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Biomedical subjects

C M Kirsch

Publications and source records attributed to C M Kirsch.

At least 73 records · Page 4Linked to original sources
PubMed1995

Radioimmunoscintigraphy of ovarian tumours with technetium-99m labelled monoclonal antibody-170: first clinical experiences.

The recently developed technetium-99m-labelled monoclonal antibody-170 (MAb-170) was designed for diagnostic use in patients suffering from gynaecological adenocarcinoma. Following in vitro studies which showed immunoreactivity of this antibody to more than 90% of human adenocarcinomas, the present investigation was initiated to verify its usefulness for radioimmunoscintigraphy of ovarian tumours. Most of the 30 patients participating in this study underwent immunoscintigraphy prior to first-look surgery. Biokinetic evaluation in two patients showed a plasma half-time of 18.9 h (mean value, n = 2, r = 0.98) and a biexponential total body curve with values of 7.7 h and 17 days (r = 0.98). The mean 24-h urinary excretion was 12% of the injected dose. Radioimmunoscintigraphy using the MAb-170 recognised 12 of 13 cases of adenocarcinoma of the ovaries, corresponding to an overall sensitivity of 92.3%. Specificity was 94.1% (16/17). The calculation of accuracy yielded a figure of 93.3% (28/30). Of 33 known lesions, 26 were visualised successfully; thus the locoregional sensitivity was 78.8%. Of 29 benign tumour sites, 28 showed no evidence of tracer accumulation, corresponding to a locoregional specificity of 96.6%. The smallest lesion visualised was an adenocarcinoma of the corpus uteri with a diameter of 1.5 cm. Technetium-99m labelled MAb-170 is a promising new radiopharmaceutical for immunoscintigraphy of ovarian adenocarcinoma.

Adenocarcinoma↗
PubMed1995

Intracavitary treatment of intrasellar cystic craniopharyngeomas with 90-Yttrium by trans-sphenoidal approach--a technical note.

Intracavitary irradiation of intrasellar cystic craniopharyngeomas by stereotactic cyst puncture and injection of radioactive solutions is not yet possible. Therefore we designed a new method which allows such intracavitary irradiation. Its principle is a transphenoidal approach with only a small bony opening of the sella floor, followed by cyst puncture, exclusion of cyst leakage by Metrizamid injection under x-ray control, injection of Y-90-colloid solution at a dosage which delivers a radiation of 200 Gy to the cyst wall, and finally tight closure of the puncture site using fibrin glue and gelfoam. This method has been used in three patients with good results (follow-up 12-15 months) and without complications. Even though long-term follow-up is not yet available, our preliminary results suggest that this method will be useful for future patients with intrasellar cystic craniopharyngeomas.

Adolescent↗
PubMed1995

Infection of a subclavian venous stent in a hemodialysis patient.

Endovascular stent placement to prevent restenosis after angioplasty is being increasingly employed. A 63-year-old hemodialysis patient with a right forearm gortex graft developed ipsilateral arm edema, and a right subclavian vein stenosis was diagnosed. This vascular stenosis was presumably secondary to previous placement of temporary access catheters. The subclavian vein stenosis was treated with angioplasty, endovascular stenting, and warfarin, which resulted in resolution of the arm edema. Three weeks after stenting, the patient developed fever to 104 degrees F, chills, and right arm and shoulder edema. All blood cultures grew Staphylococcus aureus, and an Indium-labeled white blood cell scan was positive at the sight of the subclavian stent. Infectious disease consultants recommended urgent removal of the infected stent, but the extensive surgery required posed considerable risk of major morbidity. We elected to conservatively treat the patient. With loss of all upper-extremity access sites, the patient was converted to peritoneal dialysis. Despite the patient's ambulatory status, a femoral venous Hickman catheter was placed and tunneled through the abdominal subcutaneous soft tissue. The patient received 9 weeks of antibiotics by the Hickman catheter with an infusion pump, and warfarin was continued. There has been complete clinical resolution of infection and subclavian thrombosis. Endovascular stents are being used more commonly, and this is the first description, to our knowledge, of a stent infection. The stent infection was successfully managed without surgical removal.

