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Biomedical subjects

J A Murray

Publications and source records attributed to J A Murray.

At least 91 records · Page 5Linked to original sources
PubMed1999

Colonic resection in trauma: colostomy versus anastomosis.

OBJECTIVES: The management of colonic trauma is well established for simple injuries with primary repair, and ileocolostomy for right-sided injuries that undergo colonic resection. Segmental colon resection for injuries to the left colon can be managed with either an end colostomy or primary anastomosis. A retrospective review was performed to evaluate the outcome and complications associated with colonic resection for trauma to determine the risk factors associated with anastomotic leakage. METHODS: A retrospective review included patients undergoing colonic resection for trauma. The patients were stratified into colostomy, ileocolostomy, and colocolostomy groups. Patient demographics and colon-related complications were collected. Comparison between the colostomy and colocolostomy groups was performed to determine the difference in outcome. The outcome of right-sided colon injuries managed by either an ileocolonic or colocolonic anastomosis was compared. Analysis was performed to identify the factors associated with an increased risk of anastomotic leakage. RESULTS: One hundred forty patients over a 66-month period were included in the analysis. Overall, 41% (57 of 140) of patients developed a colon-related complication; 28% (39 of 140) of patients developed an abscess. Overall, the anastomotic leak rate was 13% (7 of 56) in the colocolostomy group, 4% (2 of 56) in the ileocolostomy group. Right-sided colon injuries managed with a colocolonic anastomosis had a higher incidence of anastomotic leakage than ileocolonic anastomosis, i.e., 14 versus 4% respectively. Of the seven patients who developed a leak from a colocolonic anastomosis, two patients died (29%). Univariate analysis identified an Abdominal Trauma Index Score > or = 25 (p = 0.03) or hypotension in the emergency department (p = 0.001) to be associated with increased risk of developing an anastomotic leak from a colocolonic anastomosis. CONCLUSION: Colonic injuries that are managed with resection are associated with a high complication rate regardless of whether an anastomosis or colostomy is performed. Colonic resection and anastomosis can be performed safely in the majority of patients with severe colonic injury, including injuries to the left colon. For injuries of the right colon, an ileocolostomy has a lower incidence of leakage than a colocolonic anastomosis. For injuries to the left colon, there remains a role for colostomy specifically in the subgroups of patients with a high ATI or hypotension, because these patients are at greater risk for an anastomotic leak. The role of resection and primary anastomosis versus colostomy in colonic trauma requires further investigation.

Adult↗
PubMed1999

Value of complete cervical helical computed tomographic scanning in identifying cervical spine injury in the unevaluable blunt trauma patient with multiple injuries: a prospective study.

OBJECTIVE: To evaluate the role of routine helical computed tomographic (CT) scan of the entire cervical spine in high-risk patients with multiple injuries. METHODS: Prospective study of patients with severe blunt multiple injuries, requiring intensive care unit admission and CT scan of another body area besides the cervical spine. All patients were evaluated by means of standard cervical spine radiography. A complete cervical spine CT scan was performed during the same trip to the scanner in which other body areas were evaluated. The plain films and the CT scans were read by a radiologist in a blinded manner. RESULTS: Fifty-eight patients fulfilled the criteria for inclusion in the study. The mean Glasgow Coma Scale score was 8.9 and the mean Injury Severity Score was 24.1. Twenty patients (34.4%) had cervical spine injuries (12 stable and 8 unstable injuries). Plain radiography missed eight injuries (including three unstable) and its sensitivity was 60%, specificity 100%, positive predictive value 100%, and negative predictive value 85.1%. The helical CT scan missed two spinal injuries (both stable) and its sensitivity was 90%, specificity was 100%, positive predictive value = 100%, negative predictive value = 95%. CONCLUSION: There is a high incidence of cervical spine injuries in the severe, blunt, multiple-injury, unevaluable patients requiring intensive care unit admission. Plain radiography alone is not reliable in diagnosing many cervical spine injuries. Complete cervical spiral computed tomography is superior to plain radiography. It is suggested that in this selected group of patients, both plain radiography and spiral computed tomography should be performed.

