Trovafloxacin-associated leukopenia.

OBJECTIVE: To report a case of trovafloxacin-associated leukopenia, which occurred in a trauma patient shortly after administration and resolved following discontinuation of the drug. CASE SUMMARY: A 79-year-old white man was admitted to Yale New Haven Hospital after sustaining partial amputation of his right lower leg by an industrial lawn mower. After successful resuscitation, he underwent complete right lower amputation and was treated with intravenous alatrofloxacin mesylate. He developed leukopenia that resolved after discontinuation of the drug. DISCUSSION: Trovafloxacin is a broad-spectrum synthetic fluoroquinolone used for a wide variety of bacterial infections. We report, for the first time in the English-language literature, a case of trovafloxacin-associated leukopenia. The leukopenia resolved promptly after discontinuation of the drug. This association is further supported by the exclusion of other potential causes for this adverse effect. CONCLUSIONS: Leukopenia is a well-recognized adverse effect of several drugs. We report a case of trovafloxacin-associated leukopenia during treatment of a trauma patient. Healthcare personnel should be aware of this possible adverse reaction in patients treated with trovafloxacin.

Telemedicine, the Internet, and world wide web: overview, current status, and relevance to surgeons.

The Information Age has made profound changes in society and is slowly entering the healthcare field. Some of the most important areas are telemedicine, the Internet, and the world wide web (www). Millions of physicians, healthcare providers, and patients are accessing the web daily for patient information, consultation, and distant learning. Telemedicine is beginning to enter the mainstream of health care after decades of demonstration projects. There are many issues which have been raised, such as access to the information, the security of the information, and the quality of the content on the web. While telemedicine is beginning to Hower, there are numerous barriers that prevent its rapid implementation, such as licensure, reimbursement, liability, quality of service, and technical issues. In spite of the numerous challenges, telemedicine over the Internet was practiced in one of the most remote areas of the world--Mt. Everest--demonstrating that it is possible to utilize all the latest healthcare telecommunications tools in even the most extreme of settings.

Telemedicine at the top of the world: the 1998 and 1999 Everest extreme expeditions.

The National Aeronautics and Space Administration (NASA) initially established a Commercial Space Center (CSC) in the Department of Surgery at Yale University School of Medicine to further develop and evaluate technologies in information systems, telecommunications applied to medicine, and physiologic sensors. The CSC is known as the Medical Informatics and Technology Applications Consortium (MITAC). The overall purpose for this NASA program is to leverage technology, innovation, and resources from industry and academia through collaborative partnerships. The Yale-NASA CSC/MITAC organized the Everest Extreme Expeditions (E3) for the spring Himalayan climbing seasons in the years 1998 and 1999. The primary mission was to deliver advanced medical support with global telemedicine capabilities to one of the world's most remote and hostile settings--Mount Everest. The purpose was both humanitarian (providing medical support) and scientific (conducting medical and technology research). The Yale team provided medical care for the Everest Base Camp community; conducted validation experiments for several types of advanced medical technologies in this remote, hostile environment; and performed real-time monitoring of selected climbers, while also assessing the basic science of altitude physiology. Additionally, the teams conducted outreach medical care to the citizens of Nepal and provided several educational forums for a variety of medical and nonmedical personnel--including school-age children. As part of the project's mission, the E3 medical teams at both Nepal and New Haven were on a 24-hour emergency call system to deliver medical care in the event of a crisis. Unlike most of the teams at Everest, the mission of E3 was not to climb the 29,028-foot mountain the Nepalese call Sagarmatha ("Sky Head"). The mountain served as an extreme testing ground for telemedicine. The lessons learned from this testbed are reviewed here and further clarify the abilities to provide better health care in remote and extreme environments--which for some may even be their home environment during/after a medical illness.

The physiologic cipher at altitude: telemedicine and real-time monitoring of climbers on Mount Everest.

Advanced wearable biosensors for vital-signs monitoring (physiologic cipher) are available to improve quality of healthcare in hospital, nursing home, and remote environments. The objective of this study was to determine reliability of vital-signs monitoring systems in extreme environments. Three climbers were monitored 24 hours while climbing through Khumbu Icefall. Data were transmitted to Everest Base Camp (elevation 17,800 feet) and retransmitted to Yale University via telemedicine. Main outcome measures (location, heart rate, skin temperature, core body temperature, and activity level) all correlated through time-stamped identification. Two of three location devices functioned 100% of the time, and one device failed after initial acquisition of location 75% of the time. Vital-signs monitors functioned from 95%-100% of the time, with the exception of one climber whose heart-rate monitor functioned 78% of the time. Due to architecture of automatic polling and data acquisition of biosensors, no climber was ever without a full set of data for more than 25 minutes. Climbers were monitored continuously in real-time from Mount Everest to Yale University for more than 45 minutes. Heart rate varied from 76 to 164 beats per minute, skin temperature varied from 5 to 10 degrees C, and core body temperature varied only 1-3 degrees C. No direct correlation was observed among heart rate, activity level, and body temperature, though numerous periods suggested intense and arduous activity. Field testing in the extreme environment of Mount Everest demonstrated an ability to track in real time both vital signs and position of climbers. However, these systems must be more reliable and robust. As technology transitions to commercial products, benefits of remote monitoring will become available for routine healthcare purposes.