Bacteremia↗
PubMed1995

Tuberculous otitis media.

Tuberculous otitis media (TOM) is a rare cause of chronic suppurative infection of the middle ear and mastoid. The increasing incidence of tuberculosis in the United States may be associated with more cases of TOM than recognized previously. Patients typically have a chronic tympanic membrane perforation and ear drainage associated with progressive and profound hearing loss. The correct diagnosis starts with consideration of the disease in a patient with a chronic middle ear infection that is unresponsive to routine therapy. TOM should be strongly considered in patients with known or suspected tuberculosis and a chronic ear infection; however, the lack of evidence of tuberculosis elsewhere does not exclude the possibility of TOM. Appropriate evaluation for TOM includes a chest film, purified protein derivative (PPD) skin testing, and smears or cultures of otic secretions for mycobacteria. Operative biopsy may be required. Facial nerve paralysis is highly suggestive of TOM. Medical therapy with antituberculous drugs is usually effective, and surgery is rarely needed.

Antitubercular Agents↗
PubMed1995

A modified Abrams needle biopsy technique.

STUDY OBJECTIVE: To compare the diagnostic sensitivity of a modified Abrams needle pleural biopsy technique (A1) with the standard Abrams (A2) and Cope needle biopsy methods. The modified Abrams pleural biopsy technique consisted of suctioning each tissue sample into a syringe without removing the needle completely from the chest until the completion of the entire procedure. Both the standard Abrams and Cope needle techniques required needle removal from the chest after each pleural biopsy. DESIGN: Retrospective chart analysis. SETTING: Community teaching hospital affiliated with Stanford University. PATIENTS: Forty-seven patients (30 men and 17 women) with a mean age 44.5 years (range, 19 to 81 years) who were referred to a pulmonary consultation service for pleural biopsy. INTERVENTIONS: Two of us (C. M. K. and F. T. K.) used the modified Abrams technique and two of us (W. A. J. and A. C. C.) used the standard Abrams technique. The Cope needle was used as originally described. MEASUREMENTS: We recorded the type of pleural biopsy needle and technique used in each patient. Biopsy specimen diameter and number of tissue samples obtained, final diagnoses, and complications were recorded. RESULTS: The diagnostic sensitivity for tuberculous pleurisy was 82% for the modified Abrams method, 71% for the standard Abrams method, and 88% for the standard Cope technique (p > or = 0.3). There was no difference in size of tissue sample obtained (A1 vs A2), number of biopsies, or complications among the three methods of pleural biopsy. CONCLUSIONS: The modified method of Abrams needle biopsy demonstrates a diagnostic sensitivity for pleural tuberculosis (82%) that is equivalent to that for the standard Abrams or Cope methods.

Adult↗
PubMed1995

[Image fusion of MRI and immunoscintigraphy with MAb-170 in ovarian tumors].

In recent years multimodality imaging achieved growing importance. It is mostly performed by means of quite expensive software and hardware solutions. In the present pilot study a simple and low-cost procedure was developed to achieve image fusion in the pelvis. The image data of immunoscintigraphy (SPECT) and MRI were transferred to a personal computer and combined by standard software for image manipulation. The results in eleven patients with space-occupying lesions in the pelvis showed that adequate anatometabolic slices could be achieved. The results show a tendency to increased specificity and precision of multimodality imaging in comparison with SPECT and MRI alone. In conclusion, the low-cost solution, as developed by us, is feasible in clinical practice. Its results are reliable in clinical decision making.

Adult↗
PubMed1995

Dyspnea in ambulatory patients with SLE: prevalence, severity, and correlation with incremental exercise testing.

