56 results on '"Baldwin BJ"'
Search Results
2. Immediate breast reconstruction with the free TRAM flap.
- Author
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Smith ML, Baldwin BJ, and Schusterman MA
- Published
- 1997
3. Chemical weed control in oil-seed poppy (Papaver somniferum)
- Author
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Baldwin, BJ
- Abstract
Field experiments were conducted in north-west Tasmania to assess the herbicides diquat and nitrofen, used singly and in combination, for selective post-emergence weed control in oil-seed poppies (Papaver somniferum). The species of weeds infesting the crop influenced yield responses to the herbicides. In the absence of fat hen (Chenopodium album) and fumitory (Fumaria muralis), crop production increased linearly with rate of diquat. The highest rate of diquat (280 g ha-1) produced a yield that was not significantly different (P = 0.05) from the hand-weeded control. In the presence of these two weeds, linear yield responses to rates of both diquat and nitrofen were obtained. There was no significant interaction effect on crop yields between these two herbicides, but a mixture of both chemicals was required for effective weed control. The tolerance of the crop to the herbicides was measured in the absence of weed competition. No effects on crop yields were obtained, although some treatments retarded the growth of the crop and caused a significant (P = 0.05) reduction in the height of the crop at flowering.
- Published
- 1977
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4. Dr. Melvin Spira.
- Author
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Baldwin BJ
- Published
- 2021
- Full Text
- View/download PDF
5. Pharmacy-Led β-Lactam Allergy Interview (BLAI) Reduces Duration of Fluoroquinolones Within a Community Hospital.
- Author
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Covington EW, Baldwin BJ, and Warren E
- Subjects
- Aged, Female, Hospitals, Community, Humans, Male, Prospective Studies, Anti-Bacterial Agents adverse effects, Drug Hypersensitivity etiology, Fluoroquinolones adverse effects, Hypersensitivity etiology, beta-Lactams adverse effects
- Abstract
Background: Patients with reported β-lactam allergies often receive broad-spectrum antimicrobials and have been shown to experience a variety of negative health consequences, such as increased mortality, costs, readmission, and adverse reactions. Current literature focuses on β-lactam allergy skin testing but lacks evidence on β-lactam allergy interviews (BLAI) when skin testing is unavailable., Objective: This study aimed to test the impact of a pharmacy-led BLAI on duration of fluoroquinolones at a community hospital., Methods: A quasi-experimental design with a prospective cohort design and historical control group was used to assess patients with reported penicillin (PCN) allergies in a community hospital. The primary outcome was duration of fluoroquinolones before and after implementation of BLAI. Secondary outcomes included length of stay (LOS), percentage of patients switched to a β-lactam antibiotic, percentage of antimicrobial stewardship recommendations made/accepted, and discrepancies between allergy in medical record and interview-reported allergy. Nonparametric continuous data and medians were evaluated by Mann-Whitney U., Results: A total of 80 patients were included in the study (43 in the control group and 37 in the prospective group). Fluoroquinolone duration was reduced after the implementation of BLAI (3.7 vs 2.7 days, P = 0.027). In all, 49% of patients in the prospective group were switched to a β-lactam antibiotic after BLAI, with no allergic reactions, adverse effects, or impact on LOS. Conclusion and Relevance: BLAI resulted in a significant reduction in fluoroquinolone duration in patients with PCN allergies and may represent a safe and effective option for institutions lacking skin-testing capabilities.
- Published
- 2019
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6. Middle Eastern Rhinoplasty: Relationship of the Nasal Spine and Caudal Septum to Tip Projection and Columellar-Labial Angle.
- Author
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Arden RL, Baldwin BJ, and Coffey MP
- Abstract
Objective: To measure the anterior nasal spine length (ANSL) and septal caudal extension (SCE), as well as assess the strength of association between these variables and tip projection in the Middle Eastern nose. Our secondary aim was to assess if columellar-labial angle (CLA) or columellar-spinal angle (CSA) vary as a function of ANSL and/or SCE., Study Design/setting: Prospective single institutional study., Subjects: Middle Eastern primary rhinoplasty patients without nasal trauma or prior endonasal surgical history., Methods: Photographic and intraoperative caliper measurements were used to determine Goode ratio (GR), CLA, CSA, ANSL, and SCE. Associations between numeric variables were examined with scatterplots, including use of LOWESS curves and Pearson correlation coefficients. Linear regression models were used for predicting quantitative variables (GR, CLA, CSA). Logistic regression models were used for predicting overprojection status based on GR., Results: In total, 102 patients met inclusion criteria (82 females, 20 males). Mean ANSL and SCE were 8.6 mm and 14.9 mm, respectively; ANSL and SCE had a strong positive association with each other. SCE and ANSL were found to have low predictability for GR, CLA, or CSA., Conclusion: Determinations of projection status using the GR method do not appear to be related to ANSL or SCE values in our Middle Eastern study group. Relationships of absolute columellar-labial or columellar-spinal angles are likely more complex than isolated value implications of SCE or ANSL., Competing Interests: Competing interests: None.
- Published
- 2017
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7. Investigation into the presence of human papillomavirus in patients with obstructive sleep apnea.
- Author
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Baldwin BJ, Chitale D, Chen KM, Worsham MJ, and Yaremchuk K
- Subjects
- Adolescent, Adult, Aged, Female, Human papillomavirus 11 isolation & purification, Human papillomavirus 16 isolation & purification, Human papillomavirus 6 isolation & purification, Humans, In Vitro Techniques, Male, Middle Aged, Real-Time Polymerase Chain Reaction, Retrospective Studies, Sleep Apnea, Obstructive surgery, Tonsillectomy, Papillomavirus Infections virology, Sleep Apnea, Obstructive virology
- Abstract
Objectives/hypothesis: The human papillomavirus (HPV) is known to infect the tissues of the oropharynx as demonstrated in HPV-positive oropharyngeal squamous cell carcinoma (OPSCC). HPV has also been shown to induce benign lymphoid hypertrophy. We sought to investigate an association between obstructive sleep apnea (OSA) and the presence of HPV in palatine and lingual tonsillar oropharyngeal tissue., Study Design: Case series with chart review., Methods: This retrospective laboratory-based study of oropharyngeal tissue from patients with OSA included patients >18 years old who underwent surgical treatment for OSA at a single institution between January 2012 and May 2014. Surgical specimens of adequate size were analyzed for HPV6, 11, and 16 using real-time quantitative polymerase chain reaction from DNA extracted from formalin-fixed paraffin-embedded tissue blocks. Student t test, Pearson χ
2 test, and linear logistic regression were used to assess comparisons of body mass index (BMI), apnea-hypopnea index (AHI), age, and gender between HPV-positive and HPV-negative groups., Results: Of 99 cases included in the study, six were positive for HPV: two with HPV16 and four with HPV6. BMI, AHI, age, and gender showed no significant differences between the HPV-positive and HPV-negative groups. Logistic regression to predict HPV positivity accounting for each variable and multivariate analysis were not statistically significant., Conclusions: Our study did not show HPV to have a statistically significant association with OSA. None of the covariates analyzed (BMI, AHI, gender, age) predicted HPV positivity in surgically resected oropharyngeal tissue from OSA patients., Level of Evidence: 4 Laryngoscope, 127:1231-1234, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)- Published
- 2017
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8. Comparison of impedance cardiography with invasive hemodynamic measurements in patients with heart failure secondary to ischemic or nonischemic cardiomyopathy.
- Author
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Drazner MH, Thompson B, Rosenberg PB, Kaiser PA, Boehrer JD, Baldwin BJ, Dries DL, and Yancy CW
- Subjects
- Cardiac Output, Cardiography, Impedance, Female, Heart Failure diagnosis, Humans, Male, Middle Aged, Cardiac Catheterization, Cardiomyopathies complications, Heart Failure etiology, Hemodynamics
- Published
- 2002
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9. Postoperative adjuvant irradiation: effects on tranverse rectus abdominis muscle flap breast reconstruction.
