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Biomedical subjects

C L Witte

Publications and source records attributed to C L Witte.

At least 55 records · Page 3Linked to original sources
PubMed1992

Updating the management of salvageable splenic injury.

Because of the ready availability of autotransfusers and risk of transfusion-transmitted disease, the authors reexamined the management of splenic trauma. During the past 6 months, 20 adult and pediatric patients were treated for blunt splenic trauma. Nine had "minor" lacerations and were successfully managed nonoperatively. Eleven had ongoing hemorrhage or associated visceral injury necessitating laparotomy. In two, coexistent injuries were life threatening and total splenectomy was performed. The other nine had major splenic trauma that was either an isolated phenomenon or was associated with an injury not jeopardizing survival; eight spleens were salvaged. Mean intra-abdominal blood loss was approximately 1250 mL and, using a "cell saver," an average of approximately 790 mL was reinfused. Six received no other blood transfusion whereas three received 2250 mL homologous blood in addition to 4250 mL via the "cell-saver." With hilar laceration, repair was facilitated by temporarily occluding the splenic pedicle atraumatically, and suturing torn polar branches via the laceration site. In both children and adults with major splenic injury, the authors now recommend early laparotomy with reinfusion of autologous blood. The spleen or a large remnant can usually be salvaged, and homologous blood transfusion with its attendant complication can often be obviated altogether.

Adolescent↗
PubMed1992

Toxic shock-like syndrome.

Invasive group A streptococcal infection has important diagnostic and therapeutic implications in patients with necrotizing fasciitis. We cared for a man with the full-blown syndrome in whom many features of toxic shock syndrome were present, including profound hypotension and renal failure. The diagnostic similarities of toxic shock syndrome and the toxic shock-like syndrome caused by group A Streptococcus could have led to inappropriate treatment. Successful therapy in our patient included high doses initially of broad-spectrum antibiotics, repeated operative debridement of the lower leg (the affected limb), and ultimately, reconstructive surgery consisting primarily of split-thickness skin grafts. The reemergence of invasive streptococcal infections may relate to changes either in virulence factors of the causative streptococcus or in exotoxins elaborated by this microorganism. A causative relationship between an exotoxin produced by group A Streptococcus and the toxic shock-like syndrome has not yet been established.

Adult↗
PubMed1991

Chaos and predicting varix hemorrhage.

Despite a wide array of mechanisms implicated in esophagogastric varix hemorrhage, predicting the onset of bleeding or even identifying the dominant factor in its causation has proved elusive. In this article we re-examine variceal pathophysiology and hypothesize that bleeding is rooted in turbulent portal system flow, a phenomenon embodied in the 'new' science of chaos and the principles of non-linear, rhythmic fluid dynamics. Analogous to forecasting the weather, predicting turbulent flow hinges on defining the initial physical conditions, and, like the field theory of quantum physics, depends on probabilities and instabilities rather than direct proportional analysis. Based on the complex regional and systemic hemodynamic forces and local physical properties underlying formation and perpetuation of esophagogastric varices, we propose, as with climatologic events, that a relatively minor or remote physiologic adjustment may set into motion a sequence of destabilizing splanchnic blood flow kinetics that ultimately causes a varix to erupt. In other words, the onset of varix bleeding derives from a sudden, erratic switch from disorganized but stable to disruptive turbulent variceal blood flow, and as a 'chaotic' phenomenon, is likely to remain for the foreseeable future highly unpredictable.

Biophysical Phenomena↗
PubMed1990

The effect of alcohol in isolated blunt splenic trauma.

The effect of alcohol on trauma patients is controversial, with numerous authors citing no difference in mortality in acutely intoxicated patients. The purpose of our study was to retrospectively investigate the effect of alcohol in adult patients with isolated blunt splenic injury. From 1980 through 1989, 47 adult patients with splenic trauma as the only major injury were admitted to the Trauma Service. There were 37 males and ten females with a mean age of 29 years (range, 15 to 61). Motor vehicle accidents were responsible for 44 (94%) of the injuries. Group 1 consisted of 24 patients with a mean blood alcohol level of 185 mg/dl (range, 15 to 380). In Group 2 there were 23 patients without detectable blood alcohol. There were no statistically significant differences between the two groups in age, Abbreviated Injury Severity Score, initial hematocrit, and grade of splenic injury. Hypotension was present in 13 patients (55%) in Group 1 versus six patients (26%) in Group 2 (p less than 0.05). Significant abnormalities in clotting studies were present on admission in six patients (25%) in the alcohol-detected group versus one in the other group (p less than 0.05). Blood transfusion requirements in the first 24 hours were significantly greater in Group 1 (mean, 3.9 units) versus Group 2 (mean, 0.5 units) (p less than 0.001). If alcohol was present, there was much less chance for splenic conservation, as 18 patients (75%) underwent splenectomy versus seven patients (30%) in the nonalcohol group (p less than 0.05). There was one death and this occurred in a patient acutely intoxicated who suffered a cerebral infarct.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1990

Preeminence of lesser splanchnic blood flow in selected patients with generalized portal hypertension.

