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Biomedical subjects

J J Kelly

Publications and source records attributed to J J Kelly.

At least 37 records · Page 2Linked to original sources

Gonadal steroids reduce the density of axospinous synapses in the developing rat arcuate nucleus: an electron microscopy analysis.

The developing brain is exquisitely sensitive to gonadal steroid hormones, which permanently differentiate the neural substrate during a critical developmental period. One of the more striking sexual dimorphisms in the adult rat brain is synaptic patterning in the arcuate nucleus (ARC); females have twice the number of axospinous synapses as males (Matsumoto and Arai [1980] Brain Res. 190:238-242). Previously, we have demonstrated that a similar dimorphism in spine densities on ARC dendrites is present as early as early as postnatal day 2 (PN2) in Golgi-impregnated rat brains (Mong et al. [1999] J. Neurosci. 19:1464-1472). Males have 37% fewer dendritic spines than females. Moreover, these spine densities are sensitive to changes in the hormonal milieu such that males castrated on the day of birth have a significant increase in spine density, whereas females masculinized at birth by gonadal steroid exposure have a decreased dendritic spine density. One of the limitations of the Golgi technique is the inability to confirm the presence of synapses. The current study used quantitative electron microscopy and demonstrated that testosterone exposure dramatically reduced axospinous synapses in the ARC by PN 2. Males had 54% fewer and masculinized females had 77% fewer axospinous synapses than females (P < 0.05 and P < 0.01, respectively). We previously reported that gonadal steroids induce coincident changes in neuronal and astrocyte morphology in the neonatal ARC (Mong et al., 1999), and here confirm that these changes include an altered synaptic pattern that is strikingly similar to that observed in the adult (Matsumoto and Arai, 1980).

Animals↗

Search for quadrupole strength in the electroexcitation of the delta+(1232).

High-precision 1H(e,e'p)pi(0) measurements at Q2 = 0.126 (GeV/c)2 are reported, which allow the determination of quadrupole amplitudes in the gamma*N-->Delta transition; they simultaneously test the reliability of electroproduction models. The derived quadrupole-to-dipole ( I = 3/2) amplitude ratios, R(SM) = (-6.5+/-0.2(stat+sys)+/-2.5(mod))% and R(EM) = (-2.1+/-0.2(stat+sys)+/-2.0(mod))%, are dominated by model error. Previous R(SM) and R(EM) results should be reconsidered after the model uncertainties associated with the method of their extraction are taken into account.

Journal Article↗

Prevalence and prognostic significance of malnutrition in chronic renal insufficiency.

OBJECTIVE: Malnutrition is present in a significant proportion of patients commencing dialysis. However, the prevalence and prognostic significance of malnutrition within the chronic renal insufficiency (CRI) population before the initiation of dialysis is poorly characterized. The aim of this study was to determine the prevalence and prognostic significance of malnutrition in an unselected group of patients with CRI. DESIGN: Cohort analytic study. SETTING: Ambulatory care practice of a university teaching hospital. PATIENTS: Fifty patients with CRI (serum creatinine concentration > or = 1.7 mg/dL) were enrolled. Patients with a recent acute illness, nephrotic syndrome, intercurrent steroid therapy, gastrointestinal disease, or other severe organ failure that may have independently influenced nutritional status were excluded. INTERVENTION: At baseline, patients had a nutritional assessment consisting of subjective global assessment (SGA), measurement of body mass index (BMI), midarm circumference (MAC), serum albumin concentration, total lymphocyte count, and single frequency bioelectrical impedance analysis. Patients received standard medical care and were followed prospectively at quarterly intervals for 12 months. RESULTS: At baseline assessment, 28% of patients had evidence of malnutrition by SGA criteria. The malnourished group of patients had a significantly lower creatinine clearance (18.9 +/- 9.8 v 36.5 +/- 14.0 mL/min/1.73 m(2), mean +/- SD, P <.001), glomerular filtration rate (20.7 +/- 10.9 v 28.5 +/- 12.5 mL/min/1.73 m(2), P =.04), BMI (22.7 +/- 2.9 v 29.0 +/- 5.0 kg/m(2)), and MAC (24.3 +/- 4.9 v 30.7 +/- 4.8 cm, P <.001), but there were no differences in serum albumin concentration or total lymphocyte count between the groups. At the 12-month follow-up, there was significantly increased mortality (21% v 3%, P =.04), composite endpoint of death or dialysis (50% v 11%, P =.02), and likelihood of acute hospitalization (78% v 23%, P =.001) in the malnourished group. A significant association was observed between baseline nutritional status and subsequent admission to hospital and baseline glomerular filtration rate and progression to end-stage renal failure. CONCLUSION: These data suggest that SGA provides a useful means of assessing nutritional status and is helpful in identifying patients with increased risk of morbidity and mortality in the setting of CRI.