- Author
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Tran NV, Evans GR, Kroll SS, Baldwin BJ, Miller MJ, Reece GP, and Robb GL
- Subjects
- Adult, Aged, Breast Neoplasms surgery, Combined Modality Therapy, Female, Follow-Up Studies, Humans, Middle Aged, Postoperative Complications surgery, Radiation Injuries surgery, Radiotherapy Dosage, Radiotherapy, Adjuvant, Reoperation, Breast radiation effects, Breast Neoplasms radiotherapy, Mammaplasty methods, Postoperative Complications etiology, Radiation Injuries etiology, Surgical Flaps
- Abstract
The use of postoperative irradiation following oncologic breast surgery is dictated by tumor pathology, margins, and lymph node involvement. Although irradiation negatively influences implant reconstruction, it is less clear what effect it has on autogenous tissue. This study evaluated the effect of postoperative irradiation on transverse rectus abdominis muscle (TRAM) flap breast reconstruction. A retrospective review was performed on all patients undergoing immediate TRAM flap breast reconstruction followed by postoperative irradiation between 1988 and 1998. Forty-one patients with a median age of 48 years received an average of 50.99 Gy of fractionated irradiation within 6 months after breast reconstruction. All except two received adjuvant chemotherapy. Data were obtained from personal communication, physical examination, chart, and photographic review. The minimum follow-up time was 1 year, with an average of 3 years, after completion of radiation therapy. Nine patients received pedicled TRAM flaps and 32 received reconstruction with microvascular transfer. Fourteen patients had bilateral reconstruction, but irradiation was administered unilaterally to the breast with the higher risk of local recurrence. The remaining 27 patients had unilateral reconstruction. All patients were examined at least 1 year after radiotherapy. No flap loss occurred, but 10 patients (24 percent) required an additional flap to correct flap contracture. Nine patients (22 percent) maintained a normal breast volume. Hyperpigmentation occurred in 37 percent of the patients, and 56 percent were noted to have a firm reconstruction. Palpable fat necrosis was noted in 34 percent of the flaps and loss of symmetry in 78 percent. Because the numbers were small, there was no statistical difference between the pedicled and free TRAM group. However, as a group, the findings were statistically significant when compared with 1,443 nonirradiated TRAM patients. Despite the success of flap transfer, unpredictable volume, contour, and symmetry loss make it difficult to achieve consistent results using immediate TRAM breast reconstruction with postoperative irradiation. TRAM flap reconstruction in this setting should be approached cautiously, and delayed reconstruction in selected patients should be considered. Patients should be aware that multiple revisions and, possibly, additional flaps are necessary to correct the progressive deformity from radiation therapy.
- Published
- 2000
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10. Synchronous elective contralateral mastectomy and immediate bilateral breast reconstruction in women with early-stage breast cancer.
- Author
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Gershenwald JE, Hunt KK, Kroll SS, Ross MI, Baldwin BJ, Feig BW, Ames FC, Schusterman MA, and Singletary SE
- Subjects
- Adult, Aged, Breast Neoplasms pathology, Breast Neoplasms prevention & control, Decision Making, Female, Humans, Middle Aged, Neoplasm Recurrence, Local pathology, Retrospective Studies, Breast Neoplasms surgery, Elective Surgical Procedures, Mammaplasty, Mastectomy, Neoplasm Recurrence, Local prevention & control
- Abstract
Background: The role of elective contralateral mastectomy (ECM) in women with early-stage breast cancer who elect or require an ipsilateral mastectomy and desire immediate bilateral breast reconstruction (IBR) is an intellectual and emotional dilemma for both patient and physician. In an attempt to clarify the rationale for this approach, we reviewed our experience with ECM and IBR and evaluated operative morbidity, the incidence of occult contralateral breast cancer, and patterns of recurrence., Patients and Methods: We retrospectively reviewed the records of 155 patients with primary unilateral breast cancer (stage 0, I, or II) and negative findings on physical and mammographic examinations of the contralateral breast who underwent ipsilateral mastectomy and simultaneous ECM with IBR between 1987 and 1995., Results: The median age of the patients was 46 years (range, 25 to 69 years). Clinical stage at diagnosis was stage 0, I, and II in 19.4%, 54.2%, and 26.4% of patients, respectively. Factors likely to influence the use of ECM were family history of breast cancer in first-degree relatives (30%), any family history of breast cancer (56%), difficulty anticipated in contralateral breast surveillance (48%), associated lobular carcinoma in situ (23%), multicentric primary tumor (28%), significant reconstructive issues (14%), and failure of mammographic identification of the primary tumor (16%). Skin-sparing mastectomies were performed in 81% of patients. Overall, 70% of patients underwent reconstruction using autogenous tissue transfer. Reoperations for suspected anastomotic thrombosis were performed in seven patients. Two patients experienced significant partial or complete flap loss. Histopathologic findings in the ECM specimen were as follows: benign, 80% of patients; atypical ductal hyperplasia, 12% of patients; lobular carcinoma in situ, 6.5% of patients; ductal carcinoma in situ, 2.7% of patients; and invasive carcinoma, 1.3% of patients. Eighteen patients (12%) had evidence of locoregional or distant recurrences, with a median follow-up of 3 years. In one patient (0.6%), invasive ductal carcinoma developed on the side of the elective mastectomy., Conclusions: The use of ECM and IBR cannot be justified if the only oncologic criterion considered is the incidence of occult synchronous contralateral disease. However, in a highly selected population of young patients with a difficult clinical or mammographic examination and an increased lifetime risk of developing a second primary tumor, ECM and IBR is a safe approach.
- Published
- 1998
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11. Second free flaps in head and neck reconstruction.
- Author
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Amin AA, Baldwin BJ, Gürlek A, Miller MJ, Kroll SS, Reece GP, Evans GR, Robb GR, and Schusterman MA
- Subjects
- Adolescent, Adult, Aged, Female, Humans, Male, Microsurgery methods, Middle Aged, Postoperative Complications, Reoperation, Salvage Therapy methods, Treatment Outcome, Head and Neck Neoplasms surgery, Surgical Flaps blood supply
- Abstract
Over the past decade, free-tissue transfer has greatly improved the quality of oncology-related head and neck reconstruction. As this technique has developed, second free flaps have been performed for aesthetic improvement of the reconstructed site. This study evaluated the indications for and the success of second free flaps. Medical files for patients who underwent second free flaps for head and neck reconstruction at the University of Texas M.D. Anderson Cancer Center, from May 1, 1988 to November 30, 1996, were reviewed. The flaps were classified as being either immediate (done within 72 hr) or delayed (done within 2 years) reconstructions. Indications, risk factors, recipient vessels, outcome, and complications were analyzed. Of the 28 patients included in this study, 12 had immediate (nine as salvage after primary free flap failure, and three for reconstruction of a soft-tissue defect), and 16 had delayed second free flaps (two for reconstruction of a defect resulting from excision of recurrent tumors, and 14 for aesthetic improvement). Reconstruction sites included the oral cavity in 18 patients; the midface in six; the skull base in two; and the scalp in two. The success rate for the second free flaps was 96 percent. Five patients had significant wound complications. In a substantial number of cases, identical recipient vessels were used for both the first and second free flaps. The authors conclude that second free flaps can play an important role in salvaging or improving head and neck reconstruction in selected patients. In many cases, the same recipient vessels can be used for both the first and second flaps.
- Published
- 1998
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12. Reconstruction of complex radiation-induced injuries using free-tissue transfer.
- Author
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Gürlek A, Miller MJ, Amin AA, Evans GR, Reece GP, Baldwin BJ, Schusterman MA, Kroll SS, and Robb GL
- Subjects
- Adult, Aged, Aged, 80 and over, Arteries transplantation, Bone Transplantation, Disease-Free Survival, Extremities radiation effects, Female, Follow-Up Studies, Graft Survival, Groin radiation effects, Head radiation effects, Humans, Male, Middle Aged, Muscle, Skeletal transplantation, Neck radiation effects, Reoperation, Retrospective Studies, Survival Rate, Thrombosis etiology, Veins transplantation, Radiation Injuries surgery, Radiotherapy adverse effects, Surgical Flaps adverse effects
- Abstract
The purpose of this study was to evaluate the use of free-tissue transfers for the reconstruction of radiation-induced complex injuries. The case files for patients who underwent reconstruction for radiation-induced injuries between May 1988 and November 1995 at The University of Texas M.D. Anderson Cancer Center were retrospectively reviewed. Thirty patients in whom 33 free flaps were done were included. Radiation-induced defects were located in the head and neck (n=23), extremities (n=4), chest wall (n=2), and inguinal area (n=1) The mean period between irradiation and injury was 78 months (range: 4 months to 38 years). Free-tissue transfer was successful in 97 percent (32/33) of patients. The overall complication rate was 40 percent (12/30). Flap donor sites included the fibula (n=12), latissimus dorsi (n=6), rectus abdominis (n=6), iliac crest (n=4), scapula (n=3), and radial forearm (n=2). Large-caliber vessels in the cervical, axillary, or inguinal regions were most commonly used to revascularize flaps. Vein grafts were used in five cases for the artery (2/5) or vein (3/5). Pedicle thrombosis occurred in three cases in recipient vessels located within the irradiated field. Two flaps were salvaged; one was lost, and the patient required a second free-flap reconstruction The mean follow-up was 40 months (range: 2.5 to 83 months). The disease-free survival rate was 67 percent (20/30), local failures occurred in 10 percent (3/30) of patients, and 23.3 percent (7/30) of patients either died or were lost to follow-up. Healing of radiation-induced wounds may be achieved using free-tissue transfers, but complications are frequent. Large-caliber irradiated vessels may be used to revascularize flaps, but there may be an increased risk of pedicle thrombosis.
- Published
- 1998
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13. Does prior irradiation increase the risk of total or partial free-flap loss?
