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Biomedical subjects

J A Freeman

Publications and source records attributed to J A Freeman.

At least 55 records · Page 3Linked to original sources
PubMed1996

The use of orthotopic neobladders in women undergoing cystectomy for pelvic malignancy.

Since June 1990, 21 women aged from 31 to 78 years (mean, 62 years) have undergone lower urinary tract reconstruction by means of an orthotopic Kock ileal reservoir following cystectomy. The indication for cystectomy included 15 patients with transitional-cell carcinoma of the bladder, 2 patients with urachal adenocarcinoma, 1 patient with cervical carcinoma, 1 patient with a mesenchymal tumor of endometrial origin, 1 patient with interstitial cystitis, and 1 patient with a fibrotic irradiated bladder. A total of four complications (two early and two late) have occurred in this group of patients. Excellent continence has been achieved during the day and night in 95% and 89% of the patients, respectively. In all, 16 of 20 patients void volitionally per urethra without a residual urine volume, whereas 4 patients require intermittent catheterization to empty the neobladder. All patients are completely satisfied. One patient died of metastatic transitional-cell carcinoma without a pelvic recurrence. Of the remaining 20 patients, 18 are currently alive without evidence of recurrent disease. Tumor recurrence has occurred in two patients: one patient with an extensive mesenchymal tumor developed a sigmoid recurrence necessitating conversion to a continent cutaneous diversion, and one patient developed a right iliac recurrence. This initial experience with lower urinary tract reconstruction in women has yielded extraordinary results, and we feel that the option of orthotopic reconstruction following cystectomy can safely be offered to selected female patients.

Adult↗
PubMed1996

The Kock ileal neobladder: updated experience in 295 male patients.

PURPOSE: Since 1986 orthotopic lower urinary tract reconstruction using the Kock ileal neobladder has been our diversion of choice in patients undergoing cystectomy. We report on the first 295 male patients undergoing this procedure from May 1986 through December 1993. MATERIALS AND METHODS: Complications were assessed, tabulated, subdivided into early (3 months or less postoperatively) and late types, and further categorized with respect to relationship to neobladder construction. Continence was individually evaluated via a detailed patient questionnaire. RESULTS: The pouch related early and late complication rates were 7.2 and 11.6%, respectively, and pouch related abdominal reoperation rates were 0.0 and 1.4%, respectively. Analysis of late pouch related complications revealed 4.1% stone formation and 2.4% afferent nipple stenosis rates, and only 1 case (0.3%) of ileal urethral anastomotic stricture. Of the patients 87 and 86% reported good or satisfactory daytime and nighttime continence, respectively. With regard to age, while overall continence was similar, a significantly greater percentage of patients younger than 70 years experience good daytime and nighttime continence relative to the older counterparts. Of the patients 5% perform regular intermittent catheterization and 2.7% required an artificial urinary sphincter due to unacceptable continence. CONCLUSIONS: The Kock orthotopic ileal neobladder can be constructed with minimal morbidity and extraordinary functional results. We strongly advocate its use when possible.

Adult↗
PubMed1996

Bilateral emphysematous pyelonephritis: a case report and review of the literature.

Emphysematous pyelonephritis is a rare, rapidly progressive, life-threatening infection of the renal parenchyma. It most commonly is unilateral, is found almost exclusively in diabetics, is associated with gas-forming coliform bacteria, and is characterized by the presence of gas within the renal parenchyma. Early aggressive therapy (combined medical and surgical) is the hallmark of successful treatment. A high index of suspicion coupled with radiographic imaging is essential to make a timely diagnosis and guide therapeutic intervention. Bilateral emphysematous pyelonephritis is an even more rare phenomena, with only 14 reported cases in the English literature and is associated with a high patient mortality. We herein present an additional case and review the literature as it pertains to bilateral emphysematous pyelonephritis. Appropriate care requires aggressive combined medical and surgical therapy in an attempt to preserve renal function without increased mortality.

Emphysema↗
PubMed1996

Pharmacokinetics and pharmacodynamics of cisatracurium in patients with end-stage liver disease undergoing liver transplantation.

