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Biomedical subjects

J R Cohen

Publications and source records attributed to J R Cohen.

At least 19 recordsLinked to original sources
PubMed1992

Greenfield filter instead of heparin as primary treatment for deep venous thrombosis or pulmonary embolism in patients with cancer.

BACKGROUND AND METHOD: During the last 5 years, the authors placed Greenfield filters as primary therapy in 41 patients with cancer with deep venous thrombosis (DVT) and/or pulmonary embolism (PE) instead of administering heparin. RESULTS: There were no operative deaths. Complications included erythema of the incision in one patient, recurrent PE in one patient, and chronic filter prong penetration of the inferior vena caval wall in one patient. Follow-up was complete for 90% (37 of 41) of the patients. Forty-six percent of the patients died of their cancer early in the study. In follow-up, leg swelling improved completely or partially in 74.5% of patients and was unchanged in 22% of patients. The condition of one patient worsened secondary to recurrent DVT. The patients with improved symptoms also had improved functional ability, whereas those whose condition did not change were mostly bedridden, many with end-stage advanced metastatic disease. CONCLUSIONS: These results indicate that Greenfield filter insertion is safe and effective as primary therapy in patients with cancer with DVT and/or PE.

Adult↗
PubMed1992

Increased intestinal permeability: implications for thoracoabdominal aneurysm repair.

Coagulopathy and massive bleeding plays a major role in the mortality of thoraco-abdominal aneurysm repair. Increasing supraceliac aortic cross-clamp time from 0 to 90 minutes increases the degree of disseminated intravascular coagulation, which occurs as a result of occlusion and reperfusion of the superior mesenteric artery. The purpose of this study was to investigate the mechanism of the superior mesenteric artery reperfusion disseminated intravascular coagulation. Twenty dogs were divided into four groups: cross-clamp time of 30 minutes; cross-clamp time of 60 minutes; cross-clamp time of 90 minutes; and control. Permeability was determined by lactulose/mannitol absorption. The venous effluent was sampled for endotoxin, potassium, bacteria, and pH every hour and urine was collected for six hours. Lactulose absorption was significantly higher in all of the experimental groups. There was increased permeability in the 60 and 90 minute groups which correlated significantly with time. Venous endotoxin, potassium, and blood cultures for bacteria did not change significantly. The pH was significantly lower every hour for six hours in the 90 minute group. These data suggest that intestinal permeability is increased with supraceliac aortic clamping and can be kept to a minimum for clamp times of under one hour.

Animals↗
PubMed1992

Factors influencing wound dehiscence.

Thirty-one abdominal fascial wound dehiscences occurred in 2,761 patients undergoing major abdominal surgery during a 5-year period (1%). Twenty-two specific local and systemic risk factors were analyzed and compared with the risk factors of a control group of 38 patients undergoing similar procedures without dehiscence. Through multivariate analysis, each factor was assessed as an independent statistical variable. Significant factors (p less than 0.05) were found to include age over 65, wound infection, pulmonary disease, hemodynamic instability, and ostomies in the incision. Additional systemic risk factors that were found to be significant included hypoproteinemia, systemic infection, obesity, uremia, hyperalimentation, malignancy, ascites, steroid use, and hypertension. Risk factors not found to be important independent variables included sex, type of incision, type of closure, foreign body in the wound, anemia, jaundice, and diabetes. When dehiscence and control groups were combined, 30% of patients with at least five significant risk factors developed dehiscence, and all the patients with more than eight risk factors developed a wound dehiscence. There was an overall mortality of 29%, which was directly related to the number of significant risk factors. The co-existence of 9 risk factors portended death in one third of the patients, and all the patients with more than 10 risk factors died.

Abdominal Muscles↗
PubMed1992

Smooth muscle cell elastase, atherosclerosis, and abdominal aortic aneurysms.

Smooth muscle cells (SMC) were obtained by outgrowth of human aortic explants from abdominal aortic aneurysm (AAA) patients, aortic occlusive disease (AOD) patients, and transplant donors (controls). Specimens were incubated with medium alone or medium with either elastin-derived peptides (EDP, 5 micrograms/mL) or low-density lipoproteins (LDL, 5 micrograms/mL). Elastase activity (ng/mg total protein) was assayed from 4-week-old cultures. Control aortas obtained from patients significantly younger secrete an increased amount of elastase at baseline compared with AOD and AAA patients (p less than 0.05). Elastin-derived peptides caused a significant increase in elastase secretion in all groups. The increase in elastase secretion in response to EDP in AAA patients was significantly higher compared with AOD or control. Low-density lipoprotein had no effect on SMC elastase secretion. These data suggest that (1) aortic SMCs secrete elastase in response to EDP, (2) SMC elastase is age dependent, and (3) AAA SMC secrete an abnormally high amount of elastase compared with AOD and control aortas in response to EDP. Like the neutrophil, the SMC is highly responsive to the degradation products of elastin and in AAA patients secrete significantly increased amounts of elastase in response to the breakdown products of atherosclerosis.