- Author
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Kroll SS, Robb GL, Reece GP, Miller MJ, Evans GR, Baldwin BJ, Wang B, and Schusterman MA
- Subjects
- Adult, Breast Neoplasms surgery, Female, Humans, Incidence, Logistic Models, Postoperative Complications epidemiology, Risk Factors, Breast Neoplasms radiotherapy, Mammaplasty, Surgical Flaps
- Abstract
Answers to the question, "Does previous irradiation of a recipient site interfere with reconstruction by free-tissue transfer?" have been elusive. In an attempt to address that question, all free-flap procedures performed for reconstruction of the breast or of head and neck defects at the University of Texas M. D. Anderson Cancer Center between May 1, 1988 and February 15, 1996 were reviewed. The effects of prior irradiation of the recipient site on the incidence of total flap loss, partial flap loss, and thrombosis were assessed. During the study period, 1384 eligible free-flap reconstructions were performed. Total flap loss and partial flap loss were more common in the 428 flaps transferred to previously irradiated sites than in the patients without previous irradiation, but multiple logistic regression analysis showed that these differences were due to confounding factors. The authors conclude that previous irradiation of flap recipient sites does not statistically significantly affect the rate of partial or total free-flap loss.
- Published
- 1998
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14. A comparison of resource costs of immediate and delayed breast reconstruction.
- Author
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Khoo A, Kroll SS, Reece GP, Miller MJ, Evans GR, Robb GL, Baldwin BJ, Wang BG, and Schusterman MA
- Subjects
- Breast Neoplasms radiotherapy, Breast Neoplasms surgery, Female, Humans, Surgical Flaps economics, Time Factors, Hospital Costs, Mammaplasty economics, Mastectomy rehabilitation
- Abstract
The resource cost (cost to our hospital) of providing mastectomy plus breast reconstruction was calculated for 276 patients who had received both mastectomy and breast reconstruction at our institution. All patients had completed the entire reconstructive process, including reconstruction of the nipple. The resource costs of providing mastectomy with immediate breast reconstruction were compared with those of mastectomy with subsequent delayed reconstruction. We found that the mean resource cost for the 57 patients who had separate mastectomy followed by delayed breast reconstruction ($28,843) was 62 percent higher than that of mastectomy with immediate reconstruction ($17,801; n = 219, p < 0.001). Similar differences were found when patients were subgrouped by type of reconstruction (TRAM versus tissue expansion and implants), by laterality (unilateral versus bilateral), and by history of preoperative irradiation. We conclude that mastectomy with immediate breast reconstruction is significantly less expensive than mastectomy followed by delayed reconstruction and can potentially conserve resources.
- Published
- 1998
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15. From cadavers to implants: silicon tissue assays of medical devices.
- Author
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Evans GR and Baldwin BJ
- Subjects
- Adjuvants, Immunologic adverse effects, Adult, Aged, Autoimmune Diseases etiology, Breast chemistry, Breast Implants, Cadaver, Catheters, Indwelling, Chemical Phenomena, Chemistry, Physical, Connective Tissue chemistry, Environmental Exposure, Equipment Failure, Female, Freezing, Humans, Longitudinal Studies, Male, Middle Aged, Silicones adverse effects, Silicones analysis, Sodium Chloride, Spectrum Analysis, Tissue Distribution, Tissue Expansion Devices, Tissue Fixation, Prostheses and Implants, Silicon analysis
- Abstract
A plethora of data has been used to condemn and defend the role of silicone and its association with "adjuvant disease." In the ongoing attempt to enhance our knowledge, we have chosen to identify tissue silicon levels in patients with saline implants or tissue expanders. We have compared these levels with tissue samples from a variety of patients with and without medicinal silicone devices from both the northeast and southwest United States over a 4-year period. All specimens were harvested by a "no touch" technique, non-formalin fixed, frozen, and shipped to an independent toxicology laboratory for analysis. Inductively coupled plasma atomic emission spectroscopy was used to obtain the tissue silicon measurements. Silicon tissue values in cadaveric tissue (n = 20 cadavers; n = 120 specimens) averaged 2.2 mcg/gm of tissue with undetectable silicon levels in over 50 percent of the specimens (range 0 to 45 mcg/gm; median = 0). Silicon levels surrounding port-a-catheter devices (n = 15 patients; n = 15 specimens) averaged 8.04 mcg/gm of tissue (range 0 to 41 mcg/gm; median = 0). Tissue levels in the capsules surrounding saline (n = 10 patients; n = 22 specimens) and silicone implants (n = 31 patients; n = 58 specimens) averaged 292 mcg/gm (range 0 to 1380 mcg/gm; median = 110) and 1439 mcg/gm (range 0 to 9800 mcg/gm, median = 490), respectively. Tissue levels, however, from distant sites (n = 22 specimens) in these same patients were equivalent to the cadaveric nonaugmented values (average = 3.2 mcg/gm; range 0 to 5.8 mcg/gm; median = 2.7). The results imply that there is a continuum of exposure to silicone medical devices based on the mechanical properties of silicone. The data seem to suggest that there may be a progression of measurable tissue silicon levels based on the amount of environmental or device-related silicone exposure a person has over his or her lifetime. It is our hope that these levels will serve as a baseline for our continuing knowledge of implantable medical devices.
- Published
- 1997
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16. Cosmetic saline breast implants: a survey of satisfaction, breast-feeding experience, cancer screening, and health.
- Author
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Strom SS, Baldwin BJ, Sigurdson AJ, and Schusterman MA
- Subjects
- Adolescent, Adult, Age Factors, Aged, Attitude to Health, Autoimmune Diseases etiology, Breast Implantation, Breast Self-Examination, Esthetics, Fatigue Syndrome, Chronic etiology, Female, Follow-Up Studies, Humans, Mammography, Middle Aged, Quality of Life, Reoperation, Rheumatic Diseases etiology, Sjogren's Syndrome etiology, Breast Feeding, Breast Implants adverse effects, Breast Neoplasms prevention & control, Health Status, Mass Screening, Patient Satisfaction, Sodium Chloride
- Abstract
Saline breast implants have been used for the past 30 years for cosmetic and reconstructive purposes. Data based on a large number of patients are needed to evaluate patient satisfaction, cancer screening practices, problems associated with breast-feeding, and health effects. We conducted a follow-up study of 292 cosmetic saline breast implant patients from Texas and Louisiana who consented to a telephone interview. Using a Likert scale, we measured the patients' degree of satisfaction with the implants. The results indicated that 80.5 percent were satisfied, 73.3 percent would recommend saline breast implants to others, and 65.1 percent felt that implants improved their quality of life. The extent of satisfaction was independent of the number of additional surgeries, age at implant, and follow-up time. Mammography use and breast self-examination were reported with high frequency in this survey. Ninety-one percent of study participants who were between 40 and 49 years of age at time of interview and 94 percent of those 50 or older reported having had at least one mammogram. Breast self-examination was practiced by 75 percent of the women, and 61 percent reported checking their breasts at least once a month. Of the 46 women who had children after augmentation, 28 reported breast-feeding and 8 (28.6 percent) reported having implant-related problems. The patients were asked to provide information regarding a series of conditions for which they sought medical attention. They reported: atypical rheumatoid syndrome (n = 1), Sjögren syndrome (n = 1), atypical autoimmune disorder (n = 1), and chronic fatigue syndrome (n = 2). Overall, women who elected to have saline breast implants were satisfied with their augmentations, had mammograms and performed breast self-examinations more often than nonaugmented women. A few had problems when breast-feeding that could be related to their implants. There were no reports of breast cancer, but five women reported autoimmune conditions.
- Published
- 1997
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17. Local rotational flaps for breast conservation therapy as an alternative to mastectomy.
- Author
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Bold RJ, Kroll SS, Baldwin BJ, Ross MI, and Singletary SE
- Subjects
- Adult, Female, Follow-Up Studies, Humans, Middle Aged, Patient Satisfaction, Patient Selection, Retrospective Studies, Treatment Outcome, Breast Neoplasms surgery, Mastectomy, Segmental, Surgical Flaps
- Abstract
Background: An anticipated poor cosmetic result has traditionally been deemed a relative contraindication for breast conservation therapy (BCT). We sought to determine whether a local rotational flap could achieve satisfactory cosmesis in patients who were anticipated to have a poor cosmetic result following standard segmental mastectomy but who nevertheless desired BCT., Methods: Within the past 3 years, nine patients were treated with BCT using local rotational flap techniques. Their records were reviewed for patient characteristics, pre- and postoperative treatment, disease-free status, and patient satisfaction with cosmesis., Results: The cosmetic outcome following a segmental mastectomy was anticipated to be unacceptable due to the following features: a large previous biopsy cavity with unknown or positive margins (three patients); initial large primary tumors with unknown extent of residual disease following induction chemotherapy (five patients); and pre-existing poor cosmesis (one patient). One patient had refused modified radical mastectomy and had satellitosis from inadequately treated primary tumor (excisional biopsy with positive margins and no further therapy). The median initial tumor size was 2.7 cm (range, 1.5 cm to 5.0 cm). Final resection margins were negative in all patients. Postoperative radiotherapy was given in seven patients; one patient did not receive radiotherapy because of a pre-lupus condition and one did not require radiotherapy because her pathologic diagnosis was Paget's disease without an invasive component. Cosmesis was judged to be good to excellent by eight of nine patients. The patient who refused mastectomy was dissatisfied with cosmesis because of mild asymmetry. With a median follow-up of 24 months, only one patient has developed a local recurrence., Conclusion: Local rotational flaps composed of adjacent breast tissue are an acceptable method of achieving satisfactory cosmesis in selected patients who desire BCT.
- Published
- 1997
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18. Adjuvant therapy: the effects on microvascular lower extremity reconstruction.