We determined the pharmacokinetics and pharmacodynamics of cisatracurium, one of the 10 isomers of atracurium, in 14 patients with end-stage liver disease undergoing liver transplantation and in 11 control patients with normal hepatic and renal function undergoing elective surgery. Blood samples were collected for 8 h after i.v. bolus administration of cisatracurium 0.1 mg kg-1 (2 x ED95). Plasma concentrations of cisatracurium and its metabolites were determined using an HPLC method with fluorescence detection. Pharmacokinetic variables were determined using non-compartmental methods. Neuromuscular block was assessed by measuring the electromyographic evoked response of the adductor pollicis muscle to train-of-four stimulation of the ulnar nerve using a Puritan-Bennett Datex (Helsinki, Finland) monitor. Pharmacodynamic modelling was completed using semi-parametric effect-compartment analysis. Volume of distribution at steady state was 195 (SD 38) ml kg-1 in liver transplant patients and 161 (23) ml kg-1 in control patients (P < 0.05), plasma clearance was 6.6 (1.1) ml kg-1 min-1 in liver transplant patients and 5.7 (0.8) ml kg-1 min-1 in control patients (P < 0.05), but elimination half-lives were similar: 24.4 (2.9) min in liver transplant patients vs 23.5 (3.5) min in control patients (ns). The time to maximum block was 2.4 (0.8) min in liver transplant patients compared with 3.3 (1.0) min in control patients (P < 0.05), but the clinical effective duration of action (time to 25% recovery) was similar: 53.5 (11.9) min in liver transplant patients compared with 46.9 (6.9) min in control patients (ns). The recovery index (25-75% recovery) was also similar in both groups: 15.4 (4.2) min in liver transplant patients and 12.8 (1.9) min in control patients (ns). After cisatracurium, peak laudanosine concentrations were 16 (5) and 21 (5) ng ml-1 in liver transplant and control patients, respectively. In summary, minor differences in the pharmacokinetics and pharmacodynamics of cisatracurium in liver transplant and control patients were not associated with any clinically significant differences in recovery profiles after a single dose of cisatracurium.

Adult↗
PubMed1996

Physician and patient-oriented outcomes in progressive neurological disease: which to measure?

Outcomes can be described as either physician or patient-oriented depending on whose perspective is adopted. Both perspectives offer different yet complementary information. Traditionally, the effectiveness of interventions has been evaluated in terms of physician-oriented outcomes. recently there has been a growing recognition of the importance of the patient's point of view in assessing the outcomes of medical care. This is now held to be central to the monitoring and evaluation of health care. This review describes these two perspectives and compares the nature of the information provided by each.

Activities of Daily Living↗
PubMed1996

Outcomes-based research in neurorehabilitation: the need for multidisciplinary team involvement.

There is a need for the evaluation of neurorehabilitation to reflect the integrated multidisciplinary input which is fundamental to the intervention process. The importance of multidisciplinary involvement in achieving this is discussed with particular reference to multiple sclerosis, which exemplifies the many problems inherent in chronic neurological disease that must be addressed in the evaluation of the rehabilitation programme. Some of the current difficulties of research in this specialty are raised, and suggestions made for the future.

Brain Diseases↗
PubMed1996

Complications of the afferent antireflux valve mechanism in the Kock ileal reservoir.

PURPOSE: Since 1982 the Kock ileal reservoir has been the primary form of urinary diversion in patients requiring lower urinary tract reconstruction at our institution. The intussuscepted afferent nipple valve of the Kock ileal reservoir is designed to prevent reflux and protect the upper urinary tract. Problems associated specifically with the afferent antireflux valve have been few. We defined and characterized all complications associated with the Kock pouch antireflux nipple valve. MATERIALS AND METHODS: From November 1984 through July 1992, 802 patients underwent construction of a continent Kock ileal reservoir. All complications associated with the afferent antireflux valve in this group and their management were identified. RESULTS: Overall, 79 of 802 patients (9.8%) had a total of 84 complications of the afferent antireflux valve (10.4%), including formation of stones on staples securing the afferent nipple valve in 42 cases (5.2%), stenosis of the afferent valve in 35 (4.3%) and prolapse of the valve in 7 (0.9%). A total of 81 patients required surgical intervention to correct the afferent valve complication: 56 (7.0%) were treated endoscopically and 25 (3.1%) required open surgical revision. CONCLUSIONS: We report an overall complication rate of 10.4% associated with the afferent antireflux nipple valve in the Kock ileal reservoir. Most complications can be treated endoscopically without difficulty on an outpatient basis with the use of local sedation. With these results, and only a 3% incidence of open surgical correction of all afferent nipple problems, we encourage the continued use of the intussuscepted afferent nipple valve whenever continent urinary diversion is performed.