OBJECTIVE: We sought to determine the prevalence and severity of dyspnea, and to correlate dyspnea with clinical features and exercise limitation in ambulatory patients with systemic lupus erythematosus (SLE). METHODS: Twenty-five consecutive patients were evaluated with a validated pulmonary questionnaire, chest radiograph, 2-dimensional echocardiography, resting pulmonary function tests, and incremental exercise testing. RESULTS: Dyspnea was reported by 60% (95% CI 39-79) of patients; 20% (95% CI 7-40) had severe dyspnea (inability to dress without dyspnea) and 12% (95% CI 3-31) had moderate dyspnea (dyspnea after walking 100 yards). Compared to patients without dyspnea, patients with dyspnea were more likely to have had a history of clinical lupus involving the lung (80 vs 40%, p = 0.05), a lower total lung capacity (77.5 vs 94.8%, p = 0.002), and a reduced maximum oxygen consumption (VO2max of 53.4 vs 67.7%, p = 0.01). Patients with severe dyspnea and patients without dyspnea did not differ in duration of prednisone use, activity of disease, weight, or in frequency of Raynaud's phenomenon (p > 0.05). Only 4% of all patients had abnormal left ventricular motion on 2-dimensional echo; patients with moderate or severe dyspnea had normal left ventricular motion. Of the 5 patients with severe dyspnea, 4 (80%) had restrictive lung disease and 1 (20%) had an isolated diffusion defect. All patients with dyspnea had an abnormal exercise test, but so did 9/10 without dyspnea (p > 0.05). Severity of dyspnea correlated highly with maximum exercise tolerance measured by VO2max (R2 = 0.51, p = 0.0001). CONCLUSION: In ambulatory patients with SLE, dyspnea is common, frequently disabling, associated with a history of lupus involvement of the lung, and correlates highly with objective measures of exercise limitation.

Adult↗
PubMed1995

Prolonged confusion with nocturnal wandering arising from NREM and REM sleep: a case report.

A 51-year-old man with Machado-Joseph disease had a 3-year history of prolonged confusion following nightly nocturnal wandering. Polysomnography with videotape monitoring revealed 19- to 120-minute sleepwalking episodes emerging from non-rapid eye movement (NREM) sleep and occasionally from rapid eye movement (REM) sleep, followed by 22-47 minutes of prolonged confusion and disorientation. The patient also had a periodic limb movement disorder and obstructive sleep apnea syndrome. Excessive daytime sleepiness was evident by results from the Epworth Sleepiness Scale and Multiple Sleep Latency Test. A sleep-deprived electroencephalogram (EEG) and a polysomnogram with an expanded EEG montage before and during these episodes revealed no epileptiform activity. A contrast-enhanced brain magnetic resonance imaging (MRI) scan demonstrated findings consistent only with Machado-Joseph disease. The patient improved with a combination of temazepam and carbidopa-levodopa.

Cerebellum↗
PubMed1994

Clinical progressive supranuclear palsy: differential diagnosis by IBZM-SPECT and MRI.

In order to in vivo identify subgroups in eight patients with the clinical diagnosis of progressive supranuclear palsy (PSP), we have performed 123I-iodobenzamide single photon emission computed tomography (IBZM-SPECT), a nuclear medicine technique, to visualize dopamine D2 receptors in vivo, and high resolution (TE/TR 2900/20-90) magnetic resonance imaging (MRI) to evaluate morphological CNS changes. All patients exhibited similar clinical features including supranuclear vertical gaze palsy, especially of downward gaze, predominantly axial rigidity especially in the neck, bradykinesia, instability of balance with easy falls, and poor response to dopaminergic drugs. Specific striatal dopamine D2 receptor binding in IBZM-SPECT, as calculated by a basal ganglia to frontal cortex ratio (BG/FC) was reduced in 5 patients, but normal in 3 patients. In MRI, these 3 patients exhibited multiple hyperintense white matter lesions; 2 of them had no midbrain atrophy. In contrast, all 5 patients with reduced IBZM binding lacked multiple white matter lesions in MRI, but 4 of them showed marked midbrain atrophy. This pilot study with IBZM-SPECT for in vivo imaging of striatal dopamine D2 receptors and T2-weighted MRI supports published neuropathological findings that clinical signs of PSP appeared to be due to heterogeneous neuropathology.