Aged↗

Glucocorticoid-induced hypertension: from mouse to man.

1. Adrenocorticotrophic hormone (ACTH) raises blood pressure in humans, sheep, rat and mouse. In rat and humans, but not sheep, the hypertension can be explained by glucocorticoid excess. 2. In both rat and humans, the hypertension is associated with a rise in cardiac output and renal vascular resistance. 3. In both rat and humans, the nitric oxide system is implicated in glucocorticoid hypertension. 4. In both rat and humans, hypertension due to naturally occurring glucocorticoids is not prevented by drugs that block classical glucocorticoid or mineralocorticoid receptors. 5. Abnormalities in glucocorticoid metabolism may contribute to some forms of 'essential' hypertension.

Adrenocorticotropic Hormone↗

Effects of oral L-arginine on plasma nitrate and blood pressure in cortisol-treated humans.

OBJECTIVE: The aim of this study was to determine whether cortisol-induced hypertension can be reversed by co-administration of oral L-arginine. STUDY DESIGN: Three studies were undertaken in healthy male human subjects. The first study addressed the effect of oral L-arginine loading on plasma arginine concentration. Study 2 addressed the effect of co-administration of cortisol with L-arginine on plasma L-arginine concentrations. Study 3 was a randomized placebo crossover control comparing the effects of cortisol 80 mg/day co-administered with a placebo to cortisol 80 mg/day co-administered with L-arginine 21 g/day. METHODS: Blood pressure was measured by a random Hawksley sphygmomanometer. Plasma nitrate/nitrite concentrations were measured by a modified Greiss reaction. Plasma arginine and citrulline concentrations were measured by an automated amino acid analyser. RESULTS: Plasma arginine concentrations were doubled by oral doses of 15 g/day and 21 g/day of L-arginine (study 1). Co-administration of cortisol did not alter plasma arginine concentrations in subjects taking 21 g of L-arginine per day (study 2). Co-administration of L-arginine 21 g/day with cortisol 80 mg/day did not prevent cortisol-induced increases in blood pressure or cortisol-induced falls in plasma nitrate/nitrite concentrations. CONCLUSION: Cortisol-induced hypertension is accompanied by a fall in plasma nitrate/nitrite concentrations. Oral L-arginine administration does not prevent cortisol-induced falls in plasma nitrate/nitrite concentrations or increases in blood pressure. We propose that cortisol-induced reductions in nitrate/nitrite production occur at a point distal to L-arginine availability in the nitric oxide synthase pathway.

Administration, Oral↗

The effect of lower-extremity position on cerebrospinal fluid pressures.

OBJECTIVE: To determine the effects of lower-extremity positioning on cerebrospinal fluid opening pressure (CSFp). The authors believed that during lumbar puncture (LP), CSFp does not meaningfully decrease when the lower extremities are extended from flexion, as is often suggested. METHODS: In a convenience sample of adult patients who clinically required LP in an urban emergency department, three sequential CSFp measurements were obtained in either sequence A (knee, hip, and neck flexion [90 degrees ], then extension, then flexion) or sequence B (extension, flexion, then extension) prior to CSF withdrawal. The neck was flexed at 30 degrees when the lower extremities were flexed, while the thoracolumbar spine was kept in the neutral position for all measurements. RESULTS: Nineteen patients were studied in each sequence. Although variable, overall within-patient changes between positions were not clinically meaningful. Mean and 95% confidence intervals (95% CIs) for the decrease in CSFp from position 1 to position 3 (same position) were 0.2 cm H(2)O (1.7%) and 0.9 to -0.6 cm H(2)O (6% to -2.7%), respectively. Changing from flexion to extension decreased pressure measurements by a mean of 0.9 cm H(2)O (2.5%) [95% CI = 2.1 to -0.1 cm H(2)O (7.6% to -2.4%)]. Changing from extension to flexion increased CSFp by a mean of 1.1 cm H(2)O (6.1%) [95% CI = 0.2 to 2.0 cm H(2)O (1.3% to 11.5%)], a statistically but not clinically meaningful change. CONCLUSIONS: Changing lower-extremity position did not meaningfully change mean CSFp. These data do not support the common suggestion that extending the lower extremities during LP meaningfully decreases CSF opening pressures.

