Main Outcome Measure(s): Development of five separate embryonic sacs. Fetal reduction of three embryos at 12 weeks of gestation. Result(s): Successful completion of the twin pregnancy and full genetic analysis of the three embryos and the twins that were born at term. Conclusion(s): Despite transferring only two embryos, superfecundation occurred, resulting in five embryos. Genetic analysis can be used to determine paternity and identity of all the embryos.

"Colonization pressure" and risk of acquisition of methicillin-resistant Staphylococcus aureus in a medical intensive care unit.

To determine the roles of "colonization pressure," work load or patient severity in patient acquisition of methicillin-resistant Staphylococcus aureus (MRSA) in intensive care units (ICUs). Prospectively collected data from October 1996 through December 1998. A 12-bed medical ICU in a university-affiliated general hospital. Patients with risk factors for MRSA admitted to the ICU were screened within 72 hours of admission and weekly thereafter. MRSA was considered imported if detected during the first 72 hours of admission and nosocomial if detected only thereafter. Three screening strategies were used on admission during three consecutive periods. The unit of time chosen for measurements was the week. Weekly colonization pressure (WCP) was defined as the number of MRSA-carrier patient-days/total number of patient-days. Patient severity (number of deaths, Simplified Acute Physiologic Score [SAPS] II), work load (number of admis sions, Omega score), and colonization pressure (number of MRSA carriers at the time of admission, WCP) were compared with the number of MRSA-nosocomial cases during the following week. Of the 1,016 patients admitted over 116 weeks, 691 (68%) were screened. MRSA was imported in 91 (8.9%) admitted patients (13.1% of screened patients) and nosocomial in 46 (4.5%). The number of MRSA-nosocomial cases was correlated to the SAPS II (P=.007), the Omega 3 score (P=.007), the number of MRSA-imported cases (P=.01), WCP (P<.0001), and the screening period (P<.0001). In multivariate analysis, WCP was the only independent predictive factor for MRSA acquisition (P=.0002). Above 30% of WCP, the risk of acquisition of MRSA was approximately fivefold times higher (relative risk, 4.9; 95% confidence interval, 1.2-19.9; P<.0001). Acquisition of MRSA in ICU patients is strongly and independently influenced by colonization pressure.

Cryoprostatectomy consistently elevates serum creatine kinase-MB isoenzyme

Study Objective: To measure serum CK-MB, a market of myocardial infarction (MI), in elderly men before and after cryoprostatectomy. Design: Serum CK-MB was measured on each patient before and after cryoprostatectomy. Each patient's preoperative result was used as control measurement for comparison with measurements made after cryoprostatectomy. Setting: Inpatient operating room and postanesthetic, recovery unit of a university-affiliated general hospital. Patients: 38 male patients, mean (SEM) age 69.1 ± 1.4 years, undergoing cryoprosta-tectomy. Interventions: All patients had a 12-lead ECG prior to surgery, in the recovery room, and 24 hours after surgery. Serum CK-MB was measured prior to induction of anesthesia, on arrival in the recovery room, and at 8 and 24 hours after surgery. Lactate dehydrogenase (LDH) and isoenzymes also were measured in 10 patients before and after cryoprostatectomy. Measurements and Main Results: All patients underwent uneventful cryoprostatectomy. No patients had new ECG changes after surgery. All patients had normal serum CK and CK-MB concentrations before surgery. Serum CK and CK-MB were significantly elevated after cryoprostatectomy ( p < 0.001). Enzyme values were greatest 8 hours after surgery: total CK mean 1453 ± 145 U/L (range 199 to 3,356 U/L); CK-MB mean 52 ±3 ng/ml (range 12 to 114 ng/ml) or 5.0 ± 0.5% of total CK (range 1.6% to 12.4%). All patients had significant elevations of LDH after cryoprostatectomy but did not show an increase in the ratio of LDH 1 to LDH 2 isoenzymes. Finally, unlike patients with an acute MI, the activity of CK-MB isoenzyme when measured by gel electrophoresis was two to three times greater (mean, 2.6 ± 0. 7) than the concentration measured with the monoclonal antibody assay in patients after cryoprostatectomy. Conclusion: Serum CK-MB is an unreliable test to diagnose a MI in patients who have undergone cryoprostatectomy.