Angiography for preoperative evaluation in patients with lower gastrointestinal bleeding: are the benefits worth the risks?

OBJECTIVE: To evaluate the benefits and risks of selective angiography for the evaluation of acute lower gastrointestinal (GI) bleeding to identify the site of bleeding and theoretically limit the extent of colonic resection. DESIGN: Retrospective chart review. SETTING: Tertiary care hospital. PATIENTS: Sixty-five patients undergoing 75 selective angiograms for evaluation of acute lower GI bleeding. Mean age was 71 years (range, 27-93 years), and 37 (57%) were women. MAIN OUTCOME MEASURES: Demographic data were collected that included any associated medical problems, potential factors contributing to an increased risk for bleeding, and the diagnostic methods used in evaluating the source of lower GI bleeding. The details of angiography procedures were recorded with special attention to the impact of the procedure on clinical management and any associated complications. RESULTS: Twenty-three patients (35%) had positive angiography findings, and 14 of them (61%) required operations. Forty-two patients (65%) had negative angiography findings, and 8 of them (19%) required operations. Surgery for the 22 patients included hemicolectomy in 11 patients, subtotal colectomy in 10 patients, and small-bowel tumor resection in 1 patient. In 9 patients, a hemicolectomy was performed on the basis of angiography findings. Three patients (2 with negative angiography findings) experienced rebleeding after a hemicolectomy and required a subsequent subtotal colectomy. Overall, only 8 (12%) of the 65 patients underwent a segmental colon resection that was based on angiography findings and did not bleed after their operation. Complications from angiography occurred in 7 patients (11%). CONCLUSION: Selective angiography appears to add little clinically useful information in patients with acute lower GI bleeding and carries a relatively high complication risk.

The Spacebridge to Russia Project: internet-based telemedicine.

The National Aeronautics and Space Administration (NASA) has been a pioneer in telemedicine since the beginning of the human spaceflight program in the early 1960s. With the rapid evolution in computer technology and equally rapid development of computer networks, NASA and the Department of Surgery in Yale University's School of Medicine created a telemedicine testbed with the Russia Space Agency, the Spacebridge to Russia Project, using multimedia computers connected via the Internet. Clinical consultations were evaluated in a store-and-forward mode using a variety of electronic media, packaged as digital files, and transmitted using Internet and World Wide Web tools. These systems allow real-time Internet video teleconferencing between remotely located users over computer systems. This report describes the project and the evaluation methods utilized for monitoring effectiveness of the communications. The Spacebridge to Russia Project is a testbed for Internet-based telemedicine. The Internet and current computer technologies (hardware and software) make telemedicine readily accessible and affordable for most health care providers. Internet-based telemedicine is a communication tool that should become integral to global health care.

Benchmarking for best practice in critical care medicine: can it realistically be done?

An individual program's viewpoint on the overall benchmarking process for critical care medicine and how this process can provide a conceptual understanding of how benchmarking can be beneficial.

Nonoperative management for intra-abdominal abscesses.

Percutaneous drainage of an intra-abdominal abscess is utilized frequently. To evaluate its effectiveness at our institution over 16 months, 18 patients (mean age 49 years) who underwent radiologically directed percutaneous drainage of intra-abdominal abscesses were retrospectively reviewed. The abscesses were postoperative in 14 patients (laparotomy, 5; appendectomy, 4; colectomy, 3; hysterectomy, 2). Primary abscesses were due to diverticular disease (3), perforated appendicitis (3), perforated colon carcinoma (1), and perforated peptic ulcer (1). Percutaneous drainage was ultimately established in all patients with complete resolution of the abscesses occurring in 12 patients (67%). The average duration for drainage was 5.5 days (range 1-23). Average length of hospital stay after the establishment of drainage was 14.6 days (range 1-48). Six patients required surgical procedures because of inadequate abscess drainage (4) or continued clinical deterioration (2). There were no deaths. A major complication (colon perforation, enteric fistula) occurred in two patients (11%). Catheter-related problems were common (7/18 patients), and included drain migration (3), inadequate drainage, and catheter obstruction(2). Four patients required multiple percutaneous drainage procedures. Despite technical feasibility and clinical success in the majority of patients, percutaneous drainage of these intra-abdominal abscesses had frequent catheter-related complications. One-third of patients (31.8%) required surgical intervention despite a prolonged period (average 15 days) of percutaneous drainage. Patients demonstrated to have nonresolving abscesses by computer tomography (CT), abscesses associated with colonic diverticular disease of colon cancer, and abscesses localized to the left lower quadrant were noted to have less successful percutaneous abscess drainage. Patients with a persistent of rising leukocyte count and/or an elevated APACHE II score prior to drainage should be routinely reevaluated at 4 days. Earlier surgical intervention is felt to be warranted because these two factors in this study were indicative of a low nonoperative success rate. Post-appendectomy abscesses uniformly demonstrated prompt response to percutaneous drainage. CT-directed percutaneous drainage of intra-abdominal abscesses provides an alternative to immediate surgical intervention. The preliminary findings from this study suggest a limited application of this intervention in one-third of patients. Further detailed analysis of this patient group is required to delineate guidelines for identifying those patients where percutaneous drainage is unlikely to be successful.