Aged↗
PubMed1994

Indium-111 pentetreotide in the diagnostic work-up of patients with bronchogenic carcinoma.

In a prospective study we examined 38 patients with primary bronchogenic carcinoma to validate the use of indium-111 pentetreotide (IPT) as a diagnostic tool. Of these 38 patients, 25 had small cell lung cancer (SCLC) and 13, non-small cell lung cancer (NSCLC). The aim of the study was to investigate whether (a) the disease can be reliably detected, (b) IPT allows differentiation between SCLC and NSCLC and (c) IPT provides further information on metastatic disease. After giving their informed consent the patients were injected and imaged 4 and 24 h later using a planar whole-body technique. In addition single-photon emission tomography of the thorax and, if necessary, other areas of the body was performed at 24 h. In the 25 patients with SCLC 22 sites of primary tumour were correctly identified (true-positive, TP); one was false-negative (FN) and two were true-negative (TN), the patients being in full remission. Metastases were correctly identified in ten instances (lung, bone and brain), while the findings were FN in five cases. An additional six FN findings resulted in the area of the upper abdomen due to the physiological uptake in the liver, spleen and kidneys. In the 13 patients with NSCLC, ten findings were TP and 3 FN with respect to the primary tumour. Two FNs were squamous cell carcinoma, and one, adenocarcinoma. Metastases were TP in nine cases and FN in one.(ABSTRACT TRUNCATED AT 250 WORDS)

APUD Cells↗
PubMed1994

STA-MCA bypass in bilateral carotid artery occlusion: clinical results and long-term effect on cerebrovascular reserve capacity.

In this report we describe our experience with extracranial-intracranial arterial bypass surgery in a subgroup of 9 patients (mean age at surgery 61 +/- 9 years) with bilateral carotid artery occlusion, unilaterally symptomatic for occlusive cerebrovascular disease of haemodynamic origin. Haemodynamic insufficiency is characterized by a severely reduced cerebrovascular reserve capacity, measured with Xe-133 D-SPECT and acetazolamide challenge. Preoperatively, the mean baseline cerebral blood flow of 54 +/- 6 ml 100 g-1 min-1 did not change after challenge (54 +/- 5 ml 100 g-1 min-1) in the symptomatic hemisphere. Immediately following surgery an improvement in cerebrovascular reserve capacity for up to 14 +/- 8 ml 100 g-1 min-1 (1-2 years control) was noted. One patient subsequently died from a perioperative stroke, another patient died three months post-operatively from a myocardial infarction. Three patients were followed up to 4 years, four for 2 years. Patients with former transient ischaemic attacks had no further attacks, symptoms from PRIND or minor stroke did not progress further, nor did new symptoms occur. Unilateral extracranial-intracranial bypass surgery has a positive effect on clinical outcome in highly selected patients with bilateral carotid artery occlusion and cerebral ischaemia of haemodynamic origin.

Adult↗
PubMed1994

Comparison of 123I-IBZM SPECT and 11C-raclopride PET findings in patients with parkinsonism.

We compared the results of 123I-iodobenzamide (123I-IBZM) single photon emission computed tomography (SPECT) and 11C-raclopride positron emission tomography (PET) in 22 patients with parkinsonism. Nineteen patients were clinically diagnosed as having Parkinson's disease, two patients presented with atypical parkinsonism (i.e. clinical signs of Parkinson's disease and a subsequent poor response to dopamimetic drugs) and one patient was diagnosed as having Wilson's disease. All patients were drug naive. The SPECT data were semiquantitatively evaluated by calculating the ratios of striatal (basal ganglia, BG) IBZM binding to IBZM binding in various reference areas, i.e. the frontal cortex (BG/FC), the occipital cortex (BG/OC) and the cerebellum (BG/CE). In PET studies similar regions of interest were derived and ratios of striatal to cerebellar raclopride activity were determined. 123I-IBZM SPECT results significantly correlated to specific 11C-raclopride binding. This correlation was not significantly different when the frontal cortex (P = 0.05, r = 0.42), occipital cortex (P < 0.05), r = 0.44) or cerebellum (P 0.05, r = 0.45) were used as reference regions for non-specific IBZM binding. In comparison to PET ratios the SPECT BG/CE showed a higher variance (S.E.M. = 0.1) than BG/FC (S.E.M. = 0.05) and BG/OC (S.E.M. = 0.06) ratios. Thus, for the calculation of specific striatal IBZM binding one would prefer the frontal or occipital cortex as reference. However, when only those 19 patients with a clinical diagnosis of Parkinson's disease and increased specific 11C-raclopride binding were considered, no significant correlation was obtained. Qualitative changes of dopamine D2 receptor binding, such as asymmetry, were equally recognized.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1994