Adult↗
PubMed1992

Risk factors for myocardial infarction after distal arterial reconstructive procedures.

This study identifies the preoperative, intraoperative, and postoperative factors associated with perioperative myocardial infarction (MI). The records of all patients who had distal vascular reconstructive procedures who sustained a perioperative MI were retrospectively reviewed from 1977 to 1990. From a total of 767 procedures, 18 (2.3%) patients suffered a MI. The mean time to MI after surgery was 1.8 days. Diabetes, heart murmur, and previous major amputations were identified as significant risk factors for the development of a perioperative MI. No laboratory or cardiographic data correlated with an increased risk, and the Goldman Index was inadequate in predicting perioperative MI risk.

Age Factors↗
PubMed1991

Atypical response to luteinizing hormone-releasing hormone (LH-RH) agonist (suprefact nasal) in induction of ovulation in in vitro fertilization (IVF).

Animal and human research has indicated the presence of receptors to luteinizing hormone-releasing hormone (LH-RH) in the ovaries. However, the role of these receptors is not yet clear. Forty-five patients were treated with Suprefact (D-Serg-Des-Gly10-GnRGH), starting in the midluteal phase of a nonstimulatory menstrual cycle. The Suprefact (300 micrograms t.i.d.) was administered as a nasal spray until the administration of human chorionic gonadotropin (hCG). On the third to fifth day of the following menstrual cycle, the patients were treated with a high dose of human menopausal gonadotropin (hMG). hCG was administered when at least two follicles reached a mean diameter of 18 mm. Five of these patients who ovulated spontaneously and had normal menstrual cycles did not respond to the stimulation with hMG. Treatment was stopped after 12 days of hMG administration. During the following cycle of the five patients, levels of gonadotropins were found to be in the normal range, and all of them responded as expected to hMG administered for 3 days only (hMG test). These findings suggest that LH-RH agonist may interfere with ovarian steroidogenesis.

Administration, Intranasal↗
PubMed1991

General surgical problems requiring operation in postoperative vascular surgery patients.

Surgical intervention after vascular surgery usually occurs as a result of bleeding or thrombosis, whereas general surgical problems requiring operation after vascular surgery are unusual. The purpose of this study was to review the results of operations for general surgical problems done soon after major vascular surgery. From January 1985 to December 1989, 1,236 major vascular procedures were performed, and 15 patients developed significant postoperative general surgical problems including perforated duodenal ulcer (2), perforated diverticular disease (2), evisceration and dehiscence (2), liver infarct (1), gangrenous cholecystitis (2), clostridial myonecrosis (1), pseudomembranous colitis (1), and small bowel obstruction (4). The overall mortality was very high (47%), and the chance of dying was significantly higher (p less than 0.05) if the initial vascular procedure was an emergency (100% mortality). All the patients who died (n = 7) succumbed to sepsis. There was a long delay in diagnosis in all groups; however, the delay did not correlate with mortality. Although this is a study of a small group of patients with a very heterogenous group of complications, several observations can be made: (1) a general surgical problem after vascular surgery carries a very high mortality; (2) general surgical complications in postoperative vascular patients in whom the initial procedure was an emergency are very poorly tolerated and almost uniformly lethal; and (3) these elderly patients have multiple medical problems and seem unlikely to tolerate any septic insult.

Aged↗
PubMed1991

Neutrophil chemotaxis and neutrophil elastase in the aortic wall in patients with abdominal aortic aneurysms.