- Author
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Evans GR, Black JJ, Robb GL, Baldwin BJ, Kroll SS, Miller MJ, Reece GP, and Schusterman MA
- Subjects
- Adult, Aged, Aged, 80 and over, Bone Neoplasms drug therapy, Bone Neoplasms radiotherapy, Brachytherapy, Chemotherapy, Adjuvant, Combined Modality Therapy, Female, Fibrosarcoma drug therapy, Fibrosarcoma radiotherapy, Fibrosarcoma surgery, Follow-Up Studies, Histiocytoma, Benign Fibrous drug therapy, Histiocytoma, Benign Fibrous radiotherapy, Histiocytoma, Benign Fibrous surgery, Humans, Leiomyosarcoma drug therapy, Leiomyosarcoma radiotherapy, Leiomyosarcoma surgery, Male, Middle Aged, Neoplasm Recurrence, Local etiology, Osteosarcoma drug therapy, Osteosarcoma radiotherapy, Osteosarcoma surgery, Postoperative Complications etiology, Radiotherapy, Adjuvant, Sarcoma drug therapy, Sarcoma radiotherapy, Sarcoma surgery, Soft Tissue Neoplasms drug therapy, Soft Tissue Neoplasms radiotherapy, Treatment Outcome, Bone Neoplasms surgery, Leg surgery, Soft Tissue Neoplasms surgery, Surgical Flaps methods
- Abstract
Adjuvant therapy and microsurgery have allowed advances in surgical extirpation of lower extremity neoplasms. This retrospective study was designed to evaluate the microvascular transfer for lower extremity reconstruction in patients receiving pre- or post-operative irradiation and chemotherapy alone and in combination. Over a 5-year period, 24 free tissue transfers were performed in 22 patients undergoing surgical resection with adjuvant therapy for lower extremity neoplasms. There were 13 male and 9 female patients with an average age of 51 years. The latissimus dorsi muscle was most commonly transferred (N = 15). Eighteen tumors received pre- and three received postoperative radiotherapy. Two tumors received a combination of radiotherapy and brachytherapy. Pre- and/or postoperative chemotherapy was used in 14 patients. Twelve of these patients had both chemo- and radiation therapy. A total of six complications occurred, with no flap loss. Complications were evenly distributed among adjuvant regimens. All patients who underwent attempted limb salvage were able to ambulate postoperatively, except for 1 patients who had local recurrence. In conclusion, adjuvant therapy did not increase the complication rate for free tissue transfer in the lower extremity. Adjuvant therapy did not require alterations in the free tissue transfer and, similarly, free tissue transfer did not alter adjuvant therapy. We believe that free tissue transfer in complicated wounds allows for better wound healing with adjuvant therapy rather than local or primary wound closure alone.
- Published
- 1997
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19. Feasibility of postmastectomy radiation therapy after TRAM flap breast reconstruction.
- Author
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Hunt KK, Baldwin BJ, Strom EA, Ames FC, McNeese MD, Kroll SS, and Singletary SE
- Subjects
- Adult, Breast Neoplasms surgery, Combined Modality Therapy, Esthetics, Female, Humans, Middle Aged, Neoplasm Recurrence, Local, Patient Satisfaction, Postoperative Complications, Radiotherapy, High-Energy adverse effects, Breast Neoplasms radiotherapy, Mammaplasty, Mastectomy, Modified Radical rehabilitation, Surgical Flaps
- Abstract
Background: Postoperative radiotherapy (PORT) has been shown to decrease locoregional failure rates in high-risk breast cancer patients following modified radical mastectomy. However, there had not been a study evaluating the effect of PORT in patients after transverse rectus abdominis myocutaneous (TRAM) flap breast reconstruction. Therefore, we evaluated flap viability, cosmetic results, and locoregional recurrence in patients who underwent TRAM flap reconstruction and PORT., Methods: The charts of patients who had undergone modified radical mastectomy with TRAM flap reconstruction and PORT at our institution were reviewed. Patients were examined in the clinic and interviewed by telephone to evaluate their perceptions of the cosmetic result., Results: PORT was delivered to 19 patients with TRAM flaps (3 pedicled and 16 free flaps) between 1988 and 1994. There were no TRAM flap losses as a result of either surgical or radiotherapy complications. Two patients developed fat necrosis, one with a pedicled and one with a free TRAM flap. Patients with pedicled TRAM flaps noted more volume loss in the breast after radiation therapy. Eighty-four percent of patients felt their overall cosmetic result was excellent or good; only one patient reported a poor cosmetic result. Local control was achieved in three of the four patients who received PORT for local recurrence. There was only one local recurrence among the 14 patients who received PORT because they were at high risk of local recurrence., Conclusions: These results suggest that PORT can be given safely to high-risk patients following TRAM flap breast reconstruction with excellent cosmetic results and good locoregional control.
- Published
- 1997
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20. Comparison of nipple projection with the modified double-opposing tab and star flaps.
- Author
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Kroll SS, Reece GP, Miller MJ, Evans GR, Robb GL, Baldwin BJ, Wang BG, and Schusterman MA
- Subjects
- Female, Follow-Up Studies, Humans, Mammaplasty methods, Nipples surgery, Surgical Flaps methods
- Abstract
This study compared nipple projection after nipple reconstruction (following breast mound reconstruction) with either the modified double-opposing tab flap or the star flap. Areolar reconstruction and pigmentation of the nipple were achieved with tattooing. Nipple projection for 153 nipples was measured at least 6 months after the reconstruction, when projection was believed to have become stable. Mean follow-up was 2.27 years. In the 106 nipples reconstructed with modified double-opposing tab flaps, the mean projection was 2.4292 mm, while in the 47 nipples reconstructed with star flaps, the mean projection was 1.9681 mm (p = 0.021). We conclude that although both methods are effective, the modified double-opposing tab flap has slightly more projection after approximately 2 years. It is not known, however, whether this is because of reduced flap atrophy or longer initial projection by the modified double-opposing tab flap; further studies are ongoing.
- Published
- 1997
21. A comparison of resource costs for head and neck reconstruction with free and pectoralis major flaps.
- Author
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Kroll SS, Evans GR, Goldberg D, Wang BG, Reece GP, Miller MJ, Robb GL, Baldwin BJ, and Schusterman MA
- Subjects
- Age Factors, Analysis of Variance, Cost Savings, Forearm, Graft Survival, Hospitalization economics, Humans, Length of Stay economics, Middle Aged, Mouth Diseases etiology, Mouth Diseases surgery, Muscle, Skeletal transplantation, Oropharynx surgery, Pharyngeal Diseases etiology, Pharyngeal Diseases surgery, Physicians economics, Postoperative Complications surgery, Rectus Abdominis transplantation, Retrospective Studies, Salaries and Fringe Benefits, Skin Transplantation economics, Surgical Flaps methods, Time Factors, Head and Neck Neoplasms surgery, Hospital Costs, Pectoralis Muscles transplantation, Surgical Flaps economics
- Abstract
A series of 178 immediate reconstructions with regional or distant tissue for repair of oropharyngeal defects caused by treatment of head and neck cancer was reviewed to determine whether reconstruction with free flaps was more or less expensive than reconstruction with regional myocutaneous flaps. In this series, three types of flaps were used: the radial forearm free flap (n = 89), the rectus abdominis free flap (n = 56), and the pectoralis major myocutaneous flap (n = 33). Resource costs were determined by adding all costs to the institution of providing each service studied using salaried employees (including physicians). The two free-flap groups were combined to compare free flaps with the pectoralis major myocutaneous flap, a regional myocutaneous flap. Failure rates in the two groups were similar (3.0 percent for pectoralis major myocutaneous flap, 3.4 percent for free flaps). The mean costs of surgery were slightly higher for the free flaps, but the subsequent hospital stay costs were lower. Therefore, the total mean resource cost for the free-flap group ($28,460) was lower than the cost for the myocutaneous flap group ($40,992). The pectoralis major myocutaneous flap may have been selected for more patients with advanced disease and systemic medical problems, contributing to longer hospitalization and added cost. Nevertheless, this study suggests that free flaps are not more expensive than other methods and may provide cost savings for selected patients.