Although restricted transhepatic portal flow is necessary for development of generalized portal hypertension (GPH), increased splanchnic arterial inflow also contributes to GPH and its clinical sequelae. In this context, we describe 7 male and 6 female patients (mean age 48 years) in whom the lesser splanchnic (gastrosplenic) system played a key role in the signs and symptoms of GPH. These 13 patients (9 with hepatic cirrhosis, 3 with primary myeloproliferative disorder, and 1 with extrahepatic portal block) shared common features of massive splenomegaly, huge splenofundic gastric varices, often with a prominent natural shunt to the left renal vein. Total or near total splenectomy alone or combined where appropriate with coronary vein ligation was effective in controlling varix hemorrhage (10 patients), ascites (3), or complications of an enlarged spleen-anorexia and abdominal pain (3), hemolytic anemia (1) and profound thrombocytopenia with severe epistaxis (1). Intraoperative jejunal portal venography was crucial in operative management in order to establish definitively the presence or absence of coronary venous collaterals, and when present, to verify their operative ligation. These distinctive patients illustrate: 1) GPH is a heterogeneous syndrome of divergent splanchnic circulatory patterns, a feature which should be taken into account in selecting operative treatment; 2) one well-defined subgroup displays prominent hyperdynamic lesser splanchnic and specifically, splenic blood flow as a major contributor to clinical complications; and 3) within this subgroup, splenectomy combined with documented absence or surgical interruption of coronary venous collaterals as corroborated by intraoperative portography is effective alternative treatment.

Adolescent↗
PubMed1990

Lymphangioscintigraphy in AIDS-associated Kaposi sarcoma.

Kaposi sarcoma, a common opportunistic neoplasm complicating AIDS, is thought to arise from the vasculature and possibly from lymphatic endothelium. To evaluate the nature and extent of lymphatic involvement in AIDS-associated Kaposi sarcoma, we used an improved technique of whole-body lymphangioscintigraphy. Six human-immunodeficiency-virus-seropositive men (40-51 years old) with AIDS and extensive Kaposi sarcoma had bilateral foot and/or hand intradermal injection of 0.05 ml of 99mTc-labeled human serum albumin (500 microCi, 18.5 MBq). After sequential whole-body scanning with a digital gamma camera, the findings were interpreted by comparing them with findings from similar studies in 30 other patients without AIDS or Kaposi sarcoma (26 with primary or secondary lymphedema and four with normal extremities). Unlike in normal limbs, where lymphangioscintigraphy displayed early lymphatic truncal and regional nodal filling with radionuclide, in patients with Kaposi sarcoma, lymphangioscintigraphy disclosed a variety of abnormal patterns with some features distinct and others resembling lymphatic dysplasia as seen in primary and secondary lymphedema. These included focal accumulation of tracer within lymphatic channels in the distribution of cutaneous Kaposi lesions; delayed tracer transport with absent, faint, or intense regional lymph nodal uptake; and retarded or impeded lymphatic drainage with tracer intensification in the region of Kaposi sarcoma plaques. The impaired lymphatic drainage and nodal dysfunction seen on scintigrams in patients with AIDS-associated Kaposi sarcoma suggest a close connection between the lymphatic system and this disorder.

Acquired Immunodeficiency Syndrome↗
PubMed1990

AIDS, Kaposi sarcoma, and the lymphatic system: update and reflections.

Based on ongoing basic and clinical investigations, further evidence is presented that the AIDS-Kaposi sarcoma (AIDS-KS) complex involves a progressive disturbance of the blood-lymph circulatory loop of fluid, macromolecules, and migrating cells. We first surveyed the spectrum of vascular abnormalities including Kaposi sarcoma (KS) found in the AIDS/ARC population, then non-invasively imaged lymphatic system abnormalities in AIDS-KS by whole body lymphangioscintigraphy, and finally examined the biologic behavior of AIDS-KS cells in long-term tissue culture. These observations are viewed in terms of the lymphatic and blood vascular route of entry and transport of free and cell-associated virus and other opportunistic pathogens as well as poorly understood host endothelial-immune system interactions.