Treatment with D-penicillamine improves dopamine D2-receptor binding and T2-signal intensity in de novo Wilson's disease.

We report the results of in vivo striatal dopamine D2-receptor binding assessed by PET using 11C-raclopride (only one patient) and by single-photon emission computed tomography (SPECT) using 123I-iodobenzamide (123I-IBZM) and the findings of T2-weighted MRIs in two de novo Wilson's disease patients before and 4 months after initiation of D-penicillamine treatment. Before treatment, specific 11C-raclopride binding (only patient 1) was markedly reduced, with a putamen to cerebellum ratio of 1.99 (controls: 3.99 +/- 0.55, n = 15) and a caudate to cerebellum ratio of 2.52 (controls: 3.65 +/- 0.59, n = 15). Specific 123I-IBZM binding was reduced in both patients, with a basal ganglia to frontal cortex ratio of 1.25 (patient 1) and of 1.41 (patient 2) controls: 1.57 +/- 0.04, n = 5). After 4 months of therapy, 11C-raclopride-PET improved to a putamen to cerebellum ratio of 2.52 and a caudate to cerebellum ratio of 3.06 (patient 1). 123I-IBZM-SPECT revealed an increase of basal ganglia to frontal cortex ratios of 1.34 (patient 1) and 1.55 (patient 2). On heavily T2-weighted MRI sequences, hyperintense signal changes before therapy within the putamen (both patients), brainstem (only patient 1), and caudate (only patient 2) greatly diminished after treatment. Reduced striatal dopamine D2-receptor binding in these Wilson's disease patients improved under therapy, suggesting, in part, a reversible defect of striatal neurons.

Adolescent↗
PubMed1994

Controlled utilization of induced sputum analysis in the diagnosis of Pneumocystis carinii pneumonia.

We investigated the outcome and potential cost savings of a system designed to limit physician access to induced sputum analysis (ISA) for the diagnosis of Pneumocystis carinii pneumonia (PCP). Four respiratory medicine physicians screened all requests for ISA to determine the pretest likelihood of PCP. Twenty-two of 102 requests for ISA over a 1-year period were denied due to a low clinical suspicion for PCP. Seven individuals had a definitive alternative diagnosis confirmed and the remaining 15 were empirically treated for a presumptive diagnosis. All individuals were followed for at least 60 days or until death. None of the 22 individuals developed PCP during the follow-up period. We estimate that this approach saved $27,474, avoided exposure of health care workers to Mycobacterium tuberculosis, and was educational for the referring physicians.

AIDS-Related Opportunistic Infections↗
PubMed1994

The prevalence and response to therapy of Strongyloides stercoralis in patients with asthma from endemic areas.