- Published
- 1997
- Full Text
- View/download PDF
22. Silicon tissue assay: a measurement of capsular levels from chemotherapeutic port-a-catheter devices.
- Author
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Evans GR and Baldwin BJ
- Subjects
- Adolescent, Adult, Age Factors, Alloys, Breast chemistry, Breast Implants, Cadaver, Child, Child, Preschool, Collagen Diseases etiology, Connective Tissue chemistry, Equipment Design, Female, Humans, Male, Middle Aged, Neoplasms drug therapy, Neoplasms radiotherapy, Sample Size, Silicones, Spectrum Analysis, Time Factors, Tissue Distribution, Vascular Diseases etiology, Catheters, Indwelling, Infusion Pumps, Implantable, Silicon analysis
- Abstract
A plethora of data has been used to condemn and defend the role of silicone and its association with "adjuvant disease." In the ongoing attempt to enhance our knowledge, we have chosen to identify tissue silicon levels (n = 15) in capsules that form around chemotherapeutic port-a-catheter devices, which consist of a metal dome encapsuled by silicone. We have compared these levels with previously established silicon levels in augmented breast capsules, distant tissue sites in these same augmented women, and nonaugmented cadaveric tissues from various geographic locations in the United States. All specimens were harvested by a "no touch" technique, not formalin fixed, frozen, and shipped to an independent toxicology laboratory for analysis. Inductively coupled plasma atomic emission spectroscopy was employed to obtain the tissue silicon measurements. Results demonstrated silicon values ranging from nondetectable in 9 patients to as high as 41 micrograms/gm. These values fell in between our cadaveric (0.5 to 6.8 micrograms/gm) and augmented tissue silicon levels (18 to 8700 micrograms/gm). Although the sample size is small and the power of statistical analysis is low, there was no correlation between the patient's silicon level and age, type of cancer, type of chemotherapeutic agent, radiation therapy, or length of time the port-a-catheters were in place. Although detectable levels of silicon identified around port-a-catheter devices were higher than expected, it is impossible to make any conclusions about these levels and the role of a potential collagen-vascular disease. What we have shown, however, is that silicone breast implants may not be the only medical device that can elevate tissue silicon levels. Our data seem to suggest that there may be a progression of measurable tissue silicon levels based on the amount of environmental or device-related silicon exposure a person has had at a particular time in his or her life. It is our belief that as we identify these tissue silicon levels, they will serve as a baseline and reference for further scientific studies.
- Published
- 1997
- Full Text
- View/download PDF
23. Timing of pedicle thrombosis and flap loss after free-tissue transfer.
- Author
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Kroll SS, Schusterman MA, Reece GP, Miller MJ, Evans GR, Robb GL, and Baldwin BJ
- Subjects
- Graft Rejection prevention & control, Humans, Prospective Studies, Graft Rejection epidemiology, Surgical Flaps adverse effects, Thrombophlebitis epidemiology, Thrombophlebitis etiology
- Abstract
A series of 990 consecutive free flaps was reviewed to determine how often pedicle thrombosis occurred, when it occurred, and if the timing of thrombosis detection had any relationship to the probability of flap salvage. The overall thrombosis rate was 5.1 percent, and the flap loss rate was 3.2 percent. The majority (80 percent) of thrombi occurred within the first 2 postoperative days. Only 5 thrombi (10 percent) were known to have occurred after the third postoperative day. No flaps that developed thrombosis after the third postoperative day were salvaged successfully. Had flap monitoring been discontinued after the first 3 postoperative days, our results in this series would have been unchanged. Thrombosis of the vein (54 percent) was more common than arterial thrombosis (20 percent) or thrombosis of both artery and vein (12 percent). Almost all purely arterial thrombi (90 percent) occurred before the end of the first postoperative day, whereas 41 percent of all venous thrombi occurred later. We conclude that arterial monitoring is most critical immediately after surgery. Beginning on the second postoperative day, venous monitoring becomes progressively more important to flap success. The cost-effectiveness of postoperative monitoring of free flaps is greatest during the first 2 days, after which it decreases significantly.
- Published
- 1996
- Full Text
- View/download PDF
24. Silicon tissue assay: are there intracapsular variations?
- Author
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Evans GR and Baldwin BJ
- Subjects
- Adult, Breast metabolism, Breast pathology, Female, Humans, Middle Aged, Postoperative Complications pathology, Postoperative Complications surgery, Prosthesis Failure, Reoperation, Silicones adverse effects, Tissue Expansion, Breast Implants, Mammaplasty, Silicones pharmacokinetics
- Abstract
In previous studies, we were able to demonstrate baseline non-augmented cadaveric silicon tissue values as well as silicone-augmented breast capsular tissue silicon levels from various geographic locations in the United States. One of the limitations of these previous studies was the potential for intracapsular variations in the silicon level and whether a single measurement would be a valid comparison for the entire breast capsule. This study was then undertaken to measure the variations in tissue silicon levels from multiple sites within each breast capsule sampled. Four patients that underwent silicone breast and three tissue expander explantations were evaluated. All the women had silicone implants for breast augmentation and the placement of tissue expanders for reconstruction following mastectomy. A variety of reasons for explantation were noted. Each of the patient's breast capsules were divided into four quadrants (upper inner, upper outer, lower inner, and lower outer). All samples were harvested in a no-touch technique and were sent for silicon tissue assays. Silicon values ranged from 44 to 9,000 micrograms per gram of tissue and were consistent with our previously measured values. We conclude that random samples of breast capsules reflect the variations within the specimen samples, but can be used to measure elevated silicon values accurately. It is our belief that multiple samples do not need to be taken for each capsule measurement and that a previous potential limitation to the measurements has been eliminated.
- Published
- 1996
- Full Text
- View/download PDF
25. Choice of flap and incidence of free flap success.
- Author
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Kroll SS, Schusterman MA, Reece GP, Miller MJ, Evans GR, Robb GL, and Baldwin BJ
- Subjects
- Female, Humans, Microsurgery, Postoperative Complications, Retrospective Studies, Risk Factors, Thrombosis etiology, Treatment Outcome, Breast Neoplasms surgery, Head and Neck Neoplasms surgery, Mammaplasty, Surgical Flaps
- Abstract
A review of 854 consecutive free flaps was performed to determine whether the choice of flap used for the reconstruction influenced the probability of a successful outcome. Flaps were grouped into nine categories: rectus abdominis, free transverse rectus abdominis myocutaneous, radial forearm, jejunum, latissimus dorsi, fibula, scapula, iliac crest, and other. There were significant differences among the success rates of different flaps (p < 0.0001). Rectus abdominis-based flaps used for breast or head and neck reconstruction had lower failure rates (0.9 percent) than did non-rectus abdominis flaps (6.6 percent; p < 0.0001). Flaps requiring vein grafts had a higher rate of flap loss (18.4 percent) than did flaps that did not require vein grafts (2.9 percent; p < 0.0001). There was a strong trend favoring survival of flaps without a bone component (compared with osteocutaneous flaps), and a weaker trend favoring survival of flaps in nonobese patients (compared with flaps in obese patients). Smoking, age, and previous irradiation had no significant effect on flap failure rates. Surgeons should consider the flap success rate as one (but not necessarily the most important) factor in choosing the best reconstruction for any individual patient.
- Published
- 1996
- Full Text
- View/download PDF
26. Comparison of resource costs of free and conventional TRAM flap breast reconstruction.
- Author
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Kroll SS, Evans GR, Reece GP, Miller MJ, Robb GL, Baldwin BJ, and Schusterman MA
- Subjects
- Female, Hospital Costs, Humans, Length of Stay, Mastectomy economics, Time Factors, Mammaplasty economics, Mammaplasty methods, Mastectomy rehabilitation, Surgical Flaps
- Abstract
Resource costs, which are the costs to the hospital of providing a service, were measured for 154 patients who underwent mastectomy and immediate breast reconstruction with TRAM flaps. Unilateral and bilateral reconstructions were evaluated separately. The resource costs required to perform mastectomy and reconstruction with free TRAM flaps were then compared with those required when conventional TRAM flaps were used. The mean total resource cost in the free TRAM group was slightly higher than in the conventional TRAM group, but the difference was small (4.1 percent) and not statistically significant (p = 0.290). The mean resource cost of performing bilateral mastectomy and reconstruction was higher than that of unilateral mastectomy and reconstruction, but the difference was only 5.0 percent (p = 0.046). This study shows that the cost to an institution of providing breast reconstruction with free TRAM flaps is not significantly higher than that of performing reconstruction with conventional TRAM flaps. Also, our findings show that the resource costs of performing bilateral mastectomy and reconstruction are not much higher than those of treating only one breast.
- Published
- 1996
- Full Text
- View/download PDF
27. Unexpected vascular compromise in transverse rectus abdominis musculocutaneous (TRAM) flap reconstruction: a report of two patients.
- Author
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Wallace AM, Evans GR, Goldberg DP, and Baldwin BJ
- Subjects
- Breast Neoplasms pathology, Carcinoma in Situ pathology, Carcinoma, Ductal, Breast pathology, Female, Graft Survival physiology, Humans, Middle Aged, Necrosis, Neoplasm Staging, Postoperative Complications pathology, Postoperative Complications surgery, Regional Blood Flow physiology, Reoperation, Surgical Flaps physiology, Venous Insufficiency pathology, Breast blood supply, Breast Neoplasms surgery, Carcinoma in Situ surgery, Carcinoma, Ductal, Breast surgery, Mammaplasty methods, Mastectomy, Modified Radical methods, Microsurgery methods, Surgical Flaps methods, Venous Insufficiency surgery
- Abstract
Although the vascular anatomy of the transverse rectus abdominis musculocutaneous flap has been well described, poor flap perfusion can lead to partial or total flap ischemia. To minimize the potential for flap loss, criteria have been developed to identify those patients who are deemed to be high risk. Some of these high-risk patients include smokers and those with previous abdominal surgery, obesity, and/or poor medical health. Despite our diligence in patient and operative selection, 2 patients with no preexisting risk factors have recently had venous congestion of their transverse rectus abdominis musculocutaneous flap, necessitating a delayed procedure. The cases are presented here and the potential etiology for this venous congestion explored.
