Biomedical subjects

A C Novick

Publications and source records attributed to A C Novick.

At least 235 records · Page 13Linked to original sources

PubMed1989

Endoscopic correction of vesicoureteral reflux in the renal transplant candidate.

High grade vesicoureteral reflux is a well recognized risk factor for post-transplant infection that has been managed commonly with native nephrectomy. Recent reports have described the successful correction of vesicoureteral reflux by the subtrigonal injection of polytetrafluoroethylene (Teflon) paste. We treated 5 transplant candidates with vesicoureteral reflux with this technique. Ureteral reflux was corrected in 80 per cent of the treated ureters with 6 months of followup. Of the patients 3 have undergone successful renal transplantation without complication. This procedure is well suited to the end stage renal disease patient preparing for renal transplantation, since it avoids an open operation on the pre-transplant bladder and preserves the native kidney, thus, facilitating pretransplant dialysis.

Endoscopy↗

PubMed1989

Experience with extra-adrenal pheochromocytoma.

From 1955 to 1985, 20 patients presented with a total of 22 extra-adrenal pheochromocytomas (2 had multiple tumors and 2 had a malignant extra-adrenal pheochromocytoma). There were 13 male and 7 female patients, and the highest incidence was in the second decade. Although most patients presented with symptoms typical of pheochromocytoma, several presented with unusual features related to the anatomical location, such as mediastinal mass (chest tumor), upper airway obstruction (neck tumor) or gross hematuria (bladder tumor). In 5 of 6 patients in whom plasma catecholamine levels were fractionated epinephrine levels were elevated. The most common tumor location was the superior para-aortic region (13 patients). In 16 patients the location of tumors was established before treatment. Computerized tomography (9 patients) was the most accurate imaging study for tumor localization. A total of 19 patients underwent complete excision of all pheochromocytomas. Postoperative followup information (median interval 120 months) was available for 15 of these patients. Three patients had recurrent pheochromocytoma that was treated successfully. One patient had essential hypertension. No patient had metastatic disease. The low incidence of malignancy suggests a benign course for extra-adrenal pheochromocytoma and represents a departure from the previously reported higher incidence of malignancy with extra-adrenal pheochromocytoma.

Adolescent↗

PubMed1989

Posterior transthoracic approach for adrenal surgery.

We present a modification of the posterior surgical approach for adrenalectomy wherein the pleura and diaphragm are directly incised to expose the adrenal gland. This technique has been used in 20 patients undergoing adrenalectomy for hyperplasia or a small benign adenoma. In our series chest tube drainage usually was not necessary, operative morbidity was minimal and most patients were discharged from the hospital within 1 week postoperatively. The posterior surgical approach remains an excellent method to perform adrenalectomy in selected patients. The transthoracic modification described can enhance operative exposure of a high-lying adrenal gland through this incision, particularly on the right side.

Adrenalectomy↗

PubMed1989

The Cleveland Clinic experience with adrenal cortical carcinoma.

Between 1936 and 1987, 82 patients with adrenal cortical carcinoma were seen at our clinic. Of these patients 49 (72 per cent) have been seen during the last 25 years. A total of 40 patients (48.8 per cent) presented with a hormonally functional tumor and 42 (51.2 per cent) had a nonfunctional tumor. Forty patients (48.8 per cent) presented with localized disease, 12 (14.6 per cent) with regional disease and 30 (36.6 per cent) with distant metastases. Complete surgical removal of all gross tumor was achieved in 49 patients. Over-all 3 and 5-year patient survival rates in this series were 37.5 and 25.1 per cent, respectively. Survival was significantly improved (43.9 per cent at 5 years, p equals 0.0001) in patients with localized disease that was completely removed surgically; postoperative adjuvant therapy with op'-DDD was of no benefit in these patients. Survival in patients with metastatic disease was poor and was not improved by treatment with op'-DDD, cytotoxic chemotherapy or radiation therapy.

Actuarial Analysis↗

PubMed1989

Reversal of end stage renal failure with surgical revascularization in patients with atherosclerotic renal artery occlusion.

