Effect of insulin on donor hepatic energy charge during cross-dialysis liver support.
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Biomedical subjects
Publications and source records attributed to B Eiseman.
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The clinical scenario of multiple organ failure (MOF) is reviewed and its frequent correlation with sepsis emphasized. It is hypothesized that MOF is produced by the formation of immune complexes (IC) in response to infection with deposition on organs such as the liver, lung, and kidney. Such immune complexes trap macrophages which can directly damage endothelium. Such a pathologic picture is in keeping with that of MOF. Granular deposits of IgG, IgM, C3, C5, and fibrinogen have been identified in the organs of four patients dying of MOF and sepsis. Similar deposits have been identified using fluorescent antibody stains in the organs of rabbits following cecal perforation. It is hypothesized that sepsis may produce organ failure at a distance from the site of infection via deposits of immune complexes.
New approaches for experimental immunosuppression have been reviewed. These include the following: 1) cyclosporin A, a metabolite from fungus that suppresses multiplying but not resting T and B lymphocytes and can be used in pulsed manner with interspersed drug-free periods; 2) total lymphoid irradiation (transplantation tolerance in rats has been achieved by pretransplant radiation); 3) thoracic duct drainage, which is being revived following its demonstrated effectiveness in the treatment of some autoimmune disease; 4) hyperbaric oxygen (HBOX). We have found that HBOX 2 1/2 ATA for five hours daily depresses cell-mediated immunity in mice and that this can be reversed by intravenous administration of autologous macrophages.
Reports from several laboratories have indicated that hyperbaric oxygen might be immunosuppressive in animals. We examined the effect of hyperbaric oxygen on a well-studied model of cell-mediated immunity in the mouse, contact sensitivity to dinitrofluorobenzene (DNFB). Using this model, we showed that daily 5-hour exposure of mice to 2.5 ATA hyperbaric oxygen was markedly immunosuppressive. Immunosuppression occurred when mice were exposed to hyperbaric oxygen (HBOX) for 4 days daily before DNFB sensitization or for 5 days daily after sensitization. The immunosuppression was reversed by intravenous administration of 2 x 10(7) peritoneal exudate cells from syngeneic mice, but was not reversed by 5 x 10(7) lymph node cells intravenously. We showed that daily HBOX exposure resulted in a dramatic decrease in circulating total leukocytes and lymphocytes in spleen weight, and in DNA synthesis in draining lymph nodes of sensitized mice. Serum cortisol levels were only marginally elevated in HBOX-treated mice.
Cholecystostomy was performed on 22 patients with acute cholecystitis after partial (13) or complete (9) removal of gallbladder stones. One patient had complementary common-duct drainage. Early mortality occurred in two patients. Three patients with associated cholangitis but intraoperative reflux of cysticduct bile were all treated by cholecystostomy alone and survived. For the poor-risk patient with cholecystitis, cholecystostomy is effective. When there is associated cholangitis and documented cystic-duct patency, cholecystostomy is also sufficient. When accompanying cholangitis is associated with cystic-duct occlusion, choledochotomy and T tube drainage should be added.
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Parameters of cell-mediated and humoral-mediated immunity were measured in ten infection-free, insulin-dependent, controlled diabetic patients and in ten similar but nondiabetic patients awaiting elective operations. Tests performed included total and differential leukocyte counts, neutrophil reduction of nitroblue tetrazolium, mitogen response of lymphocyte to phytohemagglutinin, ratio of thymus-derived to bone marrow-derived lymphocytes, serum immunoglobulins IgA, IgG, and IgM, macrophage inhibition factor, serum zinc, and reaction to skin test antigens. Diabetics had a significantly (P less than .05) decreased mean response response to phytoheagglutinin stimulation and a lowered ratio of thymus-derived to bone marrow-derived lymphocytes. These findings support the concept of depressed cell-mediated immunity in the controlled, adult diabetic and might explain the propensity of the uncontrolled diabetic to increased frequency and severity of bacterial infection.
A five year experience with 782 patients requiring laparotomy for trauma is reviewed. Specifically, the 70 patients requiring unplanned reexploration have been studied to delineate the indications for and implications of such repeat laparotomies. The major indications for such reoperation were intraabdominal abscess (45.7 per cent), bleeding (15.5 per cent), peritonitis (12.1 per cent), and small bowel obstruction (8.6 per cent). There were 16 negative reexplorations (13.8 per cent). Overall mortality in the reexplored patients was 21.4 per cent, all victims of gunshot or blunt trauma. Mortality correlated with the number of required reexplorations, being 67 per cent in those requiring four operations. Of the 31 laparotomies performed initially for diffuse or localized intraabdominal sepsis, only 15 were highly suspected, and 13 of these by simple chest x-ray findings. If after laparotomy for repair of intraabdominal trauma a patient fails to meet the anticipated norm of convalescence, a high index of suspicion for early postoperative hemorrhage, or later sepsis, should be maintained. Such patients have far more to gain than lose by reexploration.