Bronchoscopic guidance makes percutaneous tracheostomy a safe, cost-effective, and easy-to-teach procedure.

BACKGROUND: We wanted to assess the efficiency of instituting a modified technique of percutaneous tracheostomy (PET) with bronchoscopic guidance. METHODS: During a 10-month period 48 consecutive trauma patients requiring tracheostomy were divided between a standard tracheostomy control group (ST) and a PET group. All patients were followed prospectively. The hospital charges were reviewed retrospectively. RESULTS: Age, gender, body habitus, and principal diagnosis were similar in the 21 ST patients and the 27 PET patients. All STs and 15 of the PETs were performed in the operating room (OR), and the 12 remaining PETs were done in the intensive care unit (ICU). Four patients in the ST group and six in the PET group died. One of these deaths occurred in a patient in the PET group with severe adult respiratory distress syndrome. Procedure time was shorter for PET (16 versus 45 minutes, p < 0.0001). Junior residents performed more PETs than STs (33% versus 10%), and PET was considered "easier" to perform than ST (81% versus 47%). Hospital charges for PET in the ICU were $3400 less per patient compared with ST or PET in the OR. CONCLUSIONS: PET was performed easily and safely in the OR and at the ICU bedside. PET required one-third the time of ST. Bronchoscopic supervision of PET may have contributed to the small number of complications and the educational experience of junior residents. PET in the ICU can reduce hospital charges significantly and avoids transport of patients to the OR. PET is as safe as ST and should be considered the procedure of choice for an ICU patient requiring an elective tracheostomy.

A comparison of transabdominal preperitoneal (TAPP) and total extraperitoneal approach (TEPA) laparoscopic herniorrhaphies.

There are a variety of accepted techniques for herniorrhaphy. With the advent of laparoscopic general surgery, laparoscopic transabdominal and total extraperitoneal techniques have been added to the many options for repair of the inguinal hernia. From 5/91 to 6/93 we had performed 290 transabdominal preperitoneal (TAPP) laparoscopic herniorrhaphies on 244 adult patients. Due to concerns of potential early and late complications associated with entering the abdominal cavity, we adopted the total extraperitoneal approach (TEPA) for laparoscopic herniorrhaphies in 6/93. Between 6/93 and 12/93, 118 hernias have been repaired in 95 patients using the total extraperitoneal approach. In a retrospective comparison between these two procedures, the recurrence rate is 1.7% (5/290) for TAPP herniorrhaphies and 0% (0/118) for the TEPA. The overall complication rate for TAPP herniorrhaphies was 11.1% and included thigh paresthesias (6), inferior epigastric artery injuries (4), enterotomy (1), bowel obstruction (1), bladder injury (1), and urinary retention (14). The overall complication rate for the TEPA was 3.2% and included bladder injury (1), and urinary retention (2). Mean operative time was similar between these groups (TAPP-81.2 minutes, TEPA-92.9 minutes).

Urban firearm deaths: a five-year perspective.

