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Biomedical subjects

J I Miller

Publications and source records attributed to J I Miller.

At least 55 records · Page 3Linked to original sources
PubMed1994

Simplified technique for improving exposure of the apical prostate during radical retropubic prostatectomy.

We describe a rapid and easily learned technique that greatly assists in exposure of the apical prostate during radical retropubic prostatectomy. The technique is a modification of the previously reported "bunching" maneuver. A curved Kocher clamp is used to compress the dorsal vein complex and surrounding fascia into a tight midline bundle. Once transected, dissection of the prostatomembranous urethra, neurovascular bundles, and apical prostate is markedly facilitated.

Constriction↗
PubMed1994

Leukemoid reaction: a rare paraneoplastic syndrome associated with advanced bladder carcinoma.

We report a case of leukemoid reaction associated with tumor recurrence and rapid progression in a patient following resection of a high-grade transitional cell carcinoma of the bladder. The clinical, pathologic, and etiologic features of tumor-associated leukemoid reactions are emphasized. In the setting of recurrent carcinoma, a leukemoid reaction suggests highly aggressive or metastatic disease.

Carcinoma, Transitional Cell↗
PubMed1994

A 12-year experience with enterovesical fistulas.

OBJECTIVES: To review our experience with enterovesical fistulas in order to determine the most accurate diagnostic studies and most effective method of treatment. METHODS: A retrospective record review of 76 patients who were diagnosed and treated for enterovesical fistulas over a 12-year period was performed. Data collection focused on presenting symptoms, urinary disease process, diagnostic studies, and methods of management. RESULTS: Diverticular disease was the primary etiologic factor in the majority of patients (59%), with colonic malignancy, granulomatous bowel disease, and radiation therapy accounting for the majority of the remainder. Cystoscopy (60%) and cystography (44%) were the most sensitive diagnostic studies. There was no statistical difference in the complication rate between groups treated with single or multistage repair. CONCLUSIONS: One-stage repair of enterovesical fistulas can be safely performed when the cause is diverticular or granulomatous bowel disease. Staged repairs may be more judicious in patients with large intervening pelvic abscesses or those in whom advanced malignancy or radiation changes are present.

Adult↗
PubMed1993

Limited resection of bronchogenic carcinoma in the patient with impaired pulmonary function.

Surgical resection is the treatment of choice for non-small cell carcinoma of the lung. In some patients with marked impairment of pulmonary function, cardiac disease, or other medical conditions, the surgeon is faced with performing either a limited resection or carrying out nonoperative therapy. Impaired pulmonary functions are defined as a maximum breathing capacity (MBC) of 35% to 40% of predicted; forced expiratory volume in 1 second (FEV1) of less than 1 L; and a forced expiratory volume 25%-75% (FEV25-75) of less than 0.6 L. When MBC values are less than 35% of predicted; the FEV1 is less than 0.6 L; and the FEV25-75 is less than 0.6 L, elective resection is contraindicated. Useful criteria for indicating an elective limited resection include the following: (1) T1 lesion, (2) peripheral location, (3) margins easily encompassed by resection, and (4) no gross lymph node involvement. In a study of 67 patients, there was 1 postoperative death, with less than an 80% 2-year survival and a 31% 5-year survival. The role of video-assisted thoracoscopy in the management of primary lung cancer remains to be defined. When the high-risk patient can be operated on with attendant low morbidity and mortality, I believe, at the current time, a video-assisted thoracic resection for primary lung cancer is not the best option, as the patient will be offered a compromised operation, and I suspect follow-up studies will prove this correct.

Carcinoma, Bronchogenic↗
PubMed1993

The present role and future considerations of video-assisted thoracoscopy in general thoracic surgery.

The past 2 years have witnessed the evolution of video-assisted thoracoscopy in the United States. Performance of the procedure has now moved from the university center to the community hospital. It is clear that thoracoscopy is the modality of choice for both the diagnosis and management of pleural disease (except mesothelioma); the identification of undiagnosed peripheral pulmonary nodules; the removal of simple mediastinal cysts; and the performance of wedge biopsy for interstitial lung disease and simple pericardial procedures. Its role in the management of primary lung cancer and esophageal disease remains to be defined. There are four areas that currently need to be addressed as the present role of therapeutic thoracoscopy evolves: (1) instrumentation, (2) economics, (3) a credentialing process, and (4) its application in certain procedures. All of these are addressed in this presentation.

Costs and Cost Analysis↗
PubMed1993

Thoracic approaches to anterior spinal operations: anterior thoracic approaches.