A total of 9 patients with end stage renal failure caused by atherosclerotic renal artery occlusion underwent surgical revascularization with subsequent recovery of renal function. The duration of dialysis preoperatively ranged from 1 week to 13 months. In all cases renal viability was being maintained by collateral vascular supply. Postoperatively, renal function improved immediately and no patient required subsequent dialysis. Excellent over-all rehabilitation was achieved in all patients. Six patients currently are alive at a mean interval of 4.0 years postoperatively and with satisfactory renal function (mean serum creatinine 2.7 mg. per dl.). Three patients died at a mean interval of 6.8 years postoperatively and they all maintained satisfactory renal function (mean serum creatinine 3.0 mg. per dl.) until death. In some patients with end stage renal failure caused by atherosclerotic arterial occlusion surgical renal revascularization can yield extended survival with freedom from chronic dialysis.

Aged↗

PubMed1989

Two-color immunofluorescence flow cytometric analysis of lymphocytes in long-term renal allograft recipients.

We used 2-color immunofluorescence flow cytometry (FACS 440) and monoclonal antibodies (Becton-Dickinson) to study peripheral blood lymphocytes subsets from 26 patients with well functioning renal allografts for longer than 5 years. Comparisons were made to a group of 25 healthy volunteers and 25 dialysis patients awaiting renal transplantation. As anticipated, there was no significant difference with respect to the absolute number or percentage of activated (T11+ and HLA-DR+) and cytotoxic (Leu-2+ and Leu-15-)T lymphocytes among the 3 groups. However, there was a significantly decreased absolute number (p equals 0.0001) and percentage (p equals 0.0001) of suppressor cells (Leu-2+ and Leu-15+) in the transplant patients compared to the healthy control group. No significant differences existed between the transplant and dialysis groups. There also was an increase in the percentage (p equals 0.000) but not in the absolute number of T helper lymphocytes (Leu-3+ and Leu-8-) in the transplant population compared to healthy controls. No significant difference existed between the transplant and dialysis groups. These findings suggest that a normal value of cytotoxic (Leu-2+ and Leu-15-) and activated (T11+ and HLA-DR+) T lymphocytes may be a good prognostic indicator of long-term survival of renal allografts. Also, the highly significant decrease in the number of Leu-2+ and Leu-15+ cells in long-term, well functioning allografts indicates that additional functional characterization of this subset may be necessary.

Adult↗

PubMed1989

Conventional immunosuppression after deliberate third party transfusions versus cyclosporine in living related renal transplant recipients.

A total of 93 recipients of either HLA-identical (34) or 1-haplotype matched (59) living related donor renal transplants was assigned prospectively into immunosuppressive treatment groups on the basis of transfusion histories obtained at the initial evaluation for transplantation. Patients who received 0 to 2 third party transfusions were given no further transfusion, and received cyclosporine and prednisone immunosuppression after transplantation (cyclosporine group). Patients who received 3 or 4 third party transfusions were given additional transfusions until 5 had been received, and were managed with azathioprine and prednisone after transplantation (azathioprine group). Patients who already received 5 or more third party transfusions had no additional transfusions and were assigned to the azathioprine group. No patient had a positive crossmatch to the potential donor after initial evaluation and confirmation of a negative crossmatch. The number of rejection episodes per patient after transplantation was significantly higher in the azathioprine group for HLA-identical (p equals 0.001) and 1-haplotype (p equals 0.003) recipients. One-year patient survival rats for the HLA-identical cyclosporine and azathioprine groups were 100 and 94 per cent, respectively, with respective 1-year allograft survivals of 100 and 89 per cent in the 2 groups. In the 1-haplotype group 1-year patient survival rates were 95 and 94 per cent for the cyclosporine and azathioprine groups, respectively; allograft survival was 81 per cent for the cyclosporine group and 91 per cent for the azathioprine group. None of the observed differences in graft or patient survival between the 2 groups was statistically significant. Deliberate third party transfusions with conventional immunosuppression and cyclosporine immunosuppression are effective methods to treat recipients of living related donor renal transplants.

