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.

The benefits of integrating Internet technology with standard communications for telemedicine in extreme environments.

The ability to continuously monitor the vital signs of a person can be beneficial especially if the environment is hazardous or a person simply has general health concerns. We wanted to ascertain if, by integrating the Internet, ubiquitous switching technologies and off-the-shelf tools, this "suite of services" could provide a topology to enable remote monitoring in extreme and remote locations. An evaluation of this approach was conducted at the base camp of Mount Everest in the spring of 1999. Three climbers were outfitted with wireless, wearable sensors and transmitters for 24 h as they ascended through the Khumbu Icefall toward Camp One. The physiologic data was forwarded to the receiving station at Base Camp where it was forwarded to the U.S. mainland. Two of the three devices delivered physiologic data 95%-100% of the time while the third unit operated at only 78%. According to the climbers, the devices were unobtrusive, however, any additional weight while climbing Everest must provide advantage.

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.

Critical care medicine education of surgeons: recommendations from the Surgical Section of the Society of Critical Care Medicine.

PERSPECTIVE: The role of surgeons in critical care medicine has a long and esteemed past. The presence of surgeons in intensive care units provides specific insights and perspectives to the care of surgical patients sometimes not fully appreciated by the non-surgical practitioners caring for the same patients. The training and education of surgeons is becoming more complex, fragmented, and lengthy. The knowledge base and skill set required to manage critically ill or injured surgical patients is also becoming more extensive but has the potential of becoming lost in the process of providing the overall educational program for surgical trainees. Simultaneously, nonsurgical specialties are continuing to train individuals with special skills in critical care medicine and the concept of "hospitalists" is becoming more accepted by institutions across the United States. The certification exams in critical care medicine remain under the aegis of the individual medical specialty boards, and there is still not a unified examination process in critical care. Surgeons, in particular, have tremendous pressures these days to spend more clinical time in the operating room, and the task of consistently conducting high quality research is also becoming arduous. This list of reasons could continue but are simply examples for why surgeons need to spend focused attention on how best to train and educate upcoming surgical trainees in regards to the principles of critical care medicine. The critically ill or injured patients need this focused attention and the specialty of surgical critical care medicine needs this attention. The Surgical Section of the Society of Critical Care Medicine has developed this position statement in the hopes that ongoing discussion and refinement of this particular aspect of surgery will continue on several levels.

Transnasal endoscopy for enteral feeding tube placement in critically ill patients.

OBJECTIVE: Early enteral feedings may improve outcomes in critically ill patients. Recently, transnasal endoscopy with an ultrathin transnasal endoscope has been shown to be of value for diagnostic endoscopy without conscious sedation. We developed a technique for the placement of postpyloric feeding tubes in critically ill patients using transnasal endoscopy. We describe our initial experience in a consecutive series of patients. METHODS: We collected data on consecutive intensive care unit patients undergoing bedside transnasal endoscopy for nasoenteric feeding tube placement using a standardized technique. Tube position was confirmed in all patients with a plain abdominal radiograph. Tube placement was deemed successful if the feeding tube traversed the pylorus. RESULTS: Transnasal endoscopy was completed in all fourteen patients, as was placement of a feeding tube. Feeding tubes were successfully placed in the jejunum or duodenum in 13 of the 14 patients (93%). Tubes remained in place from 3 to 45 days (mean 16 days). Two patients required conscious sedation during tube placement, and two ultimately required percutaneous gastrostomy. CONCLUSIONS: Transnasal endoscopy allows simple and successful postpyloric feeding tube placement at the bedside of critically ill patients. This method can facilitate early enteral feeding in intensive care units.

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.

A retrospective analysis of laparoscopically assisted ventriculoperitoneal shunts.

BACKGROUND: During the last two years, laparoscopy has been utilized to facilitate the rapid, safe and direct placement of the abdominal component of ventriculoperitoneal shunts. This study was undertaken to review the feasibility, benefits, technique, and clinical application of laparoscopically assisted ventriculoperitoneal (LAVP) shunt placement. METHODS: A retrospective analysis of the records of six patients who underwent LAVP shunt placement was undertaken. The sex, age, technique, indication for surgery, comorbid conditions, complications operative time, results, and mortality were noted. RESULTS: All patients underwent successful shunt placement. This included placement in the face of previous abdominal surgery, including a percutaneous gastrostomy. The one major complication, hemothorax, was not associated with the laparoscopic portion of the procedure. CONCLUSIONS: Using basic laparoscopic skills and nonspecialized equipment, laparoscopic assistance in ventriculoperitoneal shunt placement offers easy, direct placement of the intraabdominal portion of the catheter in most situations and provides definite patient benefits.