Adolescent↗
PubMed1999

Distinct cyclin D genes show mitotic accumulation or constant levels of transcripts in tobacco bright yellow-2 cells.

The commitment of eukaryotic cells to division normally occurs during the G1 phase of the cell cycle. In mammals D-type cyclins regulate the progression of cells through G1 and therefore are important for both proliferative and developmental controls. Plant CycDs (D-type cyclin homologs) have been identified, but their precise function during the plant cell cycle is unknown. We have isolated three tobacco (Nicotiana tabacum) CycD cyclin cDNAs: two belong to the CycD3 class (Nicta;CycD3;1 and Nicta;CycD3;2) and the third to the CycD2 class (Nicta;CycD2;1). To uncouple their cell-cycle regulation from developmental control, we have used the highly synchronizable tobacco cultivar Bright Yellow-2 in a cell-suspension culture to characterize changes in CycD transcript levels during the cell cycle. In cells re-entering the cell cycle from stationary phase, CycD3;2 was induced in G1 but subsequently remained at a constant level in synchronous cells. This expression pattern is consistent with a role for CycD3;2, similar to mammalian D-type cyclins. In contrast, CycD2;1 and CycD3;1 transcripts accumulated during mitosis in synchronous cells, a pattern of expression not normally associated with D-type cyclins. This could suggest a novel role for plant D-type cyclins during mitosis.

Animals↗
PubMed1999

Biphasic relaxation of the opossum lower esophageal sphincter: roles of NO., VIP, and CGRP.

Vasoactive intestinal polypeptide (VIP) and nitric oxide (NO.) are thought to mediate lower esophageal sphincter (LES) relaxation. Transverse muscle strips from the opossum LES were used to test this hypothesis. Electrical field stimulation (EFS) produced a biphasic LES relaxation: a rapid component during the stimulus was more prominent at lower stimulus frequencies, and a sustained component was more prominent at higher frequencies. N(omega)-nitro-L-arginine and hemoglobin inhibited the rapid component but affected the sustained component less. Exogenous VIP decreased LES tone. A number of purported VIP antagonists blocked neither VIP-induced nor EFS-induced relaxation of the LES. The calcitonin gene-related peptide (CGRP) antagonist CGRP-(8-37) did not alter EFS-induced LES relaxation. EFS-induced relaxation of opossum LES muscle is biphasic, and the initial, rapid component of the relaxation is mediated primarily by NO. The mediator of the sustained component was not identified.

Animals↗
PubMed1999

Gingival hemorrhage, myelodysplastic syndromes, and acute myeloid leukemia. A case report.

Myelodysplasia syndrome (MDS) presenting as spontaneous gingival hemorrhage is described. Gingival hemorrhage is recognized as a symptom of MDS, a rare group of potentially fatal hematological disorders, but it has not previously been documented as a presenting sign. The diagnostic pitfalls are discussed with the case, and the need for careful interpretation of laboratory findings in conjunction with clinical signs is emphasized. Finally, the MDSs are defined, classified and discussed with respect to their relevance to the clinical periodontist, from a diagnostic, therapeutic, and management standpoint.

Acute Disease↗
PubMed1999

Esophageal cancer and Barrett's esophagus. How to approach surveillance, treatment, and palliation.

Esophageal cancer is an increasingly common problem with poor survival rates in patients who present with symptoms. The underlying cause for the progressive rise in the incidence of this cancer remains to be determined. Reducing mortality to requires either early identification of patients or prevention for progression from Barrett's esophagus to cancer. Significant questions remain regarding the cost effectiveness of endoscopic and nonendoscopic methods of surveillance. For local esophageal cancer, the traditional approach has been surgical resection. Radiation therapy is sometimes used alone, but chemotherapy alone is not helpful. Combination therapy consisting of chemotherapy along with surgery or radiation may be the best choice. A new option being tried in disease limited to the mucosa is ablation of neoplastic tissue with endoscopic techniques. Treatment of advanced-stage esophageal cancer is limited and may be hampered by the presence of micrometastatic disease. Morbidity and quality-of-life issues need to be considered and discussed with patients, given the current short survival time of most patients with esophageal cancer.