Adult↗

PubMed1989

Conservative surgery for renal cell carcinoma: a single-center experience with 100 patients.

From January 1956 to March 1987, 100 patients underwent a conservative (parenchyma-sparing) operation as curative treatment for renal cell carcinoma at our clinic. This series includes 56 patients with bilateral (28 synchronous and 28 asynchronous) and 44 with unilateral renal cell carcinoma; in the latter category the contralateral kidney was either absent or nonfunctioning (17 patients), functionally impaired (17), involved with a benign disease process (6) or normal (4). The pathological tumor stage was I in 75 patients, II in 9, III in 10 and IV in 6. A nephron-sparing operation was performed in situ in 86 patients and ex vivo in 14. Postoperatively, 93 patients experienced immediate function of the operated kidney, while 7 required dialysis (4 temporary and 3 permanent). The incidence of dialysis was greater after ex vivo than in situ surgery (p equals 0.0005). The mean postoperative serum creatinine level in 97 patients with renal function was 1.7 mg. per dl. (range 0.9 to 4.6 mg. per dl.). The over-all actuarial 5-year patient survival rate in this series is 67 per cent including death of any cause and 84 per cent including only deaths of renal cell carcinoma. Survival was improved in patients with stage I renal cell carcinoma (p less than 0.05). Survival also was improved in patients with unilateral renal cell carcinoma (p less than 0.05) and fewer patients in this category had recurrent disease postoperatively (p less than 0.0005). Nine patients (9 per cent) had local tumor recurrence postoperatively and 5 of these were rendered free of tumor by secondary surgical excision. Conservative surgery provides effective therapy for patients with localized renal cell carcinoma in whom preservation of renal function is a relevant clinical consideration.

Actuarial Analysis↗

PubMed1989

Flank donor nephrectomy: efficacy in the donor and recipient.

Since August 1983, 115 patients have undergone live donor nephrectomy via an extraperitoneal flank approach with rib resection. Over-all hospital stay was short and morbidity was negligible. Early graft function was excellent as determined by urinary output in the first 20 hours postoperatively (mean 6,442 cc) and low nadir serum creatinine (mean 1.57 mg. per dl.). Acute tubular necrosis or urinary fistula developed in 3 kidneys (2.6 per cent). In the entire series, only 1 graft (0.8 per cent) was lost to technical complications. We conclude that an extraperitoneal flank approach to live donor nephrectomy is safe for the donor, and provides a structurally and functionally sound allograft for the recipient.

Adult↗

PubMed1989

Renal transplant calculi. A reevaluation of risks and management.

Between January 1977 and March 1988, 10 of 892 renal transplant recipients formed urinary tract calculi posttransplantation. The presenting symptoms were predominantly those of azotemia due to obstruction and/or hematuria. Factors predisposing to stone formation included a reconstructive urologic procedure at the time of transplantation (n = 4) or a surgical complication (n = 4), necessitating the placement of a ureteral stent and/or nephrostomy tube, secondary hyperparathyroidism (n = 5), hyperuricosuria (n = 4), and hypercalciuria (n = 1). Four patients passed their stones spontaneously; 1 patient underwent ureterolithotomy, 3 patients underwent endourologic stone extraction, 1 patient was treated with a combination of surgical and endourologic procedures, and 1 patient underwent extracorporeal shock wave lithotripsy as monotherapy. While the management of these patients can be challenging, awareness of predisposing factors, proper application of all currently available urologic techniques, and attention to certain guidelines of management can aid in minimizing morbidity from this rare urologic complication of renal transplantation.

Adolescent↗

PubMed1989

Pretransplant assessment of renal viability by phosphorus-31 magnetic resonance spectroscopy. Clinical experience in 40 recipient patients.