Adolescent↗
PubMed1996

Transitional cell carcinoma involving the prostate with a proposed staging classification for stromal invasion.

PURPOSE: We investigated the effect on survival of transitional cell carcinoma of the prostatic urethra, ducts and stroma, and determined the difference between prostatic stromal involvement occurring via direct extension through the bladder wall versus stromal invasion arising intraurethrally. MATERIALS AND METHODS: Between August 1971 and December 1989, 489 men underwent radical cystoprostatectomy for transitional cell carcinoma, including 143 (29.2%) identified with prostate involvement by transitional cell carcinoma, in the cystectomy specimen. Patients were separated into 2 groups: 1-19 in whom the primary bladder tumor extended full thickness through the bladder wall to invade the prostate (classified as P4a) and 2-124 in whom prostate involvement arose from within the prostatic urethra. RESULTS: Five-year recurrence-free and overall survival rates were 25 and 21%, respectively, in group 1 versus 64 and 55%, respectively, in group 2. In the 124 patients in group 2 survival rates were similar for those with prostatic urethral tumors or carcinoma in situ and ductal tumors (no stromal invasion). Five-year overall survival rates without and with stromal invasion were 71 and 36%, respectively (p < 0.0001). Transitional cell carcinoma of the prostatic urethra or ducts does not alter survival predicted by primary bladder stage alone. Prostatic stromal invasion arising intraurethrally significantly decreases survival, which varies based on primary bladder stage (64.6% in stage P1, 30.8% in stages P2/P3a and 13.6% in stage P3b, p = 0.0001). P1 bladder tumors with prostatic stromal invasion arising intraurethrally had a significantly higher survival rate than P4a tumors (64.6 versus 21%, p = 0.0001). P3b bladder tumors with stromal invasion had a survival rate similar to that of P4a tumors (p = 0.78). CONCLUSIONS: Prostatic urethral or ductal transitional cell carcinoma does not alter survival determined by primary bladder stage alone and it should not be classified as P4a. Prostatic stromal involvement arising intraurethrally significantly decreases survival predicted by primary bladder stage alone. P1 bladder tumors with prostatic stromal invasion arising intraurethrally have a significantly higher survival rate than P4a tumors and they should be separately classified as P1str. Muscle invasive (P2/P3a) bladder tumors with stromal invasion have a higher survival rate than P4a tumors (no statistical significance) and they should be designated separately (that is P2str). P3b bladder tumors with prostatic stromal invasion arising intraurethrally are indistinguishable from P4a tumors.

Adult↗
PubMed1996

Urethral recurrence in patients with orthotopic ileal neobladders.

PURPOSE: We identified the risk of urethral recurrence following cystectomy for transitions cell bladder carcinoma, stratified by pathological characteristics of the bladder tumor and type of urinary diversion. MATERIALS AND METHODS: The pathological characteristics and clinical courses of 174 men with a Kock ileal neobladder and 262 with a cutaneous urinary diversion were analyzed for time to urethral recurrence. RESULTS: Urethral recurrence was identified in 34 patients at a median of 1.6 years after cystectomy, for an overall 7.9% 5-year risk of recurrence. Carcinoma in situ (p = 0.71) and multifocality (p = 0.17) did not independently confer an increased risk of recurrence. Prostatic urethral involvement, particularly stromal invasion, significantly increased the probability of recurrence (p < 0.001). Patients with a Kock ileal neobladder had a significantly lower probability of recurrence compared to those with cutaneous diversion (p = 0.015), even when associated with prostatic urethral involvement. CONCLUSIONS: Patients with a Kock ileal neobladder have a lower risk of urethral recurrence than those with cutaneous urinary diversion, even when associated with a high risk pathological condition predicting increased risk of urethral recurrence.