We performed a retrospective review of 36 patients aged 23 to 71 years (mean age, 52 years) who underwent 46 operations through a thoracic or thoracolumbar approach for orthopedic or neurosurgical procedures at Emory University Affiliated Hospitals. Pathologic indications for operation were metastatic disc disease in 10, herniated nucleus pulposus in 11, osteomyelitis in 6, vertebral fracture in 2, spinal deformities in 4, spinal abscess in 1, Pott's disease in 1, and liposarcoma in 1. Major indications for operation were infection and progressive paraparesis or paresthesias. Surgical approach consisted of a posterior lateral thoracotomy in 23, thoracotomy with retroperitoneal exposure in 6, thoracoabdominal exposure in 4, and cervical/upper sternotomy in 3. Diaphragmatic mobilization was required in 12. Surgical approach is dictated by the level of the lesion and its length. Lesions of T1 to T6 are approached through an upper sternotomy or right thoracotomy; lesions of T6 to L3, through a left thoracotomy with or without diaphragmatic mobilization. Specific techniques of segmental vessel division, diaphragmatic mobilization, and evaluation of artery of Adamkiewicz are emphasized. Rib grafts are harvested as needed. The thoracic surgeon can greatly enhance preoperative assessment, operative exposure and closure, and postoperative care for patients undergoing thoracotomy for spinal conditions.

Female↗
PubMed1993

Laser-Doppler flowmetry in neurosurgery.

Laser-Doppler flowmetry (LDF) provides a reliable measurement of local cerebral blood flow (lCBF) as demonstrated by multiple validation studies. This article evaluates the clinical applications of LDF in neurosurgery. With the availability of modified probes, it is possible to carry out LDF monitoring of neurosurgical patients in the intensive care unit. Currently, there are multiple systemic and intracranial parameters that are interactive and separately monitored. A multi-channeled digital data acquisition system allows these data to be compiled in a single computer environment for the interpretation of lCBF changes. Guidelines are suggested for the clinical use of LDF monitoring, and the technical features of monitoring including the interpretation of data are summarized.

Cerebrovascular Circulation↗
PubMed1993

Anatomical basis of syringomyelia occurring with hindbrain lesions.

Hindbrain lesions that distort or compress the cervicomedullary junction are commonly associated with syringomyelia. As a basis for discussing pathogenetic mechanisms, the upper end of the central canal of the spinal cord was examined histologically in six aborted fetuses and 14 adults dying of natural causes; the results were correlated with magnetic resonance images in 40 normal subjects. The central canal of the medulla, which extends from the cervicomedullary junction to the fourth ventricle, was found to migrate dorsally, elongate in dorsoventral diameter, and dilate beneath the tip of the obex to form a large, everted aperture. This opening communicates directly with the subarachnoid space through the foramen of Magendie and is indirectly continuous with the main body of the fourth ventricle. In adults, the aperture of the central canal is located approximately 1.0 cm below the tela choroidea inferior and 3.5 cm below the midpoint of the fourth ventricle. Analysis of magnetic resonance imaging scans in 45 patients with syringomyelia and simple hindbrain lesions revealed two patterns of cavity formation: 1) lesions that obstructed the upper end of the central canal or its continuity with the subarachnoid space produced a noncommunicating type of syringomyelia; and 2) lesions that obstructed the basilar cisterns or the foraminal outlets of the fourth ventricle produced a communicating type of syringomyelia (hydromyelia) in association with hydrocephalus. Evidence is presented that syrinxes occurring with hindbrain lesions are not caused by a caudal flow of cerebrospinal fluid from the fourth ventricle into the central canal of the spinal cord.

Aged↗
PubMed1993

Noncommunicating syringomyelia following occlusion of central canal in rats. Experimental model and histological findings.

This report describes a new and reliable technique for producing experimental noncommunicating syringomyelia. In 30 rats, 1.2 to 1.6 microliters of kaolin was microinjected into the dorsal columns and central gray matter of the spinal cord at C-6. The inoculations caused transient neurological deficits in four animals and no deficits in 26 animals. Within 24 hours, kaolin and polymorphonuclear leukocytes entered the central canal and drained rostrally. The clearance of inflammatory products induced a proliferation of ependymal cells and periependymal fibrous astrocytes, which formed synechiae and obstructed the canal at the level of injection and at one or more levels up to C-1. In 22 animals followed for 48 hours or longer, the upper end of the central canal became acutely dilated and formed an ependyma-lined syrinx that enlarged to massive dimensions within 6 weeks. The rostral syrinxes did not communicate with the fourth ventricle and were not associated with hydrocephalus. The histological findings in acute noncommunicating syringomyelia were characterized by progressive stretching and thinning of the ependyma, elongation of intracanalicular septae, and the formation of periependymal edema. After 3 weeks, there was progressive compression of the periependymal tissues associated with stretching of axons, fragmentation of myelin sheaths, and the formation of myelin droplets. These findings and the sequence in which they evolved were identical in most respects to those occurring in acute and subacute noncommunicating hydrocephalus.

Animals↗
PubMed1993

Spontaneous movement of bullets in the brain.

