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A Gottlieb

Publications and source records attributed to A Gottlieb.

At least 37 records · Page 2Linked to original sources
PubMed1998

Flashback and nightmares after surgery under neuraxial anesthesia: a report of two cases.

Recall, awareness, flashback, and nightmares are reported complications of general anesthesia, but flashback and nightmares after regional anesthesia have not been described. Two patients underwent vascular and orthopedic surgery under spinal and epidural anesthesia, respectively. Local anesthetic consisted of bupivacaine, and sedation was achieved with the combination of fentanyl, midazolam, and diphenhydramine. In both patients the anesthetic course was uneventful, but the recovery process was complicated by flashbacks and nightmares leading to depression, physical complaints, and lengthy convalescence. Flashback and nightmares after neuraxial anesthesia are unreported and, therefore, their incidence is unknown.

Adjuvants, Anesthesia↗
PubMed1998

Cyclosporine consensus conference: with emphasis on the treatment of psoriasis.

Cyclosporine has been in worldwide use for 15 years for patients who have undergone transplantation operations and is now being used to control inflammatory reactions in other organs (eg, joints, bowel, and skin). Neoral, a more consistently absorbed form of cyclosporine, has recently been approved by the Food and Drug Administration for the treatment of psoriasis. This report outlines the indications, contraindications, dosage recommendations, monitoring requirements, adverse events, drug interactions, interactions with other psoriasis treatments, and suggestions for cyclosporine's use in rotational therapy.

Contraindications↗
PubMed1998

Perioperative cardiovascular morbidity in patients with coronary artery disease undergoing vascular surgery after percutaneous transluminal coronary angioplasty.

OBJECTIVE: Patients with coronary artery disease (CAD) who undergo noncardiac surgery are at increased risk for perioperative myocardial infarction (PMI). Undergoing successful coronary artery bypass grafting (CABG) before such surgery has been shown to decrease perioperative cardiac morbidity and mortality. Percutaneous transluminal coronary angioplasty (PTCA) is an alternative treatment for these patients. Perioperative cardiac morbidity in patients with CAD who underwent PTCA before their vascular surgery was reviewed. SETTING: A tertiary care referral center for patients with cardiovascular heart disease. PARTICIPANTS: Review of vascular surgery database for patients who underwent vascular surgery preceded by PTCA between 1984 and 1995. Patients were excluded if they had a history of CABG within 2 years of surgery, had PTCA more than 18 months before surgery, or had incomplete data. MEASUREMENTS: Data were collected concerning cardiac history, left ventricular (LV) function, perioperative cardiac morbidity (angina, MI, congestive heart failure [CHF], and arrhythmias). MAIN RESULTS: Of 194 patients who underwent aortic abdominal surgery, carotid endarterectomy (CEA), or peripheral vascular surgery preceded by PTCA, 104 (54%) had a previous MI. Twenty-six patients (13.4%) had perioperative cardiac morbidity. Only one patient had an MI (0.5%; 95% confidence interval [CI], 0.0 to 2.8), whereas one patient died of CHF followed by multisystem organ failure (0.5%). The median interval between PTCA and surgery was 11 days (interquartile range, [IQR] 3 to 49 days). Patients who developed perioperative cardiac morbidity were older than those who did not (p = 0.02). Patients who had a history of CABG (before PTCA) had a higher incidence of postoperative angina (p = 0.04). The degree of preoperative LV dysfunction was linearly related to the incidence of new postoperative CHF (p = 0.01). Arrhythmias were more common in patients undergoing abdominal vascular surgery (17.9%) than in those undergoing CEA (2.5%; p = 0.03) or peripheral vascular surgery (5.2%; p = 0.02). CONCLUSION: High-risk cardiac patients undergoing vascular surgery who have had PTCA performed up to 18 months preoperatively have a low incidence of perioperative cardiac morbidity. Prophylactic PTCA may be beneficial in patients with CAD who are at high risk for perioperative cardiac complications.

Aged↗
PubMed1998

Ischemic liver dysfunction after elective repair of infrarenal aortic aneurysm: incidence and outcome.