A group of 40 cadaveric kidneys was studied just prior to planned transplantation to further assess the applicability of 31P-MRS in the analysis of clinical renal transplant viability. Renal intracellular high-energy phosphorus metabolites (ATP [or NADP], phosphomonoester [PME] and inorganic phosphate [Pi]) and pH were measured noninvasively with MRS surface coils external to cold storage containers. Pretransplant MRS parameters were correlated with subsequent renal function in recipient patients (measured one week postoperatively by the need of dialysis, drop in serum creatinine, urine output, and 123I or 131I Hippuran assessed renal tubular function). ATP and NADP was detected in eleven kidneys and was significantly (P less than 0.001) associated with the best renal function posttransplantation. These kidneys also had the highest PME/Pi ratios (1.66-0.54), while lower ratios (0.36-0.10) were associated with prolonged acute tubular necrosis. The PME/Pi ratios significantly (P less than 0.0001) correlated with subsequent clinical renal function, whereas cold storage times (37 +/- 10 hr) or intracellular renal pH (6.53-7.91) did not. These preliminary data suggest that MRS is a noninvasive, nondestructive and sterile method for assessing clinical viability during hypothermic storage of human cadaver kidneys and the subsequent recovery of renal function postrenal transplantation.

Adenosine Triphosphate↗

PubMed1989

Atheroembolic renal disease: association with renal arterial stenosis.

In elderly patients with generalized atherosclerosis and longstanding hypertension, progressive renal insufficiency should suggest renal artery occlusive disease and/or renal cholesterol embolization. Renal cholesterol embolization is not an absolute contraindication to successful surgical revascularization. Renal cholesterol emboli were identified in biopsy specimens obtained in 24 cases at the Cleveland Clinic from 1978 to 1986, and renal artery stenosis was an associated finding in 19. Clinical manifestations of generalized atherosclerosis were common, including ileofemoral atherosclerosis (18), coronary artery disease (16), carotid occlusive disease (15), and carotid occlusive disease with a history of stroke (8). Evidence of embolic events in other organs was common. Hypertension worsened before biopsy in 21 patients with and without renal artery stenosis. Surgery or angiography definitely or probably contributed to renal failure in 16. Of 12 who underwent surgical revascularization of a renal artery, renal function improved in five, remained stable in five, and worsened in one. Renal function improved in the three patients undergoing dialysis before revascularization, and two were able to discontinue dialysis.

Aged↗

PubMed1989

Baseline renal function and surgical revascularization in atherosclerotic renal arterial disease in the elderly.

From 1975 to 1984, 107 patients greater than or equal to 60 years of age had surgical revascularization at the Cleveland Clinic for correction of atherosclerotic renal arterial disease. To evaluate the effect of baseline renal function (RF) on outcome in older patients, the patients were retrospectively divided according to their preoperative serum creatinine levels into Group I, less than or equal to 1.4 (N = 26), and Group II, greater than or equal to 1.5 (N = 81). Extrarenal atherosclerosis was more frequent in Group II (P less than .005). Higher rates of complications were seen both in Group II and with extrarenal atherosclerosis, but these associations did not achieve statistical significance (P = .07). Baseline RF did not affect results, but after revascularization, the fall in diastolic blood pressure was greater in Group I (28.2 +/- 4.4 mmHg v 17.4 +/- 1.8 mmHg, P less than .05). No such effect was noted in systolic blood pressure or in the frequency of cure or improvement v failure. Operative mortality for the entire group was 2.8%.

Arteriosclerosis↗

PubMed1989

Secondary renal revascularization for recurrent renal artery stenosis.

Six patients are presented who underwent secondary renal revascularization for recurrent renal artery stenosis. The initial pathologic diagnosis was fibrous dysplasia in three patients and atherosclerosis in three patients. All patients had initially undergone a successful aortorenal bypass operation. Recurrent renal artery stenosis and hypertension developed 11 to 120 months later (mean, 58 months). Secondary revascularization operations included renal autotransplantation (2 patients), hepatorenal bypass (2), iliorenal bypass (1), and aortorenal bypass (1). Hypertension was relieved, and renal function was stabilized or improved in all cases. If hypertension recurs after renal revascularization, a recurrent but correctable lesion should be suspected.

Adult↗

PubMed1989