Adenocarcinoma↗
PubMed1999

Non-metastatic Ewing's sarcoma: twenty years of experience suggests that surgery is a prime factor for successful multimodality therapy.

Eighty-five patients (37 female, 48 male; median age 14 years) with non-metastatic Ewing's sarcoma received definitive treatment at the University of Texas M.D. Anderson Cancer Center between 1969 and 1988. Multidisciplinary therapy was administered as follows: combination chemotherapy (CC) and local radiotherapy (XRT): 65 patients; CC, XRT and surgery, 19 patients; and XRT and surgery, 1 patient. This permitted a 10-20 year follow-up for 75% of our patients. The overall survival at 5 and 10-20 years was 46.1%, and 37.2%, respectively. At 5 years, 80.5% of live patients had control of local disease. The influence of sex, age, ethnicity, primary site, size, lactic dehydrogenase (LDH) level, presence or absence of systemic symptoms, and XRT dose (<60 Gy and </=60 Gy) was analyzed and was not found to be of prognostic significance in survival. The presence of a soft tissue mass at diagnosis was found to be a significant unfavorable prognostic variable. Nine of 11 patient who underwent resection after CC and/or XRT had residual tumor in the surgical specimen. Patients who received surgery as part of the planned treatment of their primary tumor had significantly better local control and disease-free survival than those who did not undergo resection. Complications in long-term survivors are described.

Adolescent↗
PubMed1999

Abdominal computed tomography scan in pediatric blunt abdominal trauma.

The purpose of this study was to evaluate the role of abdominal CT scans in pediatric patients and correlate the findings with the clinical examination. A 2-year retrospective review of 88 patients with an abdominal CT scan after blunt trauma was performed. Seventy-two patients were identified with complete clinical examination data available. In its ability to predict the need for surgery, the CT scan had a sensitivity of 67 per cent and a negative predictive value of 98.7 per cent. The combination of the clinical examination and the CT scan findings did not miss any significant injuries. No patient with a soft, nontender abdomen and a negative CT scan required an abdominal operation. We conclude that the CT scan alone may miss clinically significant injuries. In blunt abdominal trauma in the pediatric population, the CT scan findings should be coupled with the clinical examination to ensure that no significant abdominal injuries are missed.

Abdominal Injuries↗
PubMed1999

Complex repair for the management of duodenal injuries.

The management of duodenal injuries is a subject of ongoing debate. In this study we attempt to describe duodenum-related morbidity (DRM) after primary repair or complex repair (CR) and to identify risk factors for development of complications. The medical records of 145 consecutive patients admitted to Los Angeles County + University of Southern California Medical Center with duodenal injuries between January 1991 and December 1997 were reviewed. Fifty-four (37%) died within 24 hours of admission because of associated injuries. The remaining 91 were subjected to univariate and multivariate analysis. Of them, 66 (72.5%) developed complications and 3 (3%) died. CR was used in 32 (35%) patients and with increasing frequency as the grade of duodenal injury increased. DRM rate was overall low (9%) and not different between low-grade and high-grade duodenal injuries. This occurred despite a significant increase in Injury Severity Score and abdominal Abbreviated Injury Score in patients with more severe duodenal injuries. Patients with overall complications had higher Injury Severity Scores, higher abdominal Abbreviated Injury Scores, and more severe duodenal injuries. We conclude that duodenal injuries are frequently associated with other highly lethal injuries. Liberal use of CR in patients with more severe duodenal injuries prevents DRM.

Abdominal Injuries↗
PubMed1999

Approaching the patient with chronic malabsorption syndrome.