OBJECTIVE: To assess the frequency of early postoperative liver dysfunction in patients undergoing elective infrarenal aortic aneurysm repair, their hospital course, and outcome. DESIGN: A retrospective case-control study. SETTING: A single tertiary referral center. PARTICIPANTS: A review of medical records of 942 consecutive asymptomatic patients with normal preoperative liver function test results who had elective infrarenal aortic aneurysm repair with infrarenal aortic cross-clamping. The authors selected all patients who had an acute increase in serum hepatic enzyme levels (minimum fivefold increase in aspartate aminotransferase [AST] and twofold increase in lactate dehydrogenase [LDH] levels) within the first 7 perioperative days (study patients). The control group consisted of 42 patients with normal postoperative liver function test results, matched by age, sex, and year of surgery to study patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Aortic cross-clamping times, lowest intraoperative blood pressure, duration of hypotension (systolic blood pressure < or = 95 mmHg), lowest intraoperative base deficit, and estimated blood loss were compared between control and study patients. The study also analyzed perioperative metabolic, hemostatic, hepatic, and renal function variables; the intraoperative course; postoperative complications; and inhospital outcome. Fourteen of 942 patients (1.5%) comprised a study group. In 11 patients (1.2%), AST and LDH levels moderately increased, and three patients (0.3%) developed changes consistent with a diagnosis of acute ischemic hepatitis (AIH). In all patients, the serum liver enzyme levels peaked between 24 and 72 postoperative hours. Three patients with AIH developed concomitant acute renal failure; one had associated disseminated intravascular coagulation (DIC) and died. Of 11 patients with moderate increases, one subsequently developed multisystem organ failure and died. The overall in-hospital mortality rate for patients with postoperative liver dysfunction was 14% (2/14) and for the control group it was 2.3% (1/42). The duration of hypotension and metabolic acidosis were more pronounced in patients who postoperatively developed liver dysfunction (both p < 0.001); however, study and control patients did not differ in the duration of aortic cross-clamping, lowest intraoperative blood pressure, or estimated blood loss. CONCLUSION: Liver enzyme levels acutely increased in 1.5% of patients after elective infrarenal aortic aneurysm repair with infrarenal cross-clamping. In patients with moderately elevated serum liver enzyme levels, postoperative recovery was relatively uncomplicated, whereas all three patients with AIH developed acute renal failure and had a more complicated postoperative course. Those with postoperative liver dysfunction had a longer duration of intraoperative hypotension and more pronounced metabolic acidosis.

Aged↗
PubMed1997

Sequential mitoxantrone, daunorubicin, and cytosine arabinoside for patients with newly diagnosed acute myelocytic leukemia.

Mitoxantrone (M) is a synthetic aminoanthraquinone with anti-leukemic activity in patients with daunorubicin (D) resistant acute leukemia. The Cancer and Leukemia Group B (CALGB) has undertaken a limited access pilot study in which M, 12 mg/m2, over 30 min, daily for 3 days, and cytosine arabinoside (Ara-C), 100 mg/m2/day by constant infusion for 7 days were used for the induction of newly diagnosed patients with AML. Responding patients were consolidated with daunorubicin, 45 mg/m2/day for 3 days, and 7 days of Ara-C. After a second consolidation identical to induction, no further therapy was given. Twenty-nine patients with a median age of 50 years (range 18-72) were entered in the study; 18 were males and 11 females. Twenty-four (83%) patients achieved CR, 1 patient achieved a PR, and 4 died in induction from leukemia-related causes. Two patients died in CR from consolidation-related neutropenic sepsis and two additional patients died in CR. Of 24 patients, 7 remain disease-free at a median follow-up interval of 8 years. The regimen is active and well tolerated. The duration of disease-free survival in responding patients is consistent with that seen in similar regimens using intensification chemotherapy without prolonged maintenance.

Adolescent↗
PubMed1997

Pramlintide: a human amylin analogue reduced postprandial plasma glucose, insulin, and C-peptide concentrations in patients with type 2 diabetes.

