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Biomedical subjects

J Goldstone

Publications and source records attributed to J Goldstone.

At least 91 records · Page 5Linked to original sources
PubMed1982

The potential impact of digital video subtraction angiography on screening for renovascular hypertension.

The success of digital video subtraction angiography (DVSA) in screening hypertensive patients for renal artery stenosis and the apparent value of percutaneous transluminal angioplasty (PTA) prompted re-evaluation of the philosophy of indiscriminate medical therapy for newly discovered cases of hypertension. DVSA was diagnostic in 87% of cases. The cost of screening for renovascular hypertension by DVSA and treatment by PTA when feasible is about the same as that of medical therapy. Considering the problems of noncompliance and drug side effects associated with medical antihypertensive therapy, DVSA screening for renovascular hypertension in a broader population seems both medically and economically sound.

Angiography↗
PubMed1982

Digital subtraction angiography of peripheral vascular bypass procedures.

Without premedication or special preparation, digital video subtraction angiography, also known as photoelectronic intravenous angiography, was effectively used for evaluating patients who had undergone peripheral vascular reconstructive procedures. Thirty-eight studies in 20 patients were performed using computer contrast enhancement after an intravenous injection. Patency of arterial grafts was thereby evaluated, thus obviating further routine angiography. Graft patency, even of small complex graft sites, was easily recognized. Occlusions were also readily identified. Patient acceptance was excellent since the procedure is almost painless and can be done on an outpatient basis. The technique is fast, safe, and less expensive than routine angiography.

Angiography↗
PubMed1981

Detecting and localizing peripheral arterial disease: assessment of 201Tl scintigraphy.

Detection and localization of peripheral arterial disease was evaluated by intravenous injection of 201Tl at peak exercise in 22 subjects. Images of the gluteals (G), thighs (T), knees (K), and calves (C) were obtained at exercise and after a 3 hr delay, and stored in a computer, interextremity (T/T and C/C) and intraextremity (G/T, T/C, T/K) counts ratios were calculated. Normal values were defined in 11 control subjects and compared with those obtained in 11 patients with angiographically proven peripheral arterial disease. Bilateral disease was detected scintigraphically in all patients. T/T and G/T ratios correctly predicted proximal disease in nine of 12 limbs, while C/C, T/C, T/K ratios correctly predicted distal disease in 21 of 21 involved limbs. Delay images 3 hr after stress generally reverted towards the norm. Objective systematic evaluation of limb isotope uptake permits accurate detection and localization of peripheral arterial disease. Method accuracy compares favorably with physical signs and with other noninvasive methods of detection of peripheral vascular disease. Scintigraphy presents advantages which indicate great clinical potential.

Adult↗
PubMed1981

The aortofemoral graft: detection and identification of healing complications by ultrasonography.

Although accepted as an accurate method for determining the size of abdominal aortic aneurysms, the value of gray-scale ultrasound in other aspects of peripheral vascular disease is less well defined. Therefore, we studied 87 patients with are aortofemoral grafts using B-scan and real-time scanners to determine the efficacy of these techniques in the detection of healing complications. Sonography delineated the proximal anastomosis in 84%, the iliac graft limbs in 88% to 91%, and the distal anastomosis in all but one instance. Sixty-six abnormalities, most clinically unsuspected, were identified. Of these, anastomotic femoral and aortic false aneurysms were most common. Ultrasound also identified perigraft fluid collections secondary to hematoma, seroma, and infection that were not detected by angiography. Ultrasound is relatively inexpensive, atraumatic, and without radiation hazard. It is recommended as the initial method for evaluating suspected healing complications of arterial grafting and as a means of long-term follow-up of patients with aortofemoral grafts.

Aged↗
PubMed1981

Digital video subtraction angiography: screening technique for renovascular hypertension.

Significant deterrents to the detection of renovascular hypertension are the unreliability of current screening methods and the widespread belief that the incidence of renal artery stenosis is too low to justify the expense and morbidity of routine angiography. We have developed a new imaging method, digital video subtraction angiography, suitable for screening outpatients for renal artery lesions. It involves injecting a 45 cc bolus of contrast medium through a venous catheter. Instead of exposing x-ray film, images are recorded directly on an image intensifier, digitized, and stored in a computer that electronically subtracts, reconstructs, enhances, and magnifies the images on a video screen. Renal parenchymal vessels less than 1 mm in diameter can be seen. So far, 45 studies have been performed in 39 hypertensive patients. Images of diagnostic quality were obtained in all except one. Renal artery stenosis was revealed in 15 patients, renal artery occlusion in two, diffuse intrarenal arterial narrowing in two, atrophic kidney with small renal arteries in two, and normal renal vessels in 23. Digital video subtraction angiography is an inexpensive, cost-effective, safe, and accurate method for renovascular hypertension screening and for evaluating patients after surgical correction of renal artery stenosis.