The causes of chronic malabsorption may be categorized as decreased intestinal absorption, most commonly caused by celiac sprue; or maldigestion caused by pancreatic insufficiency. The initial step in the evaluation of these patients should include stool studies to confirm fat malabsorption. If fat malabsorption is confirmed, endoscopy with small-bowel biopsies and aspirates for bacterial culture usually follows. A normal endoscopic examination should lead to assessment of pancreatic function. In the setting of normal pancreatic function and the absence of bile acid deficiency, a barium radiograph of the small bowel should be made, looking for anatomical abnormalities. Celiac sprue is an intolerance to gluten caused by a combination of genetic, environmental, and immunologic factors. It classically causes malabsorption. However, it is likely that many patients who exhibit only minor manifestations of the disease go unrecognized and untreated. A presumed diagnosis of celiac sprue is confirmed after a clinical and endoscopic response to a gluten-free diet. Serological markers are available with high degrees of sensitivity and specificity, but duodenal biopsy remains the gold standard for diagnosis. A minority of patients are unresponsive to a gluten-free diet, and intestinal lymphoma should be suspected in these cases.

Adult↗
PubMed1998

Timing of fracture fixation in blunt trauma patients with severe head injuries.

BACKGROUND: Early fracture fixation in blunt trauma patients is suggested to decrease postoperative morbidity by allowing early mobilization and reducing the release of harmful inflammatory mediators. Some studies have challenged this concept in the presence of severe associated injuries, and especially head trauma. METHODS: The records of 47 consecutive blunt trauma patients with severe head injuries, as defined by a Glasgow Coma Score (GCS) < or =8 and a head Abbreviated Injury Score (AIS) > or =3, and long bone fractures requiring surgical fixation were reviewed. The study population was divided into the early fixation (EF) group, consisting of 22 patients who underwent fracture fixation within 24 hours of admission (mean time 17 +/- 8.5 hours); and the late fixation (LF) group, consisting of 25 patients, who had orthopedic repair at a later time (mean 143 +/- 178 hours). RESULTS: The two groups were similar in terms of overall injury severity, neurologic injuries, hemodynamic and neurologic status on admission, and operations received. Patients in the EF group had a higher injury severity of extremity fractures (extremity AIS: 2.9 +/- 0.2 versus 2.4 +/- 0.5, P = 0.0002) and a higher incidence of open fractures (72% versus 36%, P = 0.02). There was no difference in intraoperative and postoperative hypoxic and hypotensive episodes. Neurologic, orthopedic, and general complications were the same between the two groups. The mean GCS on discharge was 12 +/- 3 for both groups with equal distribution among patients. Although there was a trend toward longer hospital stay (25 +/- 17 versus 17 +/- 10 days, P = 0.057) among LF patients, mechanical ventilation days, length of stay, and mortality were not different. CONCLUSIONS: Timing of fracture fixation in this group of blunt trauma patients with severe head injuries did not influence morbidity, mortality, or neurologic outcome.

Adolescent↗
PubMed1998

Penetrating thoracoabdominal trauma.

Penetrating injuries to the thoracoabdominal region represent a complex and diverse population of injuries. The clinician managing such cases must be able to consider all potential injuries, rapidly recognize life-threatening sequelae, and precisely diagnose and quickly manage these patients. The diverse nature of some of the potential presentations of patients with penetrating thoracoabdominal trauma is discussed. The most recent advances and controversies involving the evaluation and management of patients with penetrating thoracoabdominal trauma are also discussed.

Abdominal Injuries↗
PubMed1998

The fate of colonic suture lines in high-risk trauma patients: a prospective analysis.