The Feasibility of an Ambulatory Surgery Service for Military Personnel

In the past, ambulatory surgery has been considered unsuitable for military personnel. In this pilot study, 69 members of the Israel Defense Forces underwent a variety of surgical procedures on an ambulatory basis in a central, university-affiliated general hospital. The waiting time for surgery was considerably reduced. The patients, the army, and the hospital staff were satisfied with the service. Although further study is needed, ambulatory surgery appears to be a suitable and advantageous modality for military personnel.

Facilitation of rapid-sequence intuhation with large-dose vecuronium with or without priming

Study Objectives: To determine the effect of priming on the intubation and onset times of vecuronium 0.3 mglkg. Design: Randomized, unblinded study. Setting: Operating rooms and postanesthetic recovery unit of a university-affiliated general hospital. Patients: Thirty female ASA physical status I and II patients scheduled for intraperitoneal surgery divided into two groups of 15 each. Interventions: Anesthesia was induced and maintained with sufentanil, droperidol, thiopental sodium, and nitrous oxide in oxygen. Patients in Group 1 were given vecuronium 0.015 mglkg 4 minutes before induction and vecuronium 0.285 mglkg 1 minute after induction. Patients in Group 2 received a single 0.3 mglkg dose of vecuronium 1 minute after thiopental sodium. The ulnar nerve was stimulated every 10 seconds with train-of-four supramaximal impulses of 0.2 millisecond duration at 2 Hz. The compound electromyogram (EMG) of the adductor pollicis was continuously recorded. The trachea was intubated when the amplitude of the EMG decreased to 15% to 25% of control. At the end of surgery, residual neuromuscular block was reversed with edrophonium 0.75 mg/kg. Measurements and Main Results: All patients in Group 1 could be intubated in 80 seconds or less, and the longest onset time was 120 seconds. In Group 2, the longest intubation time was 140 seconds, and the longest onset time was 200 seconds. Clinical durations in both groups were unpredictable, ranging from 47 to 185 minutes in Group 1 and from 63 to 160 minutes in Group 2. Ten of the 30 patients required an additional 0.5 mglkg of edrophonium for antagonism of the residual neuromuscular block. There were no significant changes in heart rate or blood pressure attributable to vecuronium. Conclusions: Seventy-five percent to 85 % neuromuscular block of the adductor pollicis, required for atraumatic tracheal intubation, developed in 80 seconds or less when vecuronium 0.3 mglkg was administered in divided doses and in 140 seconds or less when it was injected as a single bolus dose. Clinical duration of vecuronium 0.3 mgl kg is long and unpredictable, and reversal of residual neuromuscular block may require larger doses of anticholinesterases. It is recommended that an intubatiog dose of vecuronium 0.3 mg/kg be used only in patients undergoing long surgical procedures that require prolonged postanesthetic mechanical ventilation.

Risk assessment in cancer patients with fever and neutropenia: a prospective, two-center validation of a prediction rule.

The study was undertaken to validate a clinical model for predicting the medical risk of cancer patients with fever and neutropenia. A consecutive sample of 444 cancer patients with fever and neutropenia (granulocyte count less than 500/microL) at two hospitals, a specialized cancer referral center and a university-affiliated general medical hospital, was studied to identify clinical characteristics in the first 24 hours that predict subsequent serious medical complications during the hospital stay. To control for bias, major risk factors and complications were subject to blinded review. Serious medical complications occurred in 34% of patients with risk factors identified in a prior study, including prior inpatient status (group I), outpatients with a serious independent comorbidity (group II), or uncontrolled cancer (group III), compared with 5% of the remaining patients (group IV) (P less than .000001). Two of the complications in group IV patients were transient asymptomatic hypotension, and the remaining three complications occurred after at least 1 week of progressive medical deterioration. These risk groups were independently significant in stepwise logistic regression analysis. Multiple complications (17%) and death (10%) were common among patients in groups I through III but did not occur in group IV patients. This risk assessment model accurately stratified the medical risk of these patients using only clinical information available on the first day of their course. Low-risk patients are an appropriate population in which to study less intensive treatment strategies.

