Medicine Lodge, United States
Medicine Lodge, United States

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Messaris E.,Brown University | Nicastri G.,Brown University | Dudrick S.J.,Saint Marys Hospital
Archives of Surgery | Year: 2010

Objective: To determine the outcomes of patients undergoing total extraperitoneal inguinal hernia repair without fixation of the mesh. Design: Prospective cohort. Setting: Community teaching hospital. Patients: A total of 274 consecutive patients were included in the study group. Interventions: All operations were performed by the same surgeon with the patients under general anesthesia in an outpatient setting. A preformed polyester mesh (Parietex; Covidien, Mansfield, Massachusetts) was used in all cases without any fixation. Main Outcome Measures: All patients were prospectively followed up at 2 weeks, 1 month, and 1 year after surgery. Operative morbidity, chronic pain, and hernia recurrence were recorded. Results: Two hundred seventy-four consecutive patients underwent 311 total extraperitoneal inguinal hernia repairs. No conversions were made to open hernia repairs. Norecurrences were found at the 12-month follow-up visit. There were 19 inguinal seromas (6.1%) identified at 2 weeks, but only 7 (1.9%) remained at 1 month, and none at 1 year.Nowound infections, scrotal hematomas, or other perioperative complications were reported. Two hundred thirty-six patients used fewer than the 30 prescribed tablets for pain control, while 23 patients requested a refill, 12 of whom had seromas (P<.01). At 12 months, no patient was taking pain relief medication; however, 8 patients reported occasional discomfort in the groin, and 1 patient reported occasional umbilical discomfort. Conclusion: This single general surgeon experience supports total extraperitoneal inguinal hernia repair without mesh fixation as a safe, effective procedure with low morbidity and no evidence of recurrence at the 1-year follow-up visit. ©2010 American Medical Association. All rights reserved.

Ramsden S.C.,Saint Marys Hospital | Clayton-Smith J.,St Marys Hospital | Birch R.,Yorkhill Hospital | Buiting K.,Universitatsklinikum Essen
BMC Medical Genetics | Year: 2010

Background: Prader-Willi syndrome (PWS) and Angelman syndrome (AS) are clinically distinct neurodevelopmental genetic disorders that map to 15q11-q13. The primary phenotypes are attributable to loss of expression of imprinted genes within this region which can arise by means of a number of mechanisms. The most sensitive single approach to diagnosing both PWS and AS is to study methylation patterns within 15q11-q13; however many techniques exist for this purpose. Given the diversity of techniques available, there is a need for consensus testing and reporting guidelines.Methods: Testing and reporting guidelines have been drawn up and agreed in accordance with the procedures of the UK Clinical Molecular Genetics Society and the European Molecular Genetics Quality Network.Results: A practical set of molecular genetic testing and reporting guidelines has been developed for these two disorders. In addition, advice is given on appropriate reporting policies, including advice on test sensitivity and recurrence risks. In considering test sensitivity, the possibility of differential diagnoses is discussed.Conclusion: An agreed set of practice guidelines has been developed for the diagnostic molecular genetic testing of PWS and AS. © 2010 Ramsden et al; licensee BioMed Central Ltd.

Sanchez J.A.,Saint Marys Hospital | Sanchez J.A.,University of Connecticut Health Center | Barach P.R.,Utrecht Medical Center
Surgical Clinics of North America | Year: 2012

Error prevention and mitigation is the primary goal in high-risk health care, particularly in areas such as surgery. There is growing consensus that significant improvement is hard to come by as a result of the vast complexity and inefficient processes of the health care system. Recommendations and innovations that focus on individual processes do not address the larger and often intangible systemic and cultural factors that create vulnerabilities throughout the entire system. This article introduces basic concepts of complexity and systems theory that are useful in redesigning the surgical work environment to create safety, quality, and reliability in surgical care. © 2012 Elsevier Inc.