Adolescent↗

Hand-assisted laparoscopic surgery in the United States: an overview.

Hand-assisted laparoscopic surgery (HALS) was developed to bridge the gap between open surgery and advanced laparoscopic surgery. Advantages of the hand in the abdomen include tactile feedback, the ability to palpate, blunt dissection, organ retraction, control of bleeding, and rapid organ removal. There are 3 commercially available devices in the United States, as well as a fourth in Europe and a fifth in Japan. Uses for HALS include procedures requiring intact specimen removal, complex laparoscopic procedures, preventing open conversion, and overcoming a technical obstacle. HALS procedures, such as esophagectomy, gastrectomy, hepatectomy, pancreatectomy, splenectomy, bariatric surgery, colectomy, nephrectomy, hysterectomy, and aortobifemoral bypass, have all been reported in the literature. Improvement in instrumentation, specifically with newer generation devices, will allow HALS to become more popular. We advocate the use of HALS specifically for laparoscopic colectomy, laparoscopic splenectomy for massive splenomegaly, and for living-related donor nephrectomy.

Colectomy↗

The feasibility and accuracy of diagnostic laparoscopy in the septic ICU patient.

BACKGROUND: Systemic inflammatory response syndrome (SIRS) and sepsis of unknown origin are common complications of critically ill patients in the ICU. These patients frequently have unreliable clinical exams and are candidates for exploratory laparotomy. Although abdominal CT is commonly used because it is less invasive than laparotomy, it is often unreliable or unobtainable. Bedside laparoscopy is an alternative technique that may be more accurate than CT in selected patients and less invasive than laparotomy. METHODS: We performed diagnostic laparoscopy (DL) in a series of ICU patients with SIRS/septic state of unknown origin between May 1997 and June 1998. All patients were unstable and required significant respiratory and hemodynamic support. Laparoscopy was either performed in the ICU at the patient's bedside or in the operating room. CT scan of the abdomen had been performed on most of the patients who were stable enough to transport. Confirmation of diagnosis was obtained either by laparotomy, autopsy, or clinical recovery. RESULTS: Among the 17 eligible patients, 16 underwent successful DL. Insufflation was impossible in one patient because of high intraabdominal pressure. Bedside evaluations were performed in 14 of the 17 patients. There were no complications from the laparoscopy. Six patients were identified as positive (four intestinal ischemia, two cholecystitis); the other 10 had negative explorations. Follow-up on two patients with negative laparoscopy was incomplete due to denied postmortem. Laparoscopic diagnoses were confirmed in the remaining 14 patients by laparotomy (six cases), postmortem (three cases), or recovery (five cases), with an accuracy of 100%. The overall accuracy of abdominal CT obtained in nine of the 14 patients was 33%. CONCLUSIONS: DL in a select group of critical ICU patients is safe and accurate, whereas CT scan tends to be inaccurate and is often unobtainable due to patient instability. Performing the procedure at the bedside can expedite the diagnosis, eliminate the burden for transfer, and save on anesthesia and operating room charges.

Feasibility Studies↗

Cortisol inhibits cholinergic vasodilation in the human forearm.