To test the hypothesis that elastin-derived peptides (EDP) from human aortic tissue may be chemotactic for inflammatory cells, we studied the chemotaxis of neutrophils and monocytes to EDP derived from abdominal aortic aneurysm (AAA), aortic occlusive disease (AOD), and control aortas. In addition, we determined if neutrophils deliver neutrophil elastase to the aorta in vivo by staining for neutrophil elastase (NE) throughout the course of abdominal aortic aneurysms with the monoclonal antibody to human NE. EDP from AAA, AOD, and control tissue demonstrated significant chemotactic activity for both neutrophils and monocytes. All neutrophils had a greater attraction to EDP from AAA tissue compared to AOD and control aorta. Neutrophils from AAA patients were more attracted to EDP of AAA tissue than were neutrophils of AOD or control patients attracted to their respective aortic EDP. Neutrophil elastase stained positive in the adventitia and thrombus throughout the course of the aneurysm, but was not found in the intima, media, or plaque of the aorta.

Aorta, Abdominal↗
PubMed1991

Hospital costs, resource characteristics, and the dynamics of death for general surgery patients.

The world of health care finance and quality assessment is undergoing rapid change. We analyzed a large group of general surgical patients who died regarding hospital resource consumption. General surgical patients who died generated much greater resource consumption than survivors per DRG; increasing hospital LOS for general surgical patients who died was associated with increasing financial risk under DRGs. Patients who died after non-emergency admission generated similar financial risk to patients who died after emergency admission. General surgical patients who died who were referred from another clinical service generated, on average, similar resource consumption to non-referred patients who died. The results of this study support those of previous studies suggesting the payment inequities of DRGs for general surgical patients who die and suggest that attention should be directed at improving the DRG hospital payment system for these patients.

Aged↗
PubMed1991

Greenfield filter as primary therapy for deep venous thrombosis and/or pulmonary embolism in patients with cancer.

In 1985, as a result of the high complication rate associated with anticoagulants in patients who have cancer and deep venous thrombosis (DVT) and/or pulmonary embolism (PE), we established a policy of placing Greenfield filters (GFs) as primary therapy instead of anticoagulation. Since 1985 we have been asked to consult in the treatment of 18 patients with cancer and with DVT and/or PE, and we have placed a GF in each of these patients. This represented 34% (18/53) of the filters placed during that same period. Over the same 4-year period, 11 patients with cancer and DVT and/or PE underwent anticoagulation therapy. The purpose of this study was to compare the results of anticoagulation versus GF insertion in these two groups of patients. A significantly higher number of major complications (n = 4) occurred in the anticoagulation group (p less than 0.05, Fisher's exact test) than in the GF group (n = 0). The four complications that occurred in the anticoagulation group included three bleeding episodes (tumor bleeding, gastrointestinal bleeding, and hip hematoma) and one PE, despite adequate anticoagulation. Two patients died as a direct result of these complications (PE and gastrointestinal bleeding). The three patients with bleeding complications each required a transfusion of more than 3 units of blood. All four of the patients with complications had metastatic disease (pancreatic carcinoma, chronic lymphocytic leukemia, prostate carcinoma, and uterine carcinoma). Although this is a small, nonrandomized, nonprospective study, the data seem to indicate that GF placement is safer than anticoagulation for DVT or PE in patients with cancer and particularly in patients with metastatic disease. We conclude that GF insertions may be a better primary treatment than anticoagulation.

Adult↗
PubMed1991

Experience in managing 70 patients with ruptured abdominal aortic aneurysms.

Seventy cases of ruptured abdominal aortic aneurysms (RAAAs) repaired over a 14-year period from 1975 to 1989 were analyzed. Age, heart disease, chronic obstructive pulmonary disease (COPD), hypertension, diabetes, or specific postoperative complications did not correlate with mortality. If the time interval from arrival at the hospital to skin incision (emergency room (ER) or operating room (OR] was less than six hours, there was no correlation with survival. Mortality correlated significantly with admitting systolic blood pressure, blood pressure at the time of skin incision, a comparison of ER to OR time of less than or more than six hours, blood loss of less than compared to more than ten units, and time in the operating room of less than five hours compared to more than five hours. Both time in the operating room and blood loss correlated with technical problems. Prior to 1985, 11 general and vascular surgeons had repaired RAAAs with a mortality of 76%. Since 1985, six vascular surgeons repaired RAAAs with a significant decrease in mortality (54%). Our data indicate that patients profoundly hypotensive on admission or at the time of incision are unlikely to survive regardless of other factors; patients with a systolic blood pressure greater than 100 mm Hg have the best chance of survival; a delay of up to six hours prior to surgery in patients with a systolic blood pressure greater than 100 mm Hg does not increase mortality; and a smaller number of surgeons operating on RAAAs increases survival.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1990

The surgical implications of purpura fulminans.