Aged↗
PubMed1995

Radical cystectomy for high risk patients with superficial bladder cancer in the era of orthotopic urinary reconstruction.

BACKGROUND: Many patients with aggressive clinically superficial bladder cancer ultimately die of their cancer, due in part to resistance to undergo radical cystectomy. Radical cystectomy is usually curative for patients with pathologic superficial tumors. Orthotopic urinary reconstruction has lessened the morbidity and lifestyle changes in patients after cystectomy, and may increase patient acceptance of cystectomy as therapy for high risk superficial tumors. METHODS: A retrospective analysis was performed on 182 patients with clinically superficial bladder cancer (Ta, Tis, T1) who had radical cystectomy between 1971 and 1989, to determine the incidence of pathologic upstaging and to assess overall survival, cause-specific survival, and recurrence free survival. Indications for cystectomy included failure of intravesical chemo- or immunotherapy, high grade lamina propria invasive tumors, presence of bladder diverticulae, spread of superficial tumors into the prostatic urethra, and endoscopically uncontrollable tumors. RESULTS: Pathologic upstaging to muscle-invasive or metastatic tumors occurred in 34% of patients, and of these, only half remained organ confined. Metastases were present in 8% of patients at the time of cystectomy. Mucosa-confined tumors were upstaged only 19% of the time, whereas tumors demonstrating lamina propria invasion (T1) were upstaged 40% of the time. Pathologic upstaging to muscle-invasive or metastatic disease was significantly associated with a decreased probability of survival (P = 0.042). With a median follow-up of 7.2 years, overall survival was estimated to be 86%, 72%, and 47%, and recurrence free survival 90%, 83%, and 77% at 2, 5, and 10 years, respectively. CONCLUSIONS: Pathologic upstaging to muscle-invasive or metastatic tumors occurs in one third of highly selected patients with clinically superficial bladder cancer who have had radical cystectomy, half of whom have extravesical disease. Survival is significantly decreased in this group of upstaged patients. With the alternative of orthotopic urinary diversion available to most men and women requiring cystectomy, radical cystectomy should be considered a viable alternative to continued conservative measures for selected patients with aggressive superficial bladder tumors.

Aged↗
PubMed1995

Epidermal cell cycle and region-specific growth during segment development in Artemia.

During larval development in instar IV brine shrimp, segment 1 grew by cell replication and cell differentiation. Cell cycle analysis revealed that the cell cycle was synchronized with the molt cycle. Mitosis occurred late in the instar and S phase began at hr 6 of the following instar. Three populations of cells comprised the dorsal integument. The medial-dorsal region did not grow. Cell enlargement occurred in the dorsal-lateral population while cell replication took place in the lateral population. The limb bud (ventral surface) grew in width by replication in the distal population, and in height by enlargement of the general epidermal cells in the proximal population. Expansion of each region of the integument was proportional to the cell growth in that region. Moreover, both growth processes were dependent on the level of nutrients and were enhanced by diets enriched in polyunsaturated fatty acids. A nutrient-dependent growth control point occurred in the G1 period. The commitment to replication and differentiation occurred by hr 2 of instar IV. The findings show that integumental growth is a result of region-specific cell growth processes which are controlled by nutrients during the G1 period.

Animal Nutritional Physiological Phenomena↗
PubMed1995

Radical cystectomy and lower urinary tract reconstruction after cardiac allograft transplantation.

The risk of a malignancy developing as a consequence of long-term immunosuppression after allograft transplantation is well documented. To our knowledge we report on the first cardiac allograft recipient to undergo radical cystectomy with lower urinary tract reconstruction using a continent Kock ileal reservoir with bilateral ureteroileal urethrostomy for squamous cell carcinoma that developed 4 years after transplantation.

Carcinoma, Squamous Cell↗
PubMed1995

Incidence of occult lymph node metastases in pathological stage C (pT3N0) prostate cancer.