Exogenous cortisol raises blood pressure (BP) in humans and there is accumulating evidence of abnormalities of glucocorticoid activity in essential hypertension. In this study we tested the hypothesis that exogenous cortisol attenuates the cholinergic dilator response in the forearm circulation. Fourteen healthy normotensive men were studied. Using bilateral forearm venous plethysmography, we examined forearm blood flow responses to intra-arterial acetylcholine (ACh) and sodium nitroprusside (SNP) pre- and post-NG-monomethyl-L-arginine (LNMMA) after 2 or 5 days of oral cortisol or placebo in a randomized, double-blind crossover study. Exogenous cortisol increased supine systolic (P < .05) and standing systolic (P < .05) BP and produced expected metabolic changes and suppressed serum cortisol concentration (P < .001). Baseline forearm blood flow did not differ between placebo and cortisol treatments at 2 or 5 days. Cholinergic vasodilatation was impaired after cortisol administration, reaching statistical significance at 5 days (P < .05). Cortisol did not affect responses to SNP. NG-monomethyl-L-arginine inhibited cholinergic vasodilatation in placebo-treated groups but had no additional effect in the presence of cortisol. These results support our hypothesis and suggest that the mechanism of impaired cholinergic dilatation in glucocorticoid-treated subjects involves abnormalities of the endothelial nitric oxide system.

Adrenocorticotropic Hormone↗

Role of erythropoietin in cortisol-induced hypertension.

The mechanism of cortisol-induced hypertension remains unknown. We investigated a possible role of erythropoietin (EPO) as a mediator of hypertension in healthy male subjects treated with cortisol. In Study 1, blood pressure (BP) and serum EPO concentrations were measured on alternate days in nine subjects treated with 80 mg of cortisol per day for 5 days. In Study 2 the same parameters were measured in eight subjects randomised to cortisol (80 mg/day) or placebo and 10 subjects randomised to cortisol (200 mg/day) or placebo for 5 days. In Study 1, cortisol caused a significant increase in systolic BP (SBP) (115 +/- 2 vs 126 +/- 2 mm Hg, control vs day 5, P < 0.001) and serum EPO concentrations (14.5 +/- 2.7 vs 24.3 +/- 2.7 mU/mL, P < 0.001). In Study 2 both doses of cortisol increased SBP (118 +/- 2 vs 113 +/- 2 mm Hg, 80 mg cortisol vs placebo, P < 0.05 and 129 +/- 3 vs 113 +/- 2 mm Hg, 200 mg cortisol vs placebo, P < 0.001). Serum EPO concentrations were significantly increased at 200 mg cortisol (25.2 +/- 11.9 vs 15.9 +/- 3.5 mU/mL, P < 0.01) but not 80 mg cortisol (21.3 +/- 2.9 vs 14.9 +/- 3.1 mU/mL). In the 200 mg group there was a positive correlation between the change in SBP and the change in serum EPO concentration (r2 = 0.43, P < 0.05). These results point to a possible role for EPO as the mediator of cortisol-induced hypertension. Journal of Human Hypertension (2000) 14, 195-198.

Blood Pressure↗

Effects of nicotinic acid on insulin sensitivity and blood pressure in healthy subjects.

Insulin resistance and hyperinsulinaemia are associated with hypertension although a causative relationship has not been established. The aim of this study was to determine whether a short term reduction in insulin sensitivity induced by nicotinic acid treatment (NA) would alter blood pressure. The study was a double-blind randomised placebo-controlled cross-over study. Seven healthy volunteers, three males and four females were randomised to placebo or NA 500 mg daily for 7 days then 1 g daily for a further 7 days. Hyperinsulinaemic euglycaemic clamp, indirect calorimetry, 24-h ambulatory blood pressure monitoring (ABPM) and forearm blood flow measurement (FABF) were performed at day 14 of each treatment phase. NA significantly reduced the glucose infusion rate required to maintain euglycaemia in all subjects (placebo vs NA; 31.5+/-4.2 vs. 26.2+/-4.6 micromol/kg/min, P = 0.002) associated with a decrease in non-oxidative glucose disposal. NA did not significantly alter 24-h mean systolic or diastolic blood pressure. Fasting glucose, insulin and non-esterified free fatty acid (NEFA) levels remained unchanged, energy expenditure and substrate oxidation were not altered by NA. These results suggest a short term reduction in insulin sensitivity with NA is not accompanied by a change in blood pressure. This may relate to the short duration of treatment, to a dissociation between insulin resistance and hypertension or to other homeostatic mechanisms which prevent blood pressure rising in subjects not predisposed to hypertension.

Adult↗

The drug epidemic: effects on newborn infants and health resource consumption at a tertiary perinatal centre.