Angiography↗
PubMed1981

Intraoperative anticoagulation in cardiovascular surgery.

The optimal heparin dose to prevent intraoperative thrombosis or excessive bleeding during the occlusive phase of cardiovascular operations has not been determined. Therefore, we studied the kinetics of heparin effect in 28 patient undergoing peripheral vascular and cardiac operations. The activated clotting time (ACT) was measured in seconds by an electronic clot timer. The maximum ACT after initial heparin administration, the time to reach maximum ACT, and the half-time of heparin effect (t1/2) were determined. The anticoagulant effect of a given dose of heparin varies greatly among patients. No correlation was found between the t1/2 and the dosage of heparin administered. Despite higher doses of heparin administered to cardiac patients, the t1/2 in cardiac and vascular patients was not significantly different. Four patients received the same dose of heparin preoperatively and intraoperatively in an effort to predict the intraoperative effect. The times to maximum effect were the same but t1/2 intraoperatively was longer. These results indicate: (1) maximum heparin effect occurs later than previously believed and is different for cardiac and peripheral vascular patients; (2) the recommendation to give more heparin based on the 5-minute ACT is not valid; (3) individual response to a standard dose of heparin is unpredictable, both in duration and maximum effect; and (4) intraoperative monitoring of the heparin effect is practical and is the only way that any consistent, specific and point of heparin can be achieved.

Aged↗
PubMed1979

Asymptomatic carotid stenosis. Immediate and long-term results after prophylactic endarterectomy.

1. A review of the immediate and long-term results of prophylactic carotid endarterectomy for asymptomatic lesions of 78 carotid arteries in 72 patients between 1961 and 1976 is presented. 2. The inhospital operative mortality was zero. Two patients experienced postoperative transient neurologic deficit with complete recovery (2.6 per cent). There were no postoperative strokes. 3. Late follow-up data demonstrated that in only one patient did a stroke subsequently develop appropriate to the operative side, and it occurred 4 years after operation. Life table analysis for neurologic events carried out for up to 15 years indicated a 96 per cent stroke-free status of the surviving patients. 4. A 42 month survival rate of 83 per cent in patients treated by prophylactic carotid endarterectomy represented a statistically significant improvement over the 67 per cent survival of a comparable group of patients reported on in the literature. 5. Prophylactic carotid endarterectomy in the experience of vascular surgeons who can offer a low operative morbidity and mortality appears to be reasonable therapy in preventing stroke and prolonging survival until a randomized controlled study comparing surgery with the natural history of untreated patients shows evidence to the contrary.

Adult↗
PubMed1979

Therapeutic and economic impact of a modern amputation program.

The experience with 142 below-knee amputations for vascular occlusive disease and/or diabetes mellitus in 133 patients has been reviewed. The program utilized Xenon(133) skin bloodflow measurement for the selection of amputation level, emphasized the use of the long posterior skin flap as an important part of surgical technique, and employed immediate postoperative prosthesis with accelerated rehabilitation for postoperative management. The results of this program yielded a 0% postoperative mortality, 89% amputation healing, and 100% prosthesis rehabilitation of all unilateral below-knee amputees, and 93% rehabilitation of all bilateral below-knee amputees. The average time interval between amputation and fitting of a permanent prosthesis was 32 days. The use of Xenon(133) clearance as a measurement of capillary skin bloodflow for purposes of amputation level selection continues to be valid. All amputations with flows in excess of 2.6 ml/100 g tissue/min healed primarily, including the last 58 consecutive amputations. The total amputation of the 172 hospital V.A. system was surveyed and a cost analysis, based upon duration of postamputation hospitalization, comparing immediate postoperative prosthesis with conventional techniques, was performed. The savings to the system, taking into account start-up and maintenance costs for a program which employs immediate postoperative prosthesis, was projected to be $80,000,000 over five years. We conclude that a modern amputation program employing Xenon(133) clearance for amputation level selection and immediate postoperative prosthesis with accelerated rehabilitation is well justified based upon reduced morbidity, negligable mortality, and optimum patient prosthetic rehabilitation at a marked reduction in overall cost.

Adult↗
PubMed1978

Natural history of nonstenotic, asymptomatic ulcerative lesions of the carotid artery.