PURPOSE: To determine the incidence of occult lymph node metastases in patients with stage pT3N0 prostate cancer. MATERIALS AND METHODS: Lymph nodes from 95 patients with stage pT3N0 prostate cancer were analyzed by immunohistochemistry for extrinsic epithelial cells using epithelial-specific monoclonal antibodies. The extrinsic epithelial cells were also tested for prostate specific antigen expression. RESULTS: Occult lymph node metastases were identified in 15 cases (16%) and were more frequent in patients with high primary Gleason grade tumors and seminal vesicle invasion (p = 0.03). In all cases the extrinsic cells were of prostate origin based on prostate specific antigen expression. CONCLUSIONS: Occult lymph node metastases can be detected in a substantial proportion of patients with stage pT3N0 prostate cancer, are associated with known predictors of disease progression, and may be useful in identifying patients at risk for recurrence and progression.

Humans↗
PubMed1995

Evaluation of a new method for determining tracheal tube length in children.

Most paediatric tracheal tubes are marked in centimetres from the tip. In 105 children, nasotracheal tube length was set at the level of the vocal cords such that all 3.0 and 3.5 mm internal diameter tubes were placed with the 3 cm mark at the cords, all 4.0 and 4.5 tubes were set at 4 cm at the cords and all 5.0 and 5.5 tubes were set at 5 cm at the cords. Subsequent chest X ray showed that 79% of the tracheal tubes were in the ideal midtracheal position, one tube was marginally short and 20% of the tubes were marginally long. Neither bronchial intubation nor accidental extubation occurred in any subject. This is an effective method to determine tracheal tube length which may be used for both oral and nasal intubation.

Adolescent↗
PubMed1995

Learning and generalization in radial basis function networks.

The two-layer radial basis function network, with fixed centers of the basis functions, is analyzed within a stochastic training paradigm. Various definitions of generalization error are considered, and two such definitions are employed in deriving generic learning curves and generalization properties, both with and without a weight decay term. The generalization error is shown analytically to be related to the evidence and, via the evidence, to the prediction error and free energy. The generalization behavior is explored; the generic learning curve is found to be inversely proportional to the number of training pairs presented. Optimization of training is considered by minimizing the generalization error with respect to the free parameters of the training algorithms. Finally, the effect of the joint activations between hidden-layer units is examined and shown to speed training.

Artificial Intelligence↗
PubMed1995

Orthotopic urinary diversion.

Internal reservoirs constructed from segments of stomach, ileum, the ileocecal region, and the sigmoid colon provide a reliable form of continent diversion.

Carcinoma, Transitional Cell↗
PubMed1995

Indications for lower urinary tract reconstruction in women after cystectomy for bladder cancer: a pathological review of female cystectomy specimens.

PURPOSE: In an attempt to identify women who may be appropriate candidates for orthotopic lower urinary tract reconstruction, archival cystectomy specimens from female patients undergoing cystectomy for primary bladder cancer were reviewed. These pathological findings should provide a better understanding of tumor involvement at the bladder neck (vesicourethral junction) and urethra in women with transitional cell carcinoma of the bladder. MATERIALS AND METHODS: Cystectomy specimens of 67 consecutive women undergoing surgery for biopsy proved transitional cell carcinoma of the bladder between July 1982 and July 1990 were pathologically reviewed. RESULTS: Histological evidence of tumor (carcinoma in situ or gross carcinoma) involving the urethra was present in 9 patients (13%). Tumor was confined to the proximal and mid urethra, and the distal urethra was not involved. All patients with carcinoma involving the urethra had concomitant evidence of carcinoma involving the bladder neck. A total of 17 patients (25%) had tumor involvement of the bladder neck and those with an uninvolved bladder neck also had an uninvolved urethra. The association between the presence of tumor in the bladder neck and urethra was highly significant (p < or = 0.00012). Tumor involving the bladder neck and urethra tended to be more commonly associated with high grade and stage tumors, and node-positive disease. CONCLUSIONS: Although the fate of the retained urethra following cystectomy for bladder cancer in women is unknown, these results show that women with transitional cell carcinoma of the bladder without evidence of tumor involving the bladder neck are at low risk for urethral malignancy. These patients may be offered lower urinary tract reconstruction that includes preservation of and diversion through the urethra (orthotopic diversion). Urethral surveillance will be necessary, as it is in men after orthotopic urinary diversion.

Carcinoma in Situ↗