In order to determine the influence of a 5 h infusion of pramlintide compared to placebo on postprandial glucose, lactate, insulin, and C-peptide concentrations in patients with Type 2 diabetes, a single-blind, randomized, cross-over study was conducted in 24 patients; 12 treated with exogenous insulin and 12 managed with diet and/or oral hypoglycaemic agents. One hour after initiation of infusion, patients consumed a Sustacal test meal. The protocol was repeated on the following day with each patient receiving the alternate study medication. Pramlintide infusion in the insulin-treated patients resulted in statistically significant reductions in mean glucose, insulin, C-peptide, and lactate concentrations during the 4-h period after the Sustacal test meal. Pramlintide infusion also resulted in significant reductions of mean insulin, C-peptide, and lactate concentrations, but not glucose concentrations, in the patients treated with diet and/or oral hypoglycaemic agents. Within this latter group, reduction in postprandial glucose concentrations in individual patients correlated with glycated haemoglobin values. These results suggest that administration of pramlintide may improve glycaemic control in patients with Type 2 diabetes treated with insulin or poorly controlled on diet and/or oral hypoglycaemic agents.

Adult↗
PubMed1997

Disseminated intravascular coagulation associated with acute ischemic hepatitis after elective aortic aneurysm repair: comparative analysis of 10 cases.

OBJECTIVE: To assess the characteristics of patients with perioperative disseminated intravascular coagulation (DIC) and acute ischemic hepatitis after elective aortic aneurysm repair (AAR). DESIGN: A retrospective case-control study. SETTING: A single tertiary referral center. PARTICIPANTS: Between 1982 and 1993, 1966 patients underwent elective AAR. Of these, 10 patients (eight with abdominal and two with thoracoabdominal aneurysms) developed DIC and acute elevation of serum transaminases consistent with acute ischemic hepatitis during or shortly after surgery. The control group included 30 patients matched by age, sex, year of surgery, and aneurysm type and size. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: None of the patients in either group had preoperative hemostatic abnormalities or other causes for DIC. There was no difference between the two groups in the duration of aortic cross-clamping. In all study patients, severe coagulopathy or systemic hypotension developed after the aortic cross-clamp was released. This resulted in significantly increased surgery time after unclamping (p < 0.001), and increased estimated blood loss (p < 0.001). DIC developed within 24 hours, and mean concentrations of aspartate transaminase (4,021 +/- 3,579 IU/L) and lactate dehydrogenase (4,332 +/- 2,903 IU/L) peaked on the second postoperative day. Nine (90%) of the study patients required repeat operations (seven for bleeding), and all of them died; the median survival time was 6 days (mean, 8.3 +/- 8.2 days). Only one patient in the control group needed a repeat operation. Liver infarction or necrosis was seen in all seven patients who underwent autopsy or biopsy. CONCLUSIONS: The combination of DIC and acute ischemic hepatitis ("hepatohemorrhagic syndrome") rarely occurs after elective AAR and is associated with a very high mortality rate. DIC was temporally related to the release of the aortic cross-clamp. The cause-effect relationship of this rare syndrome cannot be explained by operative course before the release of the aortic cross-clamp.

Acute Disease↗
PubMed1997

The effects of carotid sinus nerve blockade on hemodynamic stability after carotid endarterectomy.

OBJECTIVE: To determine whether intraoperative administration of bupivacaine reduces the incidence of hypotension after carotid endarterectomy (CEA). DESIGN: Prospective, double-blinded, randomized controlled trial. SETTING: A single-institute, tertiary-care medical center. PARTICIPANTS: Patients (n = 135) who were referred for CEA without prior ipsilateral CEA, diabetes mellitus, or allergies to local anesthetics. INTERVENTIONS: 2 mL of 0.25% bupivacaine or 2 mL NaCl (control) injected by the surgeon at the carotid sinus immediately after CEA. MEASUREMENTS AND MAIN RESULTS: Blood pressure and heart rate were measured before induction, before carotid reperfusion, 2 minutes after reperfusion, before carotid sinus injection, and every 15 minutes thereafter for 2 hours. Anesthesia was induced and maintained with fentanyl, pancuronium, and 0.5% to 1% enflurane. Hypertension was defined as a systolic blood pressure 30% above baseline or greater than 180 mmHg. Hypotension was defined as a systolic blood pressure 30% below baseline or less than 100 mmHg. Postoperative incidences of hypertension, hypotension, and the associated use of corrective medications were compared in both groups using the chi-squared test to determine statistical significance. Patients in the bupivacaine group (n = 61) had a similar incidence of postoperative hypotension as controls (n = 74) but a higher incidence of hypertension (40% v 24%; p = 0.043). The bupivacaine group required vasodilators more often (33% v 18%; p = 0.04). Baseline hypertension and preoperative use of beta-blockers also were predictive of postoperative hypertension. CONCLUSIONS: Carotid sinus area infiltration with bupivacaine after CEA does not reduce the incidence of postoperative hypotension but significantly increases the incidence of postoperative hypertension. Thus, its routine use cannot be recommended in carotid endarterectomy.