To define the natural history of the asymptomatic, nonstenotic, ulcerative lesion involving the carotid artery bifurcation, the arteriograms and clinical course of 67 patients with 72 asymptomatic ulcerative lesions of the carotid artery were reviewed. The angiographic appearance of ulceration was classified into three groups: minimal (group A), large (group B), and compound (group C). Using life-table methods, the clinical course of these patients was compared between groups and was also compared to a nonrandomized surgically treated group of patients with nonstenotic ulcerative lesions in whom operation was performed for hemispheric or monocular symptoms. There were no significant (P greater than .1) differences in mortality, but the differences in stroke incidence was highly significant (P less than .001). The annual stroke rate, averaged over seven years, was 0.4% per year for group A, 1.47% per year for the surgically treated group, and 12.5% per year for groups B and C. The data indicate that group A ulcers have a benign prognosis, in noticeable contrast to group B and C ulcers which incur a high risk for subsequent stroke.

Adult↗
PubMed1978

Splenectomy for massive splenomegaly.

Removal of a massively enlarged spleen is a challenging surgical problem that is associated with higher death and complication rates than the removal of smaller spleens. Older age, serious and chronic primary diseases, and associated cardiopulmonary abnormalities contribute to the morbidity and mortality. Most patients with massive splenomegaly have been treated with corticosteroid and/or antineoplastic drugs, which impair wound healing, hemostatic function, and host resistance. Precise surgical technic is especially important in these cases because of the susceptibility to postoperative hemorrhage. Ligation of the splenic artery via the lesser peritoneal sac before mobilization of the spleen is associated with lower intraoperative transfusion requirements than when the spleen is mobilized before the splenic artery is ligated.

Adolescent↗
PubMed1978

Autogenous profundaplasty: The key to long-term patency in secondary repair of aortofemoral graft occlusion.

The records of 281 patients undergoing aortic grafting to 522 femoral arteries over a period of 18 years were reviewed. Fifty-four patients suffering graft limb occlusion to 71 femoral arteries requiring subsequent secondary repair were identified for detailed analysis. Occlusive disease of the profunda femoris artery was identified as the primary cause of thrombosis. Repair consisted of profunda femoris angioplasty, and transfemoral retrograde graft thrombectomy was possible in all but three instances which were managed by cross-over femoral-femoral bypass. In no instance was laparotomy and abdominal graft replacement necessary. The 30 day operative survival and graft patency were 100%. Analysis of factors that have influenced late graft patency demonstrated that the key factors were the method of profundaplasty and the association of diabetes mellitus. When autogenous profundaplasty (on-lay arterial patches, saphenous vein, or limited endarterectomy) was employed, the overall patency combining diabetics and non-diabetics was two and one-half times greater than when profundaplasty was performed with an on-lay Dacron((R)) patch. If diabetics were separated from nondiabetics in the autogenous angioplasty group, the 36 month patency for non-diabetics was 85%, and 0% for diabetics. We conclude that autogenous profundaplasty provides considerable advantage from the standpoint of long-term patency and that the diabetic patients are relatively poor candidates for secondary arterial repair of an occluded aortofemoral bypass graft.

Adult↗
PubMed1978

The use of medical audits in surgical education.

Quality of medical care audits conducted in the form of a conference attended by surgical residents, faculty, and medical students accomplish the following: (1) provide an excellent educational experience for all participants; (2) are enthusiastically received by all concerned; (3) accomplish considerably more than audits performed in the manner prescribed by the Joint Commission on Accreditation of Hospitals (JCAH); and (4) fulfill JCAH/Professional Standards Review Organization (PSRO) requirements. This modified type of audit can be used successfully as a variant of a teaching seminar in which learning is more predictable because of the active participation of all concerned. Criteria sets which include simple and complex criteria must be developed if audits are to alter patterns of care for complex surgical problems.

Education, Medical, Graduate↗
PubMed1977

Below-knee amputation: a modern approach.

Immediate and long-term results of 113 below-knee amputations in 103 patients are presented to justify a comprehensive program of management that includes an objective method for determining amputation level with xenon 133 clearance, precise surgical technic, immediate postoperative prosthesis, and an aggressive program of rehabilitaion. Prediction of healing of the last 30 below-knee amputations was 100% successful, showing the value of 133Xe clearance for determination of amputation level. Zero per cent thirty-day mortality and 100% prosthetic rehabilitation of patients on below-knee prostheses justifies the use of immediate postoperative prosthesis. Long-term follow-up of our patients demonstrates that the five year survival rate of diabetic patients is poor (39%) compared with the nondiabetic amputee (75%) who approached the survival of the normal, age-adjusted male population (85%). The fact that 75% of patients were alive after five years and were still independently ambulatory on their prostheses is final testimony to the value of the program.

Adult↗