STUDY OBJECTIVE: To evaluate the prevalence and response to therapy of Strongyloides stercoralis infection in immigrant patients with asthma from areas endemic for Strongyloides. DESIGN AND INTERVENTIONS: In all patients, we performed a complete history and physical examination, complete blood cell counts (CBC), S stercoralis serologic tests, spirometry, and evaluated three stool samples for ova and parasites. Patients treated for S stercoralis infection had follow-up CBC, spirometry, serologic tests, and at least three additional stool examinations to confirm eradication of the parasite. SETTING: Ambulatory and hospitalized patients who were referred to the respiratory medicine clinic of a general hospital for the evaluation and treatment of asthma. PATIENTS: Forty-five asthmatic adults, representing 12 endemic countries, ranging in age from 20 to 76 years, were prospectively evaluated. RESULTS: Six of 45 patients were infected with S stercoralis, which yielded a prevalence of 13 percent. The patients with asthma and S stercoralis infection had higher blood eosinophil counts (p = 0.006) and were younger (p = 0.006) compared with patients with only asthma. There was no difference in the duration of asthma, spirometry, or steroid use between the two groups. Patients with S stercoralis and asthma tended to be more recent immigrants (p = 0.05). Five of the six patients with S stercoralis agreed to be treated with thiabendazole but only four returned for follow-up evaluation. All four patients had eradication of S stercoralis infection confirmed by negative stool examinations and a decline in S stercoralis serology (160 +/- 25 percent vs 13 +/- 13 percent, p = 0.03). All four patients had a decline in total blood eosinophil counts (2,476 +/- 832 cells per cubic millimeter vs 551 +/- 138 cells per cubic millimeter, p = 0.03) without a clinical improvement in asthma. CONCLUSIONS: Our data suggest that patients with asthma from areas endemic for S stercoralis, who have elevated peripheral blood eosinophil counts, should be screened for S stercoralis infection. Successful eradication of S stercoralis, however, may not result in a clinical improvement of asthma.

Adult↗
PubMed1994

Pulmonary mucormycosis presenting as an endobronchial lesion.

A 56-year-old diabetic man presented with left upper lobe collapse and postobstructive pneumonitis. Fiberoptic bronchoscopy revealed an endobronchial mass obstructing the left mainstem bronchus. The lesion resembled a bronchial adenoma; however, cytologic and histologic examination revealed invasive mucormycosis. The patient was treated with intravenous amphotericin B followed by endoscopic laser surgery that relieved the obstruction.

Adenoma↗
PubMed1994

Improvement of cerebrovascular reserve capacity by EC-IC arterial bypass surgery in patients with ICA occlusion and hemodynamic cerebral ischemia.

Since the negative results of the international Bypass Study, extracranial-intracranial (EC-IC) bypass surgery is infrequently employed in the treatment of patients with cerebral ischemia. Newly acquired evidence concerning the pathophysiology of cerebral ischemia, however, has facilitated the identification of a small subgroup of patients with "hemodynamic" cerebral ischemia. Characteristically, these patients demonstrate severely impaired cerebrovascular reserve capacity due to occlusive disease and insufficient collateral blood supply. Over an 8-year period, 28 patients were defined by clinical and laboratory criteria as suffering from hemodynamic cerebral ischemia. All patients had recurring episodes of focal cerebral ischemia due to unilateral internal carotid artery occlusion. Computerized tomography (CT) scans either were normal or showed evidence of border zone infarction. The cerebrovascular reserve capacity was studied using 133Xe single-photon emission CT and acetazolamide challenge and was found to be significantly impaired in all patients. Based on these criteria, superficial temporal artery-middle cerebral artery anastomosis was performed to augment collateral flow to the ischemic hemispheres. Two patients died from myocardial infarction, one 4 days and the other 2 months postoperatively. One patient died from massive brain infarction and another suffered a postoperative stroke with incomplete recovery, resulting in a major morbidity and mortality rate of 14%. Minor morbidity included one patient with a subdural hematoma who subsequently recovered completely. The postoperative course was uneventful in 23 patients (82%). Over a mean follow-up period of almost 3 years, no patient had another episode of brain ischemia. Bypass patency was confirmed by postoperative angiography in 26 patients. Follow-up studies of cerebral blood flow (CBF) and cerebrovascular reserve capacity showed significant improvement of the latter while the resting CBF was essentially unchanged. In view of these findings, the authors conclude that EC-IC bypass surgery constitutes appropriate therapy for a subgroup of patients with recurrent focal cerebral ischemia, defined using the strict selection criteria employed in this study.

Adult↗