- Published
- 1996
- Full Text
- View/download PDF
28. Comparison of resource costs between implant-based and TRAM flap breast reconstruction.
- Author
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Kroll SS, Evans GR, Reece GP, Miller MJ, Robb G, Baldwin BJ, and Schusterman MA
- Subjects
- Cost-Benefit Analysis, Female, Follow-Up Studies, Humans, Mammaplasty methods, Mastectomy, Postoperative Complications, Breast Implants economics, Hospital Costs, Mammaplasty economics, Surgical Flaps economics
- Abstract
Resource costs, as measured by hours of time in the operating room, days of stay in the hospital, and other costs of care, were evaluated for 240 patients who underwent mastectomy with immediate breast reconstruction using either TRAM flaps or breast implants at The University of Texas M. D. Anderson Cancer Center. To make costs comparable, only patients who completed reconstruction of the nipple were included. As expected, the initial resource costs of implant-based reconstruction were much lower than those of TRAM flap reconstruction. After correcting for patients whose reconstructions were unsuccessful and including the costs of surgery subsequent to the initial reconstruction, however, the cost advantage of implant-based reconstruction disappeared. If current trends continue, it is likely that with increased follow-up, the long-term resource costs of implant-based reconstructions will continue to increase, while those of autogenous tissue reconstructions will not. Autogenous breast reconstruction with the TRAM flap therefore appears to be more cost-effective, in terms of time as well as dollars, in the long run than reconstruction based on prosthetic implants.
- Published
- 1996
- Full Text
- View/download PDF
29. Morbidity and functional outcome of free jejunal transfer reconstruction for circumferential defects of the pharynx and cervical esophagus.
- Author
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Reece GP, Schusterman MA, Miller MJ, Kroll SS, Robb GL, Baldwin BJ, and Luethcke DR
- Subjects
- Adolescent, Adult, Aged, Aged, 80 and over, Child, Deglutition Disorders etiology, Esophageal Neoplasms surgery, Female, Humans, Male, Middle Aged, Morbidity, Pharyngeal Neoplasms surgery, Postoperative Complications, Postoperative Period, Retrospective Studies, Treatment Outcome, Esophagus surgery, Jejunum surgery, Pharynx surgery
- Abstract
Free jejunal transfer has been criticized by some surgeons as unreliable, poorly tolerant of radiation therapy, and associated with significant morbidity and dysphagia. To determine the validity of these criticisms, we reviewed 93 patients who underwent 96 free jejunal transfers for repair of circumferential pharyngoesophageal defects over a 5-year period. The free jejunal transfer success rate was 97 percent; all 3 failures were repaired with repeated free jejunal transfer. The complication rate was 57 percent (55 of 96); fistula (19 percent) and stricture (15 percent) were the most common complications. An oral diet was tolerated by 80 percent of patients; 85 percent of these resumed their diet within 2 weeks of surgery. Causes of dysphagia were multifactorial. Postoperative radiation therapy did not increase morbidity or dysphagia. The perioperative mortality rate was 2 percent. We conclude that free jejunal transfer is a reliable method of pharyngoesophageal reconstruction that has an acceptable morbidity rate and a low mortality rate. Postoperative radiation therapy is well tolerated by the free jejunal transfer.
- Published
- 1995
- Full Text
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30. Anticoagulants and hematomas in free flap surgery.
- Author
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Kroll SS, Miller MJ, Reece GP, Baldwin BJ, Robb GL, Bengtson BP, Phillips MD, Kim D, and Schusterman MA
- Subjects
- Blood Loss, Surgical, Dextrans administration & dosage, Graft Survival, Heparin administration & dosage, Humans, Retrospective Studies, Thrombosis prevention & control, Hematoma chemically induced, Heparin adverse effects, Surgical Flaps
- Abstract
A review of systemic anticoagulant use in 517 free flap procedures was performed to determine the associated risk of hematoma formation. Patients were divided retrospectively (not randomly) into five groups: no anticoagulation (227 flaps, 5.3 percent hematomas), low-dose heparin bolus of 2000 to 3000 units and postoperative infusion at a rate of 100 to 400 units/hr for 5 to 7 days (192 flaps, 6.7 percent hematomas), intraoperative bolus of 5000 units of heparin without postoperative anticoagulation (46 flaps, 6.5 percent hematomas), high-dose heparin infusion at a rate of 500 to 1200 units/hr (30 flaps, 20 percent hematomas), and dextran 40 infusion at a rate of 25 ml/hr (22 flaps, 9.1 percent hematomas). Intraoperative blood loss was similar for all groups. The flap loss rate was lower in the bolus (1.0 percent) and low-dose (1.0 percent) heparin groups than in the no-anticoagulation group (4.4 percent), but this difference was not statistically significant. The pedicle thrombosis rate also was lower in the bolus (2.2 percent) and low-dose (2.1 percent) heparin groups than in the no-anticoagulation group (6.2 percent). A cause-and-effect relationship between the use of anticoagulants and flap loss or prevention of thrombosis could not be established. We can conclude, however, that the use of low-dose heparin does not increase significantly the risk of hematoma or intraoperative bleeding.
- Published
- 1995
- Full Text
- View/download PDF
31. Lateral thigh free flap in head and neck reconstruction.
- Author
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Miller MJ, Reece GP, Marchi M, and Baldwin BJ
- Subjects
- Adult, Aged, Cadaver, Female, Femoral Artery anatomy & histology, Humans, Male, Middle Aged, Thigh, Treatment Outcome, Head and Neck Neoplasms surgery, Surgical Flaps methods
- Abstract
To understand the role of the lateral thigh flap in head and neck reconstruction, we performed injection studies and anatomic dissections in 2 fresh and 61 preserved cadaver extremities followed by 10 clinical cases involving defects after tumor ablation. The flap, based on the third perforator of the profunda femoris artery, is designed on the posterolateral aspect of the distal thigh. The pedicle courses through the biceps short head, allowing optional transfer of this muscle. Defects of the oral cavity, pharynx, cervical esophagus, and external skin were successfully restored. One flap was unsuccessful because of intraoperative injury to the vascular pedicle. Compared with the radial forearm flap, the lateral thigh flap provides more tissue and the donor scar is more easily hidden, but the vascular pedicle is shorter, of smaller caliber, and more variable. The lateral thigh flap provides thin, pliable, and reliable tissue for a variety of needs in properly selected patients.
- Published
- 1995
- Full Text
- View/download PDF
32. Triple-drug immunosuppression with steroid discontinuation by six months after heart transplantation.
- Author
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Olivari MT, Jessen ME, Baldwin BJ, Horn VP, Yancy CW, Ring WS, and Rosenblatt RL
- Subjects
- Azathioprine therapeutic use, Cyclosporine therapeutic use, Female, Follow-Up Studies, Graft Rejection epidemiology, Humans, Incidence, Male, Middle Aged, Postoperative Complications epidemiology, Prednisone administration & dosage, Time Factors, Treatment Outcome, Graft Rejection prevention & control, Heart Transplantation immunology, Immunosuppression Therapy methods, Prednisone therapeutic use
- Abstract
Background: Triple-drug immunosuppression with cyclosporine, azathioprine, and prednisone is associated with complications which might be reduced by steroid withdrawal., Methods: In two groups of heart transplant recipients maintained on an identical regimen of cyclosporine and azathioprine, prednisone was withdrawn in group I patients (n = 35) by 6 months after transplantation, whereas in group II patients (n = 49) prednisone was never discontinued., Results: Survival was similar in the two groups. The incidence of acute graft rejection was significantly higher in group I (54%) than in group II (12%), whereas infective complications were significantly lower in group I than in group II (0.63 versus 1.02 episode/patient). The degree of posttransplantation weight gain, lipid abnormalities, and incidence of hypertension were not modified by the fast tapering of prednisone, whereas the incidence of cataract and compression fracture and the degree of bone loss were significantly reduced in group I. Graft function and incidence of coronary artery disease were similar in the two groups., Conclusions: The present data suggest that prednisone can be safely withdrawn in heart transplant recipients without jeopardizing survival and graft function. Longer follow-up is needed to assess the full impact of early withdrawal of steroids from triple-drug immunosuppression, especially on long-term graft function and incidence of coronary artery disease. Benefits of early steroid withdrawal included a reduction in bone loss, which might ultimately have a major positive impact on the extent of long-term rehabilitation and exercise tolerance after heart transplantation.