Firearm violence is an ever-increasing element in the lives of the U.S. urban population. This study examined the trends in firearm violence and victims during a 5-year period in the city of Philadelphia. Medical Examiner records of all deaths in Philadelphia County in 1985 and 1990 were reviewed. Demographic, autopsy, and criminal record information was analyzed. There were 145 firearm homicide victims in 1985 versus 324 in 1990, a 123% increase. This was primarily because of deaths among young (age 15-24 years), black male victims. Handguns were involved in at least 90% of firearm homicides in both study years. The use of semiautomatic handguns increased from 24% to 39% during the study period. In 1985, 42% of revolver homicides died at the scene, versus 18% in 1990. However, 5% of victims of semiautomatic weapons fire died at the scene in 1985 versus 34% in 1990. The decrease in survival of semiautomatic weapon victims occurred despite the implementation of six trauma centers within the county, and probably reflects a shift toward high-velocity, high-caliber ammunition. Antemortem drug use and criminal history was common. A total of 54% of victims were intoxicated in 1985 and 61% were in 1990. Cocaine became the most common intoxicant in 1990, with 39% of victims using it during the antemortem period. The percentage of victims with a criminal record increased from 44% to 67%. Although the duration of criminal history decreased from 14 to 6 years, the number of patients with previous drug offenses increased from 33% to 84%..(ABSTRACT TRUNCATED AT 250 WORDS)

On the nature of things still going bang in the night: an analysis of residency training in trauma.

In the 1982 Presidential Address to the Society of University Surgeons, Trunkey reported on the inadequacy of surgical education in trauma care. His conclusions were based on American Board of Surgery operative experience data compiled from residents completing surgical training in 1980. The purpose of this study was to compare current resident operative experience in trauma surgery with the American Board of Surgery data from 1980. Yearly resident operative experience data obtained from the Residency Review Committee from 1987 through 1991 were analyzed. The relationship between the percentile rank and the number of operative cases was defined using linear regression. The percentile rank of residents performing a specified number of operative cases was computed using a linear regression coefficient. The results were then compared with previously published 1980 American Board of Surgery summary data. Resident operative experience in trauma surgery was stable over the 5-year period investigated and no significant trends were identified. Comparison of the data from 1980 to 1991 revealed that the percentage of residents performing less than ten cases decreased markedly, from 18% to 9%. Moreover, the percentage of residents claiming fewer than 50 cases declined from 86% to 29%. Based on this analysis, it appears that resident operative experience dramatically increased from 1980 to 1987 and has since remained stable. The reasons for this are unclear but undoubtedly involve the accuracy of reporting operative experience, Residency Review Committee operative trauma definitions, and the actual number of trauma surgery cases available for trainees.(ABSTRACT TRUNCATED AT 250 WORDS)

A new approach to probability of survival scoring for trauma quality assurance.

This study examined the application of an artificial intelligence technique, the neural network (NET), in predicting probability of survival (Ps) for patients with penetrating trauma. A NET is a computer construct that can detect complex patterns within a data set. A NET must be "trained" by supplying a series of input patterns and the corresponding expected output (e.g., survival). Once trained, the NET can recall the proper outputs for a specific set of inputs. It can also extrapolate correct outputs for patterns never before encountered. A neural network was trained on Revised Trauma Score, Injury Severity Score, age, and survival data contained in 3500 of 8300 state registry records of all patients with penetrating trauma reported in Pennsylvania from 1987 through 1990. The remaining 4800 records were analyzed by TRISS, ASCOT, and the trained NET. Sensitivity (accuracy of predicting death) and specificity (accuracy of predicting survival) were 0.840 and 0.985 for TRISS, 0.842 and 0.985 for ASCOT, and 0.904 and 0.972 for the neural network. This represents a decrease in the number of improperly classified ("unexpected") deaths, from 73 for TRISS and 72 for ASCOT, to 44 for the neural network. The increased sensitivity was statistically significant by Chi-square analysis. The NET for penetrating trauma provided a more sensitive but less specific technique for calculating Ps than did either TRISS or ASCOT. This translated into a 40% reduction in the number of deaths requiring review, and the potential for more efficient use of quality assurance resources.

Extrinsic civilian trauma to the larynx and cervical trachea--important predictors of long-term morbidity.

Injuries to the larynx and cervical trachea are uncommon, making the development of treatment protocols and subsequent data analysis in any one hospital difficult. This prompted a review of our experience with emphasis on variables related to long-term morbidity. The records of 20 patients with laryngotracheal injuries seen at the Montreal General Hospital from January 1974 to December 1984 were reviewed. The majority were young males (18 to 20 years old), and there was blunt trauma in 14 and penetrating trauma in six. The level of injury was laryngeal in 16 and tracheal in four. There were no airway-related deaths. One patient died with uncontrollable retroperitoneal hemorrhage before definitive repair of the tracheal transection. All but two of the remaining 19 patients had significant morbidity in the form of aphonia, dysphonia, or airway stenosis. The major factors contributing to the high morbidity were delay in diagnosis, anatomic level of injury, and associated multisystem trauma. A high index of suspicion, liberal use of fiberoptic bronchoscopy for diagnosis, and early airway control will lead to earlier diagnosis. Computerized tomography of the upper airway facilitates definitive surgical repair. Long-term followup is essential. Laryngeal trauma remains a major challenge.