AIDS-Related Complex↗
PubMed1990

Effect of interleukin-2 on microvascular liquid and protein transport in the rat small intestine.

Interleukin-2 (IL-2), a glycoprotein lymphokine derived from activated T-lymphocytes displays potent anti-cancer properties but its therapeutic use has been limited by generalized tissue swelling. To shed light on the mechanism underlying this potentially life-threatening edematogenic syndrome, recombinant IL-2 or an equal volume of control solution (excipient or 5% dextrose) was administered to 88 adult, male Sprague-Dawley rats. Initially, rats were injected with 50,000 Cetus units (equal to 300,000 I.U.) of IL-2 intraperitoneally, either one-time ("acute" rats) or every eight hours for two or seven days ("chronic" rats). Thereafter, under pentobarbital anesthesia, the main mesenteric lymph duct was isolated, incised, and measurements made of intestinal lymph flow (JV) and the total protein content and protein fractions in lymph (L) and plasma (P) (refractometry and agarose gel electrophoresis, respectively). Final measurements were also carried out after superior mesenteric vein constriction to assess filtration-independent L/P total protein "washdown." After IL-2, JV and protein clearance (JV x L/P) were increased (p less than 0.001) while lymph and plasma total protein content and protein fractionation were unchanged. Protein washdown was also maintained. These data are not only inconsistent with bulk "plasma leak" from damaged capillaries, but in conjunction with previously demonstrated increased cardiac output and reduced systemic vascular resistance after IL-2 administration, the findings favor augmented microvascular surface exchange area from increased capillary perfusion as the primary mechanism underlying increased transcapillary liquid and protein flux. This conclusion conforms to the rapid reversal of edema in patients after cessation of IL-2 therapy.

Animals↗
PubMed1989

A curriculum on medical ignorance.

The information and technology explosions in medicine have exposed the vast realm of ignorance in human biology as well as the transiency of accepted knowledge and shortcomings of instructional methods which foster rote memorization, excessive reliance on conflicting data bases, and short-answer testing. To circumvent this serious deficiency in medical education, we have initiated a multifaceted Curriculum on Medical Ignorance consisting of 'questioning' seminars and hands-on clinical and laboratory experiences. This teaching programme not only emphasizes medicine's current deficiencies and limited insight into disease processes (i.e. ignorance) but also assists students in developing attitudes and behaviours to investigate basic biologic and clinical unknowns while rendering sound everyday clinical decisions in the face of fragmentary understanding. Based on evaluative feedback over the past 3 years, participants have made substantial progress towards recognizing and dealing constructively with medical ignorance and the limitations of 'knowledge of the day', thereby preparing them for the certain uncertainty of future medical practice.

Arizona↗
PubMed1989

Whole-body lymphangioscintigraphy: preferred method for initial assessment of the peripheral lymphatic system.

In 20 patients with congenital and acquired lymphedema in either upper or lower extremities and in four patients without extremity edema, human serum albumin labeled with technetium-99m was injected intradermally into a digital web space of the hand or foot. With a digital gamma camera that permitted a "sweep" of the torso, serial extremity and whole-body lymphagioscintigraphy (LAS) of the peripheral lymphatic system was performed. In 11 patients with acquired lymphedema, a well-defined obstructive pattern was seen, characterized by discrete peripheral lymphatic trunks, delayed or absent depiction of regional nodes, and delayed but extensive soft-tissue tracer extravasation. Five of nine patients with congenital lymphedema showed hypoplasia characterized by poorly defined lymphatic trunks, delayed depiction of regional nodes, and early and extensive extravasation of tracer. The other four patients showed aplasia, with absence of trunks, no depiction of nodes, and little or no tracer extravasation. LAS is technically simple to perform and requires no special training. Radiation exposure is minuscule, and the procedure is safe and without apparent side effects. For these reasons, whole-body LAS should be the preferred method for the initial assessment of congenital or acquired lymphedema.

Adolescent↗
PubMed1989

Massive lymphocele following pelvic lymphadenectomy for staging of prostatic cancer.

Two patients developed massive pelvic lymphoceles within 30 days of retroperitoneal node dissection for staging of prostatic cancer. Excised lymph nodes were negative for metastases. Both patients developed severe bilateral peripheral edema, and one developed pulmonary thromboembolism from intraluminal thrombi in the adjacent, compressed inferior vena cava. Each patient responded to unroofing of the cyst wall with either concomitant external or internal drainage.

Aged↗