BACKGROUND: Some authors have stated that virtually all patients with penetrating colon injuries can be safely managed with primary repair. The purpose of this study is to test the applicability of this statement to all trauma patients by evaluating a protocol of liberal primary repair applied to a group of patients at high risk of septic complications. STUDY DESIGN: We performed a prospective analysis of a liberal policy of primary repair applied to patients at high risk of developing postoperative septic complications admitted to a Level I urban trauma center. Inclusion criteria were full-thickness colon injury and at least one of three additional risk factors: 1) Penetrating Abdominal Trauma Index (PATI) of 25 or more; 2) 6 U or more of blood transfused; and 3) 6 hours or longer elapsed between injury and surgery. RESULTS: Of 56 patients studied (55 male, 1 female, average age 28.8 years, mean PATI 35.3), the vast majority had gunshot wounds as the mechanism of injury (89%), PATI 25 or more (95%), multiple blood transfusions (77%), an Injury Severity Score greater than 15 (66%), and a need for postoperative ventilatory support in the surgical intensive care unit (61%). Of 56 patients, 49 (88%) had at least one colonic suture line, and 25 patients (45%) had destructive colon injuries requiring resection. Intraabdominal infections occurred in 15 (27%) of 56 patients and colon suture line disruption occurred in 3 (6%) of 49. Two of these patients developed multisystem organ failure, and death was directly related to breakdown of their colonic anastomosis. CONCLUSIONS: On the basis of these data and the relative infrequency of patients in prospective randomized trials with destructive colon injuries, we believe there is still room for consideration of fecal diversion in patients in high-risk categories with destructive colon injuries requiring resection.

Adolescent↗
PubMed1998

Lethal abdominal gunshot wounds at a level I trauma center: analysis of TRISS (Revised Trauma Score and Injury Severity Score) fallouts.

BACKGROUND: The TRISS methodology (composite index of the Revised Trauma Score and the Injury Severity Score) has become widely used by trauma centers to assess quality of care. The American College of Surgeons recommends including negative TRISS fallouts (fatally injured patients predicted to survive by the TRISS methodology) as a filter to select patients for peer review. The purpose of this study was to analyze the TRISS fallouts among patients with lethal abdominal gunshot wounds admitted to a level I trauma center. STUDY DESIGN: All patients categorized as TRISS fallouts admitted from January 1995 through December 1996 were analyzed. RESULTS: During the study period, 848 patients with abdominal gunshot wounds were admitted. Of the 108 patients with any sign of life on admission who subsequently died, 39 (36%) were TRISS fallouts. The patients were largely young (mean age, 29 years) and male (87%), received rapid transport (mean scene time, 11 minutes), and had an attending-led trauma-team response (<5 minutes, 87%). Major vascular (80%) and multiple intraabdominal injuries (90%) predominated. The mean Penetrating Abdominal Trauma Index was 40.3. The mean TRISS probability of survival was 89%. The peer-review process deemed the deaths to be nonpreventable in 38 patients (97%) and potentially preventable in one patient (3%). CONCLUSIONS: "TRISS fallouts" were predominantly patients who died despite receiving rapid prehospital transport, rapid senior-level trauma-team response, and surgical intervention for a serious complex of injuries. We conclude that without regional adjustment of coefficients used to predict the probability of survival, the TRISS methodology is of limited use in patients with abdominal gunshot wounds.

Abdominal Injuries↗
PubMed1998

Inability of an aggressive policy of thromboprophylaxis to prevent deep venous thrombosis (DVT) in critically injured patients: are current methods of DVT prophylaxis insufficient?

BACKGROUND: Deep venous thrombosis (DVT) in severely injured patients is a life-threatening complication. Effective and safe thromboprophylaxis is highly desirable to prevent DVT. Low-dose heparin (LDH) and sequential compression device (SCDs) are the most frequently used methods. Inappropriate use of these methods because of the nature or site of critical injuries (eg, brain lesion, solid visceral or retroperitoneal hematoma, extremity fractures) may lead to failure of DVT prophylaxis. STUDY DESIGN: A prospective study was performed to evaluate the efficacy of a policy of aggressive use of LDH and SCDs in patients who are at very high risk for DVT. From January 1996 to August 1997, 200 critically injured patients were followed by weekly Doppler examinations to detect DVT at the proximal lower extremities. Only 3 patients did not receive any thromboprophylaxis. SCDs were applied in 97.5% and LDH was administered to 46% of the patients; 45% had both. RESULTS: DVT was found in 26 patients (13%). The majority (58%) developed DVT within the first 2 weeks, but new cases were found as late as 12 weeks after admission. The incidence of DVT was the same among patients who had SCDs only or a combination of LDH and SCDs. Mechanism of injury, type and number of operations, site of injury, Injury Severity Score, and the incidence of femoral lines were not different between patients with and without DVT. Differences were found in the severity of injury to the chest and the extremities and the need for high-level respiratory support. Patients with DVT had prolonged ICU and hospital stays (on average, 34 and 49 days, respectively) and a high mortality rate (31%). CONCLUSIONS: The incidence of DVT remains high among severely injured patients despite aggressive thromboprophylaxis. A combination of LDH and an SCD showed no advantage over SCD alone in decreasing DVT rates. Risk factors in this group of patients who are already at very high risk are hard to detect; Doppler examinations are justified for surveillance in all critically injured patients. Current methods of thromboprophylaxis seem to offer limited efficacy, and the search for more effective methods should continue.