Aged↗
PubMed1997

Tobacco use among male high school athletes.

PURPOSE: The purpose of this study was to compare tobacco use among high school male athletes with their nonathlete counterparts. We hypothesized that there was an inverse correlation between the intensity level of the sport and frequency of tobacco use. METHODS: Students were surveyed at seven high schools in northwest Louisiana using a 109-item questionnaire. Of the 1,200 males tested, 83% participated in one or more sports. The mean age was 15.8, and mean grade level was 10th. Sixty-seven percent were white, 27% African-American (AA), and 6% other. RESULTS: Forty-one percent of the adolescent males tested were one or more tobacco products, 31% reported cigarette smoking, 21% chewed tobacco, and 18% used snuff. Eleven percent reported using all three tobacco products. Race was a significant determinant of tobacco use, with whites being more likely to use each of the three tobacco products (P < .001). Medium- and high-intensity athletes were significantly (P < .01) less likely to be heavy smokers than athletes participating in low-intensity sports and nonathletes. However, athletes of each intensity sport used chewing tobacco and snuff at significantly higher rates (P < .001) than nonathletes. When race and grade point average were controlled, sports intensity was a significant predictor of smokeless tobacco use but not overall smoking behavior. Both AA and white high school male athletes at all sport intensity levels were using chewing tobacco and snuff at a rate higher at least 1.5 times that of their nonathlete counterparts. CONCLUSIONS: In our study, high school males' sports participation was a predictor of smokeless tobacco use but not overall smoking behavior. Although the probability of AA high school athletes using smokeless tobacco was low compared to whites, the pattern of use was similar across intensity levels of sports.

Adolescent↗
PubMed1997

Effects of pramlintide, an analog of human amylin, on plasma glucose profiles in patients with IDDM: results of a multicenter trial.

The effects of subcutaneous administration of 10, 30, or 100 microg q.i.d. pramlintide, an analog of human amylin, on plasma glucose regulation in patients with IDDM were evaluated in a multicenter trial. The plasma glucose response to a Sustacal test meal was significantly reduced compared with placebo both after 1 week and after 2 weeks of administration of 30 or 100 microg pramlintide. In addition, 24-h mean plasma glucose concentrations were significantly lowered in patients receiving 30 microg of pramlintide for 2 weeks compared with placebo, while the 100-microg pramlintide dose did not reach statistical significance for the 24-h glucose profiles. At 10 microg, pramlintide had no effect on the 24-h glucose profile or on the plasma glucose response to a Sustacal test meal. The reduction in 24-h glucose concentrations and glucose concentrations after the Sustacal test meal observed at the 30-microg pramlintide dose was not accompanied by an increased incidence of hypoglycemic events. The most frequent adverse events were dose-related and involved transient upper gastrointestinal symptoms. A majority (>80%) of the patients who reported these adverse events during week 1 did not report them in week 2. These data indicate that pramlintide effectively reduces plasma glucose concentrations as reflected in both a 24-h glucose profile and a Sustacal test meal while maintaining an acceptable safety profile.

Adult↗
PubMed1996

Effect of 14 days' subcutaneous administration of the human amylin analogue, pramlintide (AC137), on an intravenous insulin challenge and response to a standard liquid meal in patients with IDDM.