OBJECTIVES: Illicit drug taking in Australia, with its attendant social and medical consequences, is increasing and the effects extend to maternity hospitals where infants born to addicted mothers have more health problems in the neonatal period. The aims of this study were to evaluate (1) the patterns of illness of such infants and (2) the burden imposed on the neonatal department of a large tertiary maternity centre. METHODOLOGY: An audit was conducted of all Chemical Dependency Unit (CDU) mothers and babies delivered at the Royal Women's Hospital, Melbourne, Australia during 1997. Data were compared with those from a concurrent control group of mothers and babies randomly generated from the hospital's obstetric database. RESULTS: Ninety-six infants born to CDU mothers were compared with a control group of 200 infant/mother pairs. The majority of women in the CDU clinic were treated for narcotic addiction with methadone (90%) but most continued to use heroin during pregnancy (68%). Infants born to CDU mothers were significantly less mature and lighter than control infants. Fifty-three (55%) CDU infants required admission to the Special Care Nursery either because of neonatal abstinence syndrome (n = 29) or other medical reasons (n = 24). The median length of hospital stay was significantly longer in CDU compared with control infants (8 vs 3 days, P < 0.01). CONCLUSIONS: Infants born to drug dependent mothers have more neonatal problems requiring specialized medical and nursing expertise, compared with control infants. These infants are large consumers of scarce health resources.

Adult↗

Hand-assisted laparoscopic aortobifemoral bypass grafting.

OBJECTIVE: Aortobifemoral bypass grafting is a durable operation for arterial reconstruction in patients with symptomatic aortoiliac occlusive disease. In several small laparoscopic series technically demanding aortic operations have been described that have not gained widespread acceptance or applicability. To simplify the laparoscopic approach to the aorta, we have developed a technique of aortobifemoral bypass grafting that uses hand-assisted laparoscopic surgery (HALS) to minimize the complexity of aortic dissection and reconstruction. METHODS: Five patients with symptomatic aortoiliac occlusive disease underwent successful HALS aortobifemoral bypass grafting. With the use of a specialized sleeve device (Hand-Port), an operative hand was introduced into the laparoscopic field while pneumoperitoneum was maintained. Laparoscopic dissection of the infrarenal aorta was then performed with retraction provided by the operative hand. Proximal aortic anastomosis was performed with an open technique through the same 7.5-cm Hand-Port incision, and femoral anastomoses were performed in the standard fashion. RESULTS: Five hand-assisted laparoscopic aortobifemoral bypass grafts were performed (two end-to-end, three end-to-side proximal anastomoses). Mean operative time was 231 minutes. Mean blood loss was 440 mL. All patients underwent extubation immediately after surgery, were ambulatory on postoperative day (POD) 1, and were tolerating their diet by POD 3. The mean length of hospital stay was 3.8 days. One patient was discharged on POD 5 and started a clear liquid diet after a self-limiting postoperative ileus. All patients were asymptomatic and back to full activity/work by 14.6 days postoperatively, on average (range, 11-20 days). CONCLUSION: The HALS offers the advantages of tactile feedback, flexible retraction, and the introduction of conventional surgical instruments, all of which extend laparoscopic surgery and its established benefits to a wide array of more complex surgical problems, including major vascular surgery. Ease of performance, shorter hospital stays, and faster recovery times all suggest that HALS may become a valuable adjunct to conventional aortobifemoral bypass grafting.

Adult↗

Hand-assisted laparoscopic surgery (HALS) with the HandPort system: initial experience with 68 patients.