We report two patients in whom bullets in the brain migrated into the adjacent lateral ventricle and moved freely as a consequence of gravity. A review of the literature suggests that the spontaneous migration of intracerebral bullets is influenced by cerebral softening, the specific gravity of the bullet compared with brain tissue, and the sink function of the cerebral ventricles. In patients undergoing the surgical removal of intracerebral or intraventricular bullets, it is recommended that an x-ray be obtained after the final positioning of the head.

Adolescent↗
PubMed1993

Physiologic evaluation of pulmonary function in the candidate for lung resection.

From July 1, 1974, to December 31, 1990, 2340 patients who underwent pulmonary resection were evaluated by comprehensive analysis of pulmonary function. Pulmonary function test criteria for resection were (1) pneumonectomy: forced expiratory volume in 1 second greater than 2 L; forced expiratory flow rate from 25% to 75% greater than 1.6 L; maximum voluntary ventilation greater than 55%; (2) lobectomy: forced expiratory volume in 1 second greater than 1 L; forced expiratory flow rate from 25% to 75% greater than 0.6 L; maximum voluntary ventilation greater than 40%; (3) wedge or segmental resection: forced expiratory volume in 1 second greater than 0.6 L; forced expiratory flow rate from 25% to 75% greater than 0.6 L; maximum voluntary ventilation greater than 35%. Split perfusion lung scan and Reichel exercise stress testing were utilized as indicated. When these values of pulmonary function have been applied, a more precise method of selecting patients for various types of pulmonary resection has resulted in a lower mortality while denying operation to less than 1% of the patients who are considered for surgical resection.

Exercise Test↗
PubMed1992

Thallium imaging in preoperative evaluation of the pulmonary resection candidate.

The major determinants of morbidity and mortality after pulmonary resection are the physiologic status of the cardiac and pulmonary systems. The role of thallium 201 imaging was reviewed in 151 consecutive patients to determine its significance in physiologic assessment. 10.3% of patients were found to have serious asymptomatic coronary artery disease, and thallium imaging made a difference in the management of 50% of these patients. When used appropriately, thallium imaging is an important modality in physiologic assessment of the pulmonary resection candidate.

Cardiac Catheterization↗
PubMed1992

Treatment of castration-induced menopausal symptoms with low dose diethylstilbestrol in men with advanced prostate cancer.

Menopausal symptoms manifesting as hot flashes and sweats occur in up to 75 percent of patients following either orchiectomy or treatment with a luteinizing hormone-releasing hormone agonist for prostate cancer. As many as one third of these patients will experience symptoms severe enough to seek palliation. We treated 12 such patients with low dose diethylstilbestrol (1/3 mg daily). Nine patients demonstrated both objective and subjective improvement in their menopausal symptoms. Five patients experienced toxicity including new onset of gynecomastia or breast soreness although no patient discontinued treatment on this basis. No cardiovascular complications were noted. We conclude that low dose diethylstilbestrol is an inexpensive, effective means of controlling troublesome postorchiectomy menopausal symptoms in carefully selected patients.

Aged↗
PubMed1992

The clinical usefulness of serum prostate specific antigen after hormonal therapy of metastatic prostate cancer.

We longitudinally followed serum prostate specific antigen (PSA) levels in 48 patients who were treated with either orchiectomy, monthly luteinizing hormone-releasing hormone injection or continuous diethylstilbestrol for stage D2 prostate adenocarcinoma and achieved an objective response. Of the patients 34 had clinical evidence of disease progression (median remission duration 19 months). Median length of followup for the 14 patients who remained in remission was 42 months. Pretreatment performance status, pretreatment extent of metastases as measured by a bone scan and post-treatment nadir PSA level were univariately correlated with remission duration. After adjustment for the 2 former pretreatment variables, a highly significant independent effect of the nadir PSA level on remission duration persisted. Patients whose post-treatment nadir PSA level decreased below 4 ng./ml. had a significantly longer remission duration than those whose nadir PSA remained elevated (median 42 versus 10 months, p less than 0.0001). No cases were observed to progress (as defined by our criteria independent of PSA level) while the serial post-treatment PSA levels continued to decrease or remained at a plateau after reaching the nadir. The time at which the PSA began to increase once the nadir was reached predated objective evidence of progression in all patients except 2 in whom the 2 events occurred simultaneously (mean lead time 7.3 +/- 5.0 months). We conclude that following serial PSA levels in patients treated with androgen ablation for metastatic prostate cancer can aid in distinguishing favorable from nonfavorable responders early in the course of therapy and greatly assist in monitoring for progression.

Aged↗
PubMed1992

Rupture of a hydrocele: an unusual event.

A rupture of a large, tense hydrocele is presented. The patient was chronically treated with steroids for asthma control. Scrotal ultrasound was used to document hydrocele presence, rupture and recurrence.

Aged↗