Individuals with insulin-dependent diabetes mellitus (IDDM or type 1 diabetes) are deficient in both insulin and amylin, peptides secreted by the beta cell. We have investigated the effects of amylin replacement therapy employing the human amylin analogue, pramlintide (25, 28, 29-pro-human amylin, previously referred to as AC137), upon the responses to a standardized insulin infusion (40 mU. kg-1. h-1) for 100 min and a liquid Sustacal meal (360 kcal) in 84 healthy IDDM patients. Following baseline evaluations, patients were randomly assigned to receive subcutaneous injections of placebo, 30, 100 or 300 micrograms pramlintide 30 min before meals for 14 days. There was no meaningful difference between adverse events reported by the 30-micrograms pramlintide and the placebo groups, but ten subjects withdrew due to nausea, eight of these in the 300-micrograms dose group. Peak plasma pramlintide concentrations for the 30-micrograms group were 21 +/- 3 and 29 +/- 5 pmol/l on Days 1 and 14, respectively. These values are similar to postprandial plasma amylin concentrations in normal volunteers. The plasma glucose, free insulin, glucagon, epinephrine and norepinephrine concentrations during the insulin infusion test before and after therapy were identical in each of the group. Prior to pramlintide therapy, Sustacal ingestion produced a 4.0-4.8 mmol/l rise in plasma glucose concentrations in each of the groups. Pramlintide therapy reduced postprandial hyperglycaemia as reflected by the 3-h incremental AUCglucose (AUCglucose above or below fasting glucose concentration) Day 1 vs Day 14: 30 micrograms, 322 +/- 92 vs -38 +/- 161 mmol/l.min, p = 0.010; 100 micrograms, 317 +/- 92 vs -39 +/- 76 mmol/l.min, p = 0.001; and 300 micrograms, 268 +/- 96 vs -245 +/- 189 mmol/l.min, p = 0.077. Thus, pramlintide therapy with these regimens did not appear to impair either in vivo insulin action or the counter-regulatory response to hypoglycaemia but did show a clear effect of blunting postprandial hyperglycaemia following a standardized meal.

Adolescent↗
PubMed1996

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Association↗
PubMed1996

Postsurgical adjuvant chemotherapy of stage II breast carcinoma with or without crossover to a non-cross-resistant regimen: a Cancer and Leukemia Group B study.

PURPOSE: To compare two cyclophosphamide, methotrexate, fluorouracil, vincristine, and prednisone (CMFVP) regimens with a doxorubicin-based regimen--vinblastine, doxorubicin, thiotepa, and Halotestin (Upjohn, Kalamazoo, MI) (VATH)--in patients with stage II node-positive breast carcinoma. METHODS: Nine hundred forty-five women were treated with a 6-week induction course of CMFVP. They were then randomized to receive one of two consolidation CMFVP regimens: 6-week courses or 2-week courses. Following completion of CMFVP consolidation, patients were again randomized to either continue the CMFVP regimen or to receive six escalating doses of VATH. RESULTS: Among all patients, with a median follow-up time of 11.5 years, there is no statistically significant difference in disease-free survival (DFS) between the two consolidation CMFVP regimens. VATH intensification treatment is statistically significantly superior to CMFVP in terms of DFS (P = .0040). For patients with one to three involved nodes, there is currently no significant difference between VATH and CMFVP; however, among those with four or more positive lymph nodes, there is a significant difference in favor of VATH (P = .0037). There is also improved overall survival with VATH (P = .043; median, > 14 years v 10 years). This difference is also statistically significant in patients with four or more involved lymph nodes, among postmenopausal patients, and among postmenopausal estrogen receptor-positive patients. CONCLUSION: Chemotherapy with crossover to escalating doses of VATH following CMFVP was well tolerated and effective. Inauguration of VATH as a treatment intensification at the eighth month produced a major increase in relapse-free and overall survival. The observation that sensitivity to VATH is retained so long after mastectomy raises questions about the proper duration of adjuvant chemotherapy and lends support to further investigation of cross-over designs in future trials to postoperative adjuvant chemotherapy regimens.