Purpura fulminans is an uncommon catastrophic syndrome that occurs in children, typically one to four weeks after a seemingly benign infectious process. The child usually presents with a high fever, purpuric ecchymosis, hypotension, disseminated intravascular coagulation, and gangrene of the extremities. We have recently treated six children, whose mean age was 22 months; three were male and three were female. Five of the six had a change of mental status upon initial examination. Their mean temperature was 104 degrees F. All six children had purpuric involvement of their extremities; three had involvement of their hands, two had involvement of their faces, and two had involvement of their trunks. All had absent palpable pulses and sluggish capillary refill in the involved hands and feet. Two patients died shortly after admission as a result of severe end-stage sepsis. The platelet counts in these two patients, and the white blood cell counts were markedly depressed. The mean platelet count of the survivors was 370,000 and the mean white blood cell count was 25,000. Lumbar punctures were positive for bacterial meningitis in five patients and viral meningitis in one patient. All patients were treated with intravenous heparin. Of the four survivors, two lost significant tissue and required multiple plastic reconstructive procedures, and two improved on heparin alone with no tissue loss. In addition to systemic support and intravenous antibiotics, the mainstay of treatment is one of immediate heparinization and a continuous heparin drip. Heparin prevents subsequent small vessel thrombosis and limits tissue loss due to ongoing purpura. Conservative management of the purpuric lesions is the treatment of choice until final demarcation occurs.

Anti-Bacterial Agents↗
PubMed1990

Alpha 1-antitrypsin phenotypes in patients with abdominal aortic aneurysms.

The alpha 1-antitrypsin phenotypes were determined in 47 patients with abdominal aortic aneurysms. The MM phenotype was present in 85%, the MS phenotype in 4%, the MZ phenotype in 11%, and the ZZ phenotype not present in any patients. The MZ phenotype occurred significantly more often in patients with aneurysms than would be expected in the general population. The current data would support a genetic mechanism of either autosomal-dominant or multifactorial influences but not an X-linked mechanism for families with a history of abdominal aortic aneurysms.

Aorta, Abdominal↗
PubMed1990

Route of admission and hospital costs for urologic patients.

This study of 2,549 urology patients examined resource consumption by route of admission into the hospital. Almost all urologic admissions were more expensive as emergencies. These more expensive emergency urologic admissions had higher diagnostic costs, a longer hospital length of stay, and a greater severity of illness than their less expensive non-emergency counterpart. The more expensive emergency admission had a high referral rate to urology from non-urologic clinical services. These findings suggest that efficiency might be improved in the emergency urologic patients by increasing the speed of diagnosis and admission of patients to the appropriate clinical service (urology).

Costs and Cost Analysis↗
PubMed1990

The calcium messenger system and the kinetics of elastase release from human neutrophils in patients with abdominal aortic aneurysms.

Aortic elastase and neutrophil elastase is higher in patients with abdominal aortic aneurysms. The purpose of this study was to determine if these proteolytic elevations occur after abdominal aortic aneurysms have been repaired. Specifically, we studied the stimulation and inhibition of elastase degranulation from neutrophils in postoperative abdominal aortic aneurysm patients compared to aortic occlusive disease patients. Neutrophil elastase was determined in postoperative abdominal aortic aneurysm and aortic occlusive disease patients in response to calcium and the ionophore A23187. Inhibition of elastase release was determined with the calcium channel blocking agent Verapamil. Neutrophil elastase secretion was significantly higher in the abdominal aortic aneurysm patients (47%) versus aortic occlusive disease (20%) (p less than .05), while the effect of Verapamil in blocking this response was significantly lower in the abdominal aortic aneurysm patients (14%) compared to aortic occlusive disease patients (27%) (p less than .02). The time for degranulation to occur was longer in the abdominal aortic aneurysm patients (14.7 minutes) versus aortic occlusive disease patients (3.5 minutes), but the rate of secretion was not different between the two groups. These data indicate that, (1) neutrophils secrete more elastase in response to a calcium stimulus in abdominal aortic aneurysm patients; (2) it takes longer to secrete the increased amount of elastase in abdominal aortic aneurysm patients since the rate of secretion is similar between the two groups; and (3) Verapamil blocks elastase secretion ineffectively in abdominal aortic aneurysm patients. We conclude that the proteolytic alterations in abdominal aortic aneurysm patients are more likely a primary event and not a response to the abdominal aortic aneurysm and that Verapamil is a poor drug to use to medically manipulate the protease system in abdominal aortic aneurysm patients.

Aorta, Abdominal↗