- Published
- 1995
33. Morbidity associated with free-tissue transfer after radiotherapy and chemotherapy in elderly cancer patients.
- Author
-
Reece GP, Schusterman MA, Miller MJ, Kroll SS, Baldwin BJ, and Wang B
- Subjects
- Aged, Aged, 80 and over, Antineoplastic Agents therapeutic use, Female, Graft Survival, Humans, Male, Neoplasms drug therapy, Neoplasms radiotherapy, Radiotherapy Dosage, Retrospective Studies, Risk Factors, Wound Healing, Neoplasms surgery, Postoperative Complications, Surgical Flaps adverse effects
- Abstract
Because of their ages and associated medical problems, many elderly cancer patients are treated with radiotherapy and/or chemotherapy to avoid the increased morbidity perceived to occur with prolonged surgical procedures such as tumor resection and reconstruction with free tissue transfer (FTT). The failure of such therapy still often requires tumor resection and reconstruction in irradiated tissue, which may add to the morbidity of surgery. To determine the validity of these concerns, 66 elderly cancer patients who underwent tumor resection and FTT after previous radiotherapy and/or chemotherapy (PT) were compared to a similar group of 64 elderly patients who had not received such previous therapy (NPT). Despite the two groups having similar patient traits, reconstructive-site characteristics, types of flaps used, medical risk factors, and time variables, there were no statistically significant differences between groups for FTT failure (PT3 percent, NPT 6 percent), medical complication rate (PT 16 percent, NPT 27 percent), surgical complication rate (PT 41 percent, NPT 49 percent), or wound-healing problems. The perioperative mortality rate was 2 percent. The authors conclude, that when medical problems are appropriately corrected before surgery, FTT may be safely performed in elderly patients with a high degree of success, acceptable morbidity, and low mortality. Previous cancer treatment does not appear to predispose elderly patients to a higher rate of FTT failure or wound-healing problems after FTT reconstruction.
- Published
- 1994
- Full Text
- View/download PDF
34. Bilateral breast reconstruction: conventional versus free TRAM.
- Author
-
Baldwin BJ, Schusterman MA, Miller MJ, Kroll SS, and Wang BG
- Subjects
- Blood Loss, Surgical, Female, Humans, Length of Stay, Mammaplasty adverse effects, Mastectomy rehabilitation, Middle Aged, Retrospective Studies, Time Factors, Mammaplasty methods, Surgical Flaps methods
- Abstract
Free TRAM flap transfer is now routinely offered to patients requiring breast reconstruction. This study compares results of conventional superior-pedicled TRAM flaps and free TRAM flaps in bilateral breast reconstructions. A total of 92 breasts were reconstructed in 46 patients. Eighteen patients had free TRAM flap reconstructions, and 28 patients were reconstructed with conventional TRAM flaps. Comparison of average operative blood loss and average operative time for the two techniques showed blood loss of 575 cc and an operative time of 9.6 hours for the free TRAM reconstructions and a blood loss of 313 cc and an operative time of 6.6 hours for the conventional TRAM reconstructions. For free TRAM flap reconstructions, both blood loss and operative time decreased significantly between the first and second group of nine patients: from 819 to 360 cc of blood loss and from 10.5 to 8.9 hours of operative time. Partial flap loss (skin and fat necrosis) and fat necrosis only occurred in 13 and 7 percent, respectively, of conventional TRAM flaps, but neither occurred in free TRAM flaps. However, early in the series, three free flaps were lost in two patients, requiring implant placement. Bilateral breast reconstruction using the free TRAM flap may offer a lower complication rate than the conventional TRAM flap by virtue of improved blood supply and less abdominal wall disruption. Surgeons, however, are forewarned that this procedure has a steep learning curve, and surgeons lacking microsurgical expertise may be better served by the conventional TRAM flap.
- Published
- 1994
35. The free transverse rectus abdominis musculocutaneous flap for breast reconstruction: one center's experience with 211 consecutive cases.
- Author
-
Schusterman MA, Kroll SS, Miller MJ, Reece GP, Baldwin BJ, Robb GL, Altmyer CS, Ames FC, Singletary SE, and Ross MI
- Subjects
- Adult, Fat Necrosis, Female, Hernia, Ventral, Humans, Middle Aged, Postoperative Complications, Prospective Studies, Surgical Flaps, Mammaplasty methods, Rectus Abdominis transplantation, Skin Transplantation methods
- Abstract
All patients undergoing breast reconstruction with free transverse rectus abdominis musculocutaneous (TRAM) flaps from February 1989 to November 1992 were registered into a computerized database and followed prospectively. There were 211 free TRAM flap breast reconstructions in 163 patients; 48 reconstructions were bilateral. A muscle split technique was used in 108 of 211 reconstructions (51%). Total flap loss occurred in 3 of 211 reconstructions for a success rate of 99%. Complications occurred in 81 of 211 reconstructions (38%). Fat necrosis or partial flap loss occurred in 15 of 211 (7%). Hernia or bulge occurred in 11 patients (5%). The bulge/hernia rate tended to be lower in the muscle split group (4 of 108 [4%]) than in those who did not have muscle split procedures (7 of 103 [7%]), whereas the fat necrosis rate was slightly higher in the former group (9 of 108 [8%]) than in the latter (6 of 103 [6%]). Neither difference was statistically significant. However, patients who currently or previously smoked cigarettes did have a significantly higher incidence of fat necrosis: 12 of 99 smokers (12%) had fat necrosis compared with 3 of 112 nonsmokers (3%; p = 0.02).
- Published
- 1994
- Full Text
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36. Differential reflex control of forearm and calf resistance vessels by chemosensitive cardiac afferent activation.
- Author
-
Jacobsen TN, Lange RA, Olivari MT, Yancy CW, Horn VP, Ring WS, Baldwin BJ, Cooley RA, and Victor RG
- Subjects
- Adult, Aged, Chemoreceptor Cells drug effects, Coronary Angiography, Coronary Vessels, Diatrizoate Meglumine pharmacology, Female, Forearm physiology, Heart drug effects, Heart innervation, Heart Rate drug effects, Heart Ventricles innervation, Humans, Injections, Intravenous, Leg physiology, Male, Middle Aged, Muscle Denervation, Neurons, Afferent drug effects, Plethysmography, Reflex drug effects, Vascular Resistance drug effects, Vasodilation drug effects, Vasodilation physiology, Ventricular Function, Chemoreceptor Cells physiology, Forearm blood supply, Heart physiology, Leg blood supply, Neurons, Afferent physiology, Reflex physiology, Vascular Resistance physiology
- Abstract
The aim of this study was to determine whether chemosensitive ventricular afferent activation in humans evokes a diffuse pattern of reflex vasodilation involving the skeletal muscle circulation of all the extremities or a highly specified pattern of vasodilation that is limited to the rather small vascular bed of the forearm. In 10 patients with innervated ventricles and 7 patients with denervated ventricles resulting from heart transplantation, we performed simultaneous plethysmographic recordings of blood flow in the forearm and calf during chemosensitive ventricular afferent activation with intracoronary Renografin. In patients with innervated ventricles, intracoronary Renografin evoked directionally opposite vascular responses in the forearm and calf: forearm resistance decreased from 50 +/- 11 to 31 +/- 8 units, whereas calf resistance increased from 42 +/- 7 to 59 +/- 9 units (P < 0.05, calf vs. forearm). Forearm vasodilation was eliminated after heart transplantation, indicating that this is a reflex response caused by ventricular afferents. In contrast, calf vasoconstriction was well preserved despite ventricular deafferentation, indicating that this response is caused by mechanisms other than ventricular afferent activation, possibly the sinoaortic baroreceptors. Taken together, these findings document a remarkable degree of specificity in the effects of cardiac afferent activation on the reflex regulation of regional vasomotor tone in humans.
- Published
- 1994
- Full Text
- View/download PDF
37. Immediate versus delayed free-tissue transfer salvage of the lower extremity in soft tissue sarcoma patients.
- Author
-
Reece GP, Schusterman MA, Pollock RE, Kroll SS, Miller MJ, Baldwin BJ, Romsdahl MM, and Janjan NA
- Subjects
- Female, Humans, Male, Middle Aged, Prospective Studies, Time Factors, Leg surgery, Sarcoma surgery, Soft Tissue Neoplasms surgery, Surgical Flaps
- Abstract
Background: Free tissue transfer (FTT) can extend the limits of limb salvage in patients with soft tissue sarcoma (STS), but few data exist on the efficacy and morbidity in this patient population., Methods: We prospectively examined 19 patients who underwent resection of STS and an immediate or a delayed FTT reconstruction between November 1989 and May 1992., Results: There were 11 immediate and eight delayed FTT reconstructions (mean age 52 years). All delayed patients presented with complications resulting from previous STS treatment. Defects involved the leg (n = 7), knee (n = 2), and thigh (n = 10) and had a mean size of 129 cm2, 154 cm2, and 283 cm2, respectively. Preoperative radiatiotherapy had been administered to 74% of patients in the series (mean dose 53 Gy). FTT success rate was 95% (one failure in the delayed group). Limb salvage and postreconstruction ambulatory rates were both 95%. The overall complication rate was 47%, with the trend of a higher rate (63%) in the delayed group compared with the immediate group (36%). The immediate reconstruction group required no additional operative procedures before FTT and had a shorter hospital stay (13 days) compared with that of the delayed reconstruction group (40.6 days). Mean follow-up was 11.9 months (range 2-30)., Conclusions: FTT is a reliable and versatile adjunctive treatment for lower extremity salvage of patients with STS. Immediate reconstruction appears to carry a lower complication rate and a faster rehabilitation for the patient.
- Published
- 1994
- Full Text
- View/download PDF
38. Head and neck reconstruction with the rectus abdominis free flap.
- Author
-
Kroll SS and Baldwin BJ
- Subjects
- Humans, Rectus Abdominis transplantation, Head and Neck Neoplasms surgery, Surgical Flaps methods
- Abstract
The rectus abdominis free flap is a versatile tool that is well suited to a variety of reconstructive problems in the head and neck, including defects of the orbit, the tongue, the cheek, the posterior mandible, and the neck. This flap, which has a high success rate, can be harvested while the ablative team is still excising the tumor. The donor site morbidity is minimal, and the time required to complete the surgery is less than that for most other free flaps. For these reasons, the rectus abdominis free flap has become an increasingly popular tool for use in head and neck reconstruction.