Adult↗
PubMed1996

Trigeminal evoked potential-monitored thermorhizotomy: a novel approach for relief of trigeminal pain.

This paper presents a complete method for performing trigeminal thermorhizotomy, guided by neurophysiological data, to relieve tic douloureux. The method involves the use of trigeminal evoked potentials (TEPs) produced by stimulation of the supraorbital, infraorbital, and mental nerves and recorded from electrodes at both the scalp and the trigeminal nerve. To perform the thermorhizotomy, a cannula is modified to produce a concentric bipolar electrode that is suitable for both recording and lesion making. The operating procedure is divided into five steps: Step 1, recording of baseline scalp TEPs from the derivation of the cervical vertex to C-7 to ensure that all stimulating electrodes are correctly placed; Step 2, recording of TEPs from the trigeminal electrode after stimulation of the peripheral nerve trunks to ascertain the electrode's position relative to the root bundles; Step 3, fine positioning of the trigeminal electrode by recording the root activity evoked by stimulation of cutaneous trigger points or of the most painful areas; Step 4, assessing the position of the trigeminal electrode relative to the motor root by stimulating the nerve via the electrode and observing the masseter motor responses; and Step 5, recording scalp TEPs immediately before and after each thermolesion. Thermolesions are made until the scalp-recorded wave W2 decreases its amplitude by 20% to 50% of the original value or until it is delayed by 0.30 msec. This procedure has the potential to enable extremely precise monitoring of the position of the trigeminal electrode relative to the activated fibers and provides very effective monitoring of the extent of the lesion. The authors have performed this procedure with very satisfactory results in 30 patients with trigeminal neuralgia in the second branch.

Adult↗
PubMed1996

Oral tramadol and buprenorphine in tumour pain. An Italian multicentre trial.

In this multicentre trial tramadol and buprenorphine were compared for the treatment of neoplastic pain no longer responsive to non-steroidal antiinflammatory drugs. A total of 131 adults (86 M, 45F) were treated with tramadol (one 100-mg slow-release tablet every 8-12 h), or buprenorphine (one sublingual 0.2-mg tablet every 6-8 h). The trial was to continue for up to six months. Most patients started treatment with 2-3 tablets/day in both groups, and the mean treatment period was 58 days for tramadol and 51 for buprenorphine. Almost all dose changes needed were made in the first fortnight in both treatment groups, and the largest number of patients dropped out because of inadequate pain relief or progression of the underlying disease. The results achieved in the first two weeks persisted throughout the rest of the trial, and the investigator's assessments on each patient's clinical chart corresponded closely with those that patients made in their own daily diaries. In the four hours after the first dose both drugs virtually halved the severity of pain (measured using a visual analogue scale), and this relief lasted throughout treatment. By the end of the first week the proportion of patients with strong/unbearable pain in the tramadol group had fallen significantly (from 98.4% to 48.1%, p < 0.05), as compared to a drop from 92% to 66.7% for buprenorphine. The quality of sleep also tended to improve in the tramadol group, with the proportion of patients enjoying good or deep sleep rising from 37% to 50%, as compared to 33% to 40-44% with buprenorphine. Karnofsky's and Spitzer's indices reflecting the quality of life did not change in the tramadol group; in the buprenorphine group the Karnofsky index dropped slightly after a fortnight (p < 0.05 between treatments). In the first two months of the trial the number of patients with no/moderate pain rose continuously in the tramadol group (71% and 80% after one and two months); the rise was less marked in the buprenorphine group (number of patients with mild/moderate pain, 45% and 65%). In both the short term and in the longer term, it was found that the levels of efficacy and acceptability were always significantly better in the tramadol group than in the buprenorphine group. General and biological safety in both drugs was good. The most typical side-effects were those characteristic of opioids (nausea and/or vomiting, drowsiness). Adverse reactions were reported in 17 patients taking tramadol (25%) and in 16 taking buprenorphine (26%). There were six drop-outs in the first group (9%) and seven in the second (11%). Serious symptoms arose more frequently in the buprenorphine group (19% cf. 10%). No signs of dependence or tolerance were noted.

Adult↗