Adult↗
PubMed1998

Occult injuries to the diaphragm: prospective evaluation of laparoscopy in penetrating injuries to the left lower chest.

BACKGROUND: To evaluate the incidence of occult diaphragmatic injuries and investigate the role of laparoscopy in patients with penetrating trauma to the left lower chest who lack indications for exploratory celiotomy other than the potential for a diaphragm injury. STUDY DESIGN: Patients with penetrating injuries to the left lower chest who were hemodynamically stable and without indications for a celiotomy were prospectively evaluated with diagnostic laparoscopy to determine the presence of an injury to the left hemidiaphragm. Diagnostic laparoscopy was performed in the operating room under general anesthesia. RESULTS: One-hundred-ten patients (94 stab wounds, 16 gunshot wounds) were evaluated with laparoscopy. Twenty-six (24%) diaphragmatic injuries were identified (26% for stab wounds and 13% for gunshot wounds). Comparison of patients with diaphragmatic injuries with those without diaphragmatic injuries demonstrated a slightly greater incidence of hemo/pneumothoraces (35% versus 24%, NS). The incidence of diaphragmatic injuries in patients with a normal chest x-ray was 21% versus 31% for patients with a hemo/pneumothorax. An elevated left hemidiaphragm was associated with a diaphragmatic injuries in only 1 of 7 patients (14%). The incidence of diaphragmatic injuries was similar for anterior, lateral, and posterior injuries (22%, 27%, and 22% respectively). CONCLUSIONS: The incidence of occult diaphragmatic injuries in penetrating trauma to the left lower chest is high, 24%. These injuries are associated with a lack of clinical and radiographic findings, and would have been missed had laparoscopy not been performed. Patients with penetrating trauma to the left lower chest who do not have any other indication for a celiotomy should undergo videoscopic evaluation of the left hemidiaphragm to exclude an occult injury.

Adolescent↗
PubMed1998

The maize retinoblastoma protein homologue ZmRb-1 is regulated during leaf development and displays conserved interactions with G1/S regulators and plant cyclin D (CycD) proteins.

Recent discoveries of plant retinoblastoma (Rb) protein homologues and D-type cyclins suggest that control of the onset of cell division in plants may have stronger parallels with mammalian G1/S controls than with yeasts. In mammals, the Rb protein interacts specifically with D-type cyclins and regulates cell proliferation by binding and inhibiting E2F transcription factors. However, the developmental role of Rb in plants and its potential interaction with cell cycle regulators is unknown. We show that the maize Rb homologue ZmRb-1 is temporally and spatially regulated during maize leaf development. ZmRb-1 is highly expressed in differentiating cells, but almost undetectable in proliferating cells. In vitro, both ZmRb-1 and human Rb bind all classes of plant D-type cyclins with the involvement of a conserved N-terminal Leu-x-Cys-x-Glu (LxCxE) Rb-interaction motif. This binding is strongly reduced by mutation of the conserved Cys-470 of ZmRb-1. ZmRb-1 binds human and Drosophila E2F, and inhibits transcriptional activation of human E2F. We also show that ZmRb-1 is a good in vitro substrate for all human G1/S protein kinases. The functional conservation of proteins that control the G1/S transition in mammals and plants points to the existence of plant E2F homologues. We conclude that evolution of Rb and cyclin D proteins occurred after separation of the fungi from the higher eukaryotic lineage, but preceded the divergence of plant and animal kingdoms.

Arabidopsis↗