- Published
- 1994
39. Influence of prior radiotherapy on the development of postoperative complications and success of free tissue transfers in head and neck cancer reconstruction.
- Author
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Bengtson BP, Schusterman MA, Baldwin BJ, Miller MJ, Reece GP, Kroll SS, Robb GL, and Goepfert H
- Subjects
- Adolescent, Adult, Aged, Aged, 80 and over, Combined Modality Therapy, Female, Head and Neck Neoplasms radiotherapy, Humans, Male, Microsurgery, Middle Aged, Preoperative Care, Prospective Studies, Vascular Surgical Procedures, Head and Neck Neoplasms surgery, Postoperative Complications, Surgical Flaps
- Abstract
The purpose of this study was to determine whether prior radiotherapy had any effect on the development of postoperative complications in patients undergoing microvascular tissue transfers for reconstruction of head and neck cancer. A prospective database was used to review 354 consecutive patients who had a total of 368 free tissue transfers limited to the head and neck during the 4-year period from July 1988 to June 1992. Postoperative complications in 167 patients who received preoperative radiotherapy (XRT) were compared with those of 187 patients who did not undergo radiotherapy preoperatively (NR). No statistical differences in complications or flap loss between the two groups were noted using the chi 2 test or Fisher's exact test (p > 0.2). Total flap loss occurred in 5.3% of the XRT group (9 of 169) and 5.0% of the NR patient group (10 of 199), and partial flap loss occurred in 4.1% of the irradiated patients and 2.5% of the nonirradiated patients. Major wound complications requiring additional surgery occurred in 16% of the XRT group and 11% of the NR group. Minor wound complications that did not require further surgery occurred in 21% of the irradiated patients and 18% of the nonirradiated patients. No significant difference in the timing or dose of preoperative radiation, previous neck dissection, or anastomotic type could be documented in failed versus successful flaps (two-tailed t-test, p > 0.80, and chi 2, p > 0.2). Our results show that, in a large group of cancer patients undergoing free tissue transfers to the head and neck, prior radiotherapy or surgery did not predispose them to a higher rate of acute flap loss or wound complications than their nonirradiated cohorts.
- Published
- 1993
- Full Text
- View/download PDF
40. Electrocardiographic findings in mitral stenosis. Hemodynamic correlation.
- Author
-
Bassan R, Ehl PR, Luz FS, Nogueira AA, and Baldwin BJ
- Subjects
- Cardiac Catheterization, Cardiomegaly physiopathology, Heart Rate, Humans, Pulmonary Wedge Pressure, Electrocardiography, Hemodynamics, Mitral Valve Stenosis physiopathology
- Published
- 1983
41. Subvalvular left ventricular pseudoaneurysm: a rare complication of mitral valve replacement.
- Author
-
Bassan R, Jasbik W, de Souza MA, Nogueira AA, Luz FS, and Baldwin BJ
- Subjects
- Adult, Heart Aneurysm diagnosis, Humans, Male, Mitral Valve Stenosis surgery, Postoperative Complications, Heart Aneurysm etiology, Heart Valve Prosthesis, Mitral Valve surgery
- Abstract
A patient who developed a subvalvular left ventricular pseudoaneurysm following mitral valve replacement is presented, the fourth such case in the literature. The etiology of this uncommon complication is felt to be caused by excessive surgical resection of the diseased mitral valve, which may weaken or cause rupture of the heart at the mitral annulus. The diagnosis can only be made by left ventriculography. Surgical treatment is indicated, because rupture of the pseudoaneurysm can occur.
- Published
- 1981
- Full Text
- View/download PDF
42. Hemodynamic profile of mitral stenosis. Correlation with valve area.
- Author
-
Bassan R, Rocha AS, and Baldwin BJ
- Subjects
- Adult, Blood Pressure, Cardiac Output, Female, Humans, Male, Middle Aged, Mitral Valve Stenosis pathology, Pulmonary Wedge Pressure, Cardiac Catheterization, Hemodynamics, Mitral Valve pathology, Mitral Valve Stenosis physiopathology
- Published
- 1986
43. Permanent atrial paralysis.
- Author
-
Harris CL and Baldwin BJ
- Subjects
- Acute Disease, Adult, Angiocardiography, Bundle of His physiopathology, Cardiac Catheterization, Electrocardiography, Exercise Test, Female, Heart Rate, Hemiplegia complications, Humans, Sinoatrial Node physiopathology, Tricuspid Valve Insufficiency complications, Heart Atria physiopathology, Paralysis physiopathology
- Abstract
A forty-four year old female presented with hemiparesis a slow supraventricular rhythm without "P" wave activity and was subsequently found to have atrial paralysis. On treadmill exercise testing the patient's heart rate increased to 118/min. It is felt that this most likely represents sinus rhythm with sinoventricular conduction and that the slow resting heart rate is secondary to a sick sinus node syndrome.
- Published
- 1976
- Full Text
- View/download PDF
44. Inadvertent hypothermia. Clinical nursing research.
- Author
-
Wehmer MA and Baldwin BJ
- Subjects
- Adult, Body Temperature, Humans, Hypothermia etiology, Hypothermia physiopathology, Hypothermia prevention & control, Hypothermia nursing, Operating Room Nursing methods, Surgical Procedures, Operative
- Published
- 1986
- Full Text
- View/download PDF
45. Right atrial myxoma. Unusual presentation with cyanosis and clubbing.
- Author
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Talley RC, Baldwin BJ, Symbas PN, and Nutter DO
- Subjects
- Cardiac Catheterization, Electrocardiography, Female, Heart Neoplasms diagnostic imaging, Humans, Middle Aged, Myxoma diagnostic imaging, Radiography, Cyanosis etiology, Heart Neoplasms diagnosis, Myxoma diagnosis, Osteoarthropathy, Secondary Hypertrophic etiology
- Published
- 1970
- Full Text
- View/download PDF
46. Rupture of an aortic aneurysm into the pulmonary artery. An unusual case with antemortem diagnosis.
- Author
-
Blumenthal J and Baldwin BJ
- Subjects
- Aged, Aorta, Thoracic diagnostic imaging, Aortic Rupture pathology, Cardiac Catheterization, Emergencies, Female, Humans, Radiography, Aortic Rupture diagnosis, Pulmonary Artery diagnostic imaging
- Abstract
An acquired aorta-to-pulmonary artery shunt from rupture of a thoracic aortic aneurysm in an elderly patient is reported. The diagnosis was suspected clinically and was confirmed by special cardiac studies. Surgical intervention was refused by the patient who died shortly after admission to the hospital.
- Published
- 1970
- Full Text
- View/download PDF
47. Unusual complications of bacterial endocarditis.
- Author
-
Symbas PN, Baldwin BJ, Schlant RC, and Hurst JW
- Subjects
- Adolescent, Adult, Aortic Valve, Aortography, Cardiac Catheterization, Electrocardiography, Endocarditis, Bacterial drug therapy, Female, Heart Septal Defects, Ventricular diagnosis, Heart Septal Defects, Ventricular surgery, Heart Ventricles diagnostic imaging, Humans, Male, Middle Aged, Mitral Valve, Motion Pictures, Penicillins therapeutic use, Aneurysm, Infected complications, Endocarditis, Bacterial complications, Heart Septal Defects, Ventricular complications
- Published
- 1971
- Full Text
- View/download PDF
48. Sympathetic Insanity Proceeding from the Rectum.
- Author
-
Baldwin BJ
- Published
- 1879
49. Aneurysms of all sinuses of Valsalva in patients with Marfan's syndrome: an unusual late complication following replacement of aortic valve and ascending aorta for aortic regurgitation and fusiform aneurysm of ascending aorta.
- Author
-
Symbas PN, Raizner AE, Tyras DH, Hatcher CR Jr, Inglesby TV, and Baldwin BJ
- Subjects
- Adolescent, Aortic Aneurysm complications, Aortic Valve surgery, Aortic Valve Insufficiency complications, Aortography, Electrocardiography, Female, Humans, Methods, Polymers, Time Factors, Aortic Aneurysm etiology, Aortic Aneurysm surgery, Aortic Valve Insufficiency surgery, Blood Vessel Prosthesis, Heart Valve Prosthesis, Marfan Syndrome complications, Postoperative Complications
- Published
- 1971
- Full Text
- View/download PDF
50. Left ventricular function during acute ethanol intoxication and hemodialysis.
- Author
-
Symbas PN, Tyras DH, and Baldwin BJ
- Subjects
- Animals, Aorta, Blood Pressure drug effects, Coronary Circulation drug effects, Dogs, Ethanol pharmacology, Femoral Artery surgery, Femoral Vein surgery, Fistula, Hemodynamics, Humans, Regional Blood Flow, Alcoholic Intoxication therapy, Ethanol blood, Heart Ventricles physiopathology, Renal Dialysis
- Published
- 1973
- Full Text
- View/download PDF
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