Briggs M.D.,Northumbria University | Brock J.,Saint Marys Hospital | Ramsden S.C.,Saint Marys Hospital | Bell P.A.,Northumbria University
European Journal of Human Genetics | Year: 2014

Pseudoachondroplasia (PSACH) and autosomal dominant multiple epiphyseal dysplasia (MED) are chondrodysplasias resulting in short-limbed dwarfism, joint pain and stiffness and early onset osteoarthritis. All PSACH, and the largest proportion of MED, result from mutations in cartilage oligomeric matrix protein (COMP). The first mutations in COMP were identified in 1995 in patients with both PSACH and MED and subsequently there has been over 30 publications describing COMP mutations in at least 250 PSACH-MED patients. However, despite these discoveries, a methodical analysis of the relationship between COMP mutations and phenotypes has not been undertaken. In particular, there has, to date, been little correlation between the type and location of a COMP mutation and the resulting phenotype of PSACH or MED. To determine if genotype to phenotype correlations could be derived for COMP, we collated 300 COMP mutations, including 25 recently identified novel mutations. The results of this analysis demonstrate that mutations in specific residues and/or regions of the type III repeats of COMP are significantly associated with either PSACH or MED. This newly derived genotype to phenotype correlation may aid in determining the prognosis of PSACH and MED, including the prediction of disease severity, and in the long term guide genetic counselling and contribute to the clinical management of patients with these diseases. © 2014 Macmillan Publishers Limited All rights reserved.

Rezak A.,Brigham and Women's Hospital | Abbas H.M.A.,Saint Marys Hospital | Ajemian M.S.,Saint Marys Hospital | Dudrick S.J.,Saint Marys Hospital | Kwasnik E.M.,Brigham and Women's Hospital
Archives of Surgery | Year: 2011

Hypothesis: Use of a modified clinical grading score improves accuracy in diagnosing acute appendicitis in the pediatric population while decreasing the use of computed tomography (CT). Design: Retrospective medical records review after approval by the institutional review board. We determined the Alvarado score for each patient and correlated it with the pathological findings and imaging studies to evaluate the efficacy of CT and its attendant radiation exposure. Setting: Community teaching hospital. Patients: Sixty-one patients, aged 3 to 16 years, admitted with suspected acute appendicitis. Main Outcome Measures: Sensitivity, specificity, and accuracy of the modified Alvarado scoring system. Results: The standard Alvarado score for acute appendicitis had a sensitivity of 92% and a specificity of 82%, with an accuracy of 92%. In the modified Alvarado scoring system, CT findings were substituted for Alvarado scores in the ranges of 5 or 6, 5 to 7, 5 to 8, and 5 to 9. The modification resulted in the greatest accuracy (98%) in diagnosing appendicitis in patients with scores in the range of 5 to 7. This modification theoretically would have decreased the use of CT by about 27% in this group of retrospectively studied patients. Furthermore, in patients with Alvarado scores of 1 to 4, another diagnosis should be considered; in patients with scores of 5 to 7, CT should be performed; and, in patients with scores of 8 to 10, an appendectomy should be performed promptly without further studies. Conclusions: The modified Alvarado score is useful as an aid in diagnosing acute appendicitis in the pediatric population. This scoring system eliminates unnecessary use of CT and the attendant potential cancer-inducing radiation in the pediatric population. ©2011 American Medical Association. All rights reserved.

Dudrick S.J.,Yale University | Dudrick S.J.,Saint Marys Hospital
Surgical Clinics of North America | Year: 2011

Surgery in geriatric patients is accompanied by increases in morbidity and mortality, increases in functional abnormalities and poor outcomes, and increases in severe malnutrition, compared with surgery of similar magnitude in nongeriatric patients. Hospitalized elderly patients are at significant risk of presenting with, or developing, protein-energy and other nutrient deficiencies. However, nutritional assessment of older geriatric patients, 65 to 100 years of age, is a challenging task because of lack of adequate age-specific reference data in this diverse and heterogeneous population. Dietary counseling and conscientious, aggressive nutritional support are required for optimal metabolic and surgical care of this age group. © 2011 Elsevier Inc.