OBJECTIVE: To evaluate the feasibility and potential benefits of hand-assisted laparoscopic surgery with the HandPort System, a new device. SUMMARY BACKGROUND DATA: In hand-assisted laparoscopic surgery, the surgeon inserts a hand into the abdomen while pneumoperitoneum is maintained. The hand assists laparoscopic instruments and is helpful in complex laparoscopic cases. METHODS: A prospective nonrandomized study was initiated with the participation of 10 laparoscopic surgical centers. Surgeons were free to test the device in any situation where they expected a potential advantage over conventional laparoscopy. RESULTS: Sixty-eight patients were entered in the study. Operations included colorectal procedures (sigmoidectomy, right colectomy, resection rectopexy), splenectomy for splenomegaly, living-related donor nephrectomy, gastric banding for morbid obesity, partial gastrectomy, and various other procedures. Mean incision size for the HandPort was 7.4 cm. Most surgeons (78%) preferred to insert their nondominant hand into the abdomen. Pneumoperitoneum was generally maintained at 14 mmHg, and only one patient required conversion to open surgery as a result of an unmanageable air leak. Hand fatigue during surgery was noted in 20.6%. CONCLUSIONS: The hand-assisted technique appeared to be useful in minimally invasive colorectal surgery, splenectomy for splenomegaly, living-related donor nephrectomy, and procedures considered too complex for a laparoscopic approach. This approach provides excellent means to explore, to retract safely, and to apply immediate hemostasis when needed. Although the data presented here reflect the authors' initial experience, they compare favorably with series of similar procedures performed purely laparoscopically.

Abdomen↗

Follow-up program for emergency department patients with gonorrhea or chlamydia.

OBJECTIVES: To study the performance of a centralized regional follow-up program organized by a municipal department of health (DH) for female patients presenting to the emergency department (ED) with Neisseria gonorrhoeae and/or Chlamydia trachomatis, who are not diagnosed or treated at the time of presentation. METHODS: This was a retrospective observational study of female patients seen in the ED with positive cervical specimens, and their subsequent treatment and follow-up by the DH. Medical records were reviewed to determine the female patients seen in the ED who had positive specimens for N. gonorrhoeae or C. trachomatis. The DH followed up those not treated in the ED. Analysis of how long it took for these patients to be treated and the proportion lost to follow-up was performed. RESULTS: Of 2,121 specimens, 342 were positive for N. gonorrhoeae or C. trachomatis. Of the 342, 154 (45%) were recognized and appropriately treated in the ED. One hundred fifty-nine of the 342 (46.5%) patients were discharged from the ED without treatment but were contacted by the DH and appropriate treatment was provided. The DH could not locate 23 (6.7%) patients, and four (1.2%) refused treatment. One died before treatment. Only 21 of the 159 were treated within nine days. Median time to treatment was 36 days. CONCLUSIONS: Centralized laboratory analysis and follow-up by the DH for N. gonorrhoeae and C. trachomatis identified many female patients undiagnosed and untreated in the ED. The DH follow-up program provided appropriate treatment to most female patients.

Chlamydia Infections↗

High spatial resolution measurements of organ blood flow in small laboratory animals.

With the use of a newly developed Imaging Cryomicrotome to determine the spatial location of fluorescent microspheres in organs, we validate and report our processing algorithms for measuring regional blood flow in small laboratory animals. Microspheres (15-microm diameter) of four different fluorescent colors and one radioactive label were simultaneously injected into the left ventricle of a pig. The heart and kidneys were dissected, and the numbers of fluorescent and radioactive microspheres were determined in 10 randomly selected pieces. All microsphere counts fell well within the 95% expected confidence limits as determined from the radioactive counts. Fluorescent microspheres (15-microm diameter) of four different colors were also injected into the tail vein of a rat and the left ventricle of a rabbit. After correction for Poisson noise, correlation coefficients between the colors were 0.99 +/- 0.02 (means +/- SD) for the rabbit heart and 0.99 +/- 0.02 for the rat lung. Mathematical dissection algorithms, statistics to analyze the spatial data, and methods to visualize blood flow distributions in small animal organs are presented.

Animals↗

Cushing, cortisol, and cardiovascular disease.

Cushing's syndrome of glucocorticoid excess is named after the eminent Boston neurosurgeon Harvey W. Cushing (1869-1939). The recognition that glucocorticoid excess produces hypertension led to examination of the role of cortisol in essential hypertension, but it is only over the last decade that evidence has emerged to support the concept. Despite the widespread assumption that cortisol raises blood pressure as a consequence of renal sodium retention, there are few data consistent with the notion. Although it has a plethora of actions on brain, heart and blood vessels, kidney, and body fluid compartments, precisely how cortisol elevates blood pressure is unclear. Candidate mechanisms currently being examined include inhibition of the vasodilator nitric oxide system and increases in vasoconstrictor erythropoietin concentration.

Cardiovascular Diseases↗