Acute phase reactants and risk of bacterial meningitis among febrile infants and children

To test the hypothesis that quantitation of either C-reactive protein (CRP) or the total peripheral WBC count can improve clinical detection of underlying bacterial meningitis among young febrile children. Cross-sectional survey of selected symptoms of central nervous system infection, signs of meningeal irritation and/or elevated intracranial pressure, levels of CRP in serum, and total peripheral WBC counts among unselected pediatric patients undergoing lumbar punctures for evaluation of acute febrile illnesses. Emergency department and acute care "walk-in" clinic of an urban, university-affiliated general hospital. 160 previously well, acutely febrile infants and children (median age, 6 months). The prevalence of bacterial meningitis was 6%. Sensitivity of symptoms was 1.00 and specificity was 0.17. Sensitivity of signs was 0.70 and specificity was 0.81. Of the acute phase reactants, sensitivity of a CRP level of more than 1.0 mg/dL was 0.80, while that of a total peripheral WBC count of more than 15,000/mm3 was 0.40. The presence of signs and/or a CRP level of more than 1.0 mg/dL correctly identified all children with bacterial meningitis (sensitivity, 1.00). The absence of signs and a CRP level of 1.0 mg/dL or less correctly identified 71 of 150 children without bacterial meningitis (specificity, 0.47). Of 125 children without meningeal signs, the combination of symptoms and a CRP level of more than 1.0 mg/dL correctly identified all three children with bacterial meningitis (sensitivity, 1.00). The absence of these symptoms and/or a CRP level of 1.0 mg/dL or less correctly identified 80 of 122 children without bacterial meningitis (specificity, 0.66). Quantitation of CRP but not the total peripheral WBC count can increase the sensitivity of physical examination findings and the specificity of symptoms for the diagnosis of bacterial meningitis. Measurement of CRP in serum is useful as an adjunct to history and physical examination for the detection of acute bacterial meningitis in the acutely febrile child.

Acute Inferior Vena Cava Thrombosis: Early Results of Heparin Therapy

To determine, during heparin therapy, the embolic risk associated with acute inferior vena cava thrombosis compared with noncaval thrombosis. Prospective controlled study. University-affiliated general hospital. Of 68 consecutive patients considered, 18 with cavographically proved inferior vena cava thrombosis and 45 with phlebography-proved noncaval proximal thrombosis met all other eligibility criteria and completed the study. All patients received adjusted continuous IV heparin therapy for ten days. All 63 patients underwent systematic baseline and "day 10" perfusion lung scanning and phlebocavography. None suffered pulmonary embolism within the ten days, but 11/63 patients showed thrombus extension on day 10 phlebocavograms. Retrospectively, no significant difference could be found between the groups with and without extension. (a) The early embolic risk associated with heparin-treated venous thromboses appears low and does not seem to depend on the location (caval or more peripheral) of venous clots. (b) Thrombus extension may occur in spite of apparently "adequate" anticoagulation with heparin.

Psychiatric consultation: A survey and review of utilization

Regardless of what has been written of the need for evaluation of the psychiatric consultation service in the general hospital, there is a dearth of such studies. 1 In a 400-bed university-affiliated general hospital, we have recently increased the staffing and scope of consultation service. In a period of 2 mo, two and one-half staff positions were added. Here was a point at which to take stock of prior performance and future course. One evaluative approach herein involves a survey of recipients of the consultation service, staff physicians of the hospital. We were also interested in the relationship between the findings of such a survey instrument and the actual clinical practice. To that end, we used our service records to explore the following possible associations: Would concurrent use of consultation services by various subgroups within the staff reflect survey support and approval? How would survey respondents' declared profile of reasons to request consultation compare with actual practice?

Adverse occurrences in the intensive care unit.

To the Editor.— Inasmuch as we have been studying the frequency of human error in the emergency center as a basis for improving the quality of medical care, we welcome this splendid article (1980;244:1582) that recommends vigorous investigation of hazards in hospital. We would like to call the attention of the Pittsburgh group to the well-documented diurnal rise in human error that peaks at about 3 AM and 3 PM. This interesting phenomenon has been confirmed in a variety of settings including gas company personnel reading meters, automatic train breakers, and near-misses in train and truck operators. It is perhaps more pertinent to point out that at 3 PM, detection of hypertension in the emergency center of a university-affiliated public general hospital fell to one third its previous rate. 1 We would like the authors' opinion as to the relevance of these findings to their observation that intensive care unit