Brenes-Salazar J.A.,Saint Marys Hospital | Forman D.E.,Saint Marys Hospital
Progress in Cardiovascular Diseases | Year: 2014

Coronary heart disease (CHD) is one of the leading causes of morbidity and the most common cause of death in older adults. Paradoxically, elderly patients tend to be systematically excluded from randomized-controlled cardiovascular trials, which complicates decision-making in this population. Management of CHD in the elderly is frequently more difficult in virtue of chronic comorbid conditions and aging-intrinsic dynamics. Despite these challenges, the number of elderly and very elderly patients undergoing percutaneous coronary interventions (PCI) is increasing. Elderly patients in many registries and large clinical series exhibit even a greater benefit from interventional procedures than younger patients, but they have a higher rate of overall complications. We present an overview of the current available evidence of PCI in older adults with stable and unstable CHD, including comparisons between drug-eluting and bare-metal stents, transfemoral and transradial access, and methods of revascularization. Adjuvant antiplatelet and antithrombotic therapies are also discussed. © 2014.

Abunnaja S.,Saint Marys Hospital | Cuviello A.,Saint Marys Hospital | Sanchez J.A.,Saint Marys Hospital
Nutrients | Year: 2013

Nutritional support of surgical and critically ill patients has undergone significant advances since 1936 when Studley demonstrated a direct relationship between pre-operative weight loss and operative mortality. The advent of total parenteral nutrition followed by the extraordinary progress in parenteral and enteral feedings, in addition to the increased knowledge of cellular biology and biochemistry, have allowed clinicians to treat malnutrition and improve surgical patient's outcomes. We reviewed the literature for the current status of perioperative nutrition comparing parenteral nutrition with enteral nutrition. In a surgical patient with established malnutrition, nutritional support should begin at least 7-10 days prior to surgery. Those patients in whom eating is not anticipated beyond the first five days following surgery should receive the benefits of early enteral or parenteral feeding depending on whether the gut can be used. Compared to parenteral nutrition, enteral nutrition is associated with fewer complications, a decrease in the length of hospital stay, and a favorable cost-benefit analysis. In addition, many patients may benefit from newer enteral formulations such as Immunonutrition as well as disease-specific formulations. © 2013 by the authors licensee MDPI, Basel, Switzerland.

Jammalamadaka D.,Saint Marys Hospital | Raissi S.,Saint Marys Hospital
American Journal of the Medical Sciences | Year: 2010

In clinical practice, poisoning with ethylene glycol, methanol, and isopropyl alcohol is common. These alcohol-related intoxications can present with high anion gap metabolic acidosis and increased osmolality. Toxicity and clinical symptoms are due to the accumulation of their metabolites, causing increased anion gap, rather than the parent compounds that are associated with an increase of serum osmolality. Clinical manifestations result from abnormalities of neurologic, cardiopulmonary, and renal function. Laboratory abnormalities when present are helpful for diagnosis but may be absent depending on the time of ingestion and time of presentation. Fomepizole and ethanol are potent inhibitors of alcohol dehydrogenase and reduce generation of toxic metabolites. Hemodialysis is an effective way of detoxification because it can remove unmetabolized alcohol in addition to the organic anions. High index of suspicion and early diagnosis can prevent the significant morbidity and mortality associated with these intoxications. © Copyright 2010 Southern Society for Clinical Investigation.

McCabe P.J.,Saint Marys Hospital
Journal of Multidisciplinary Healthcare | Year: 2011

Clinicians in a variety of settings are called upon to care for patients diagnosed with atrial fibrillation (AF), a common chronic condition that affects up to 3 million people in the USA. Evidence-based guidelines provide clinicians with direction for treatment of AF, but recommended content for educating patients and counseling about self-management of AF is not included in published guidelines. When patients believe they have a good understanding of AF they report fewer symptoms, perceive greater control over AF, and attribute less emotional distress to AF. Thus, providing patients with information about AF and how to manage it is important for promoting positive outcomes. The purpose of this article is to offer evidence-based recommendations for content to include in self-management education and counseling for patients with AF. Approaches for educating and counseling patients related to AF pathophysiology, the nature of AF (its cause, consequences, and trajectory), treatments, action plans, and symptom management, and managing the psychosocial challenges of living with AF, are discussed. © 2011 McCabe.

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