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Biomedical subjects

J R Hiatt

Publications and source records attributed to J R Hiatt.

At least 91 records · Page 5Linked to original sources
PubMed1988

Surgical considerations in the management of the immunocompromised patient.

We have attempted to give a broad overview of issues of importance to the surgeon that may arise in the management of the immunocompromised patient. These include airway obstruction, diffuse and focal pulmonary lesions, vascular access problems, gastrointestinal bleeding, perforation, obstruction, and soft tissue infections. Principles of perioperative management in this patient group are discussed in detail. Often they will require broad metabolic and hemodynamic support. The spectrum of pathology ranges from common problems found in the general patient population that present with only subtle clinical findings, making diagnosis difficult, to conditions unique to the patient with a deficient immune system. The importance of early consultation with the surgeon for the indications that have been described cannot be overemphasized. One should attempt to identify certain surgeons who have a particular interest in dealing with these complex problems. It is of the utmost importance for the surgeon to have the guidance of the primary physician with regard to aggressiveness of therapy. This decision must take into account the basic underlying disorder as well as the wishes of the patient and family. Many of these patients can be salvaged despite the seemingly endless problems that may arise along the way.

Acquired Immunodeficiency Syndrome↗
PubMed1988

Impact of urban disaster on a university trauma center.

On the eve of the 1984 Summer Olympics, a deranged man drove his car at high speed onto a pedestriancrowded sidewalk in a suburb of Los Angeles. The UCLA Medical Center, located two blocks from the scene, received 17 of 51 casualties. One patient arrived in full cardiac arrest and could not be resuscitated. Six had minor injuries or temporary hysteria and did not require admission to hospital. The mean injury severity score of the 10 patients who were admitted was 13.6 (range 3 to 48). Three patients required immediate surgical procedures, and two had delayed orthopedic operations. Specialty consultations were needed in orthopedics, neurosurgery, plastic surgery, otolaryngology, pediatric surgery, and pediatric intensive care. There were no subsequent deaths, although two patients had substantial residual neurologic disability. This episode of unexpected urban violence underscores the need for dedicated trauma services in university centers. Functions of such services include disaster planning, deploying surgical personnel, managing injured patients, and analyzing outcomes.

Academic Medical Centers↗
PubMed1987

Effect of endarterectomy on arterial fibrinolytic activator activity.

Although endarterectomy leaves a raw subintimal surface, thrombotic complications are rare. This may be the result of activation of the fibrinolytic system. Fibrinolytic activator activity (FAA) was studied after intimectomy of 3-cm segments of carotid artery in dogs. Endarterectomized segments and contralateral control arteries were resected immediately following intimectomy (group 1) and after blood flow restoration of ten minutes, three hours, and 24 hours (groups 2, 3, and 4, respectively). Areas of fibrinolysis around punch biopsy specimens from each endarterectomy segment and from the control artery were measured. Fibrinolytic activator activity, the ratio of the areas in endartectomized segments to control arteries, was reduced in groups 1 through 3 (mean, 60.7%, 70.1%, and 79.7%, respectively) and was normal in group 4 (94.3%). We conclude that canine FAA is significantly depressed at the endarterectomy site initially but returns to normal at 24 hours. The source of FAA may be synthesis by subintimal structures or delivery by the circulation. During this period of increased thrombogenicity, use of antiplatelet or anticoagulant therapy would be justified.

Animals↗
PubMed1987

Variables influencing the outcome following orthotopic liver transplantation.

Seventy-two patients who underwent orthotopic liver transplantation (OLT) were studied to identify perioperative variables that would predict survival and intraoperative blood loss. Survival and intraoperative blood loss were not affected by encephalopathy, length of donor liver ischemia, or any of the preoperative laboratory values studied. Survival was significantly decreased in patients requiring postoperative dialysis (41%) and in patients who had severe rejection requiring retransplantation (33%). Intraoperative blood loss was significantly greater in patients over 50 years of age (11.6 blood volumes) and patients with biliary atresia (8.7 blood volumes). These results may aid in choosing future recipients for orthotopic liver transplantation and in anticipating the postoperative support needed.

Adolescent↗
PubMed1987

A prospective study on the use of monoclonal anti-T3-cell antibody (OKT3) to treat steroid-resistant liver transplant rejection.

Conventional treatment of acute liver allograft rejection has included high doses of corticosteroids and antithymocyte globulin. Urgent retransplantation was the only option for patients who failed to respond. We report our initial experience with the use of monoclonal anti-T3-cell antibody (OKT3) in 25 patients with acute hepatic allograft rejection that was resistant to steroid and/or antithymocyte globulin therapy. Twenty-four of 25 patients had a response to OKT3, which was complete in 14 and partial in ten. With a mean follow-up of 8.2 months, allograft salvage has been 80% and patient survival 88%; two patients underwent successful retransplantation. Side effects have been mild and well tolerated. Repeated rejection has occurred in 40% of patients, but these episodes have responded to steroid therapy. We conclude that OKT3 is well tolerated and highly effective in reversing severe episodes of acute hepatic allograft rejection that is resistant to high-dose steroid therapy.

Acute Disease↗
PubMed1987

The amylase profile: a discriminant in biliary and pancreatic disease.

Serial serum amylase determinations were made in 85 consecutive patients who presented with an initially elevated value. In 35 patients (Group A), the clinical findings were consistent with biliary tract disease. All underwent cholecystectomy for documented cholelithiasis within a week of diagnosis, and 23 percent had choledocholithiasis as well. Fifty patients (Group B) presented with a first episode of acute alcoholic pancreatitis. An amylase profile, consisting of initial and final values and the daily rate of change, was significantly different between the two groups. The initial serum amylase value was higher in Group A patients and decreased more rapidly to a lower value than in Group B patients. We conclude that both the initial value and pattern of serum amylase decay distinguish the hyperamylasemia of biliary tract disease from that of alcoholic pancreatitis.

Acute Disease↗
PubMed1987

Management of soft-tissue infections of the upper extremity in parenteral drug abusers.

Management of extensive soft-tissue infections of the upper extremity in 23 parenteral drug abusers was reviewed. Bacterial cultures most often revealed oral flora, including streptococcal species in 77 percent of patients and anaerobes in 59 percent. Staph. aureus was present in only one patient. Ninety percent of the organisms were sensitive to penicillin and 98 percent to first-generation cephalosporins. Blood culture specimens, obtained at admission, were negative in 15 patients. All patients responded well to operative debridement, excision of involved veins, and local wound care. Surgical debridement is the mainstay of therapy. We believe that intravenous antibiotic therapy with a first-generation cephalosporin should be used in the acute phase for control of surrounding cellulitis and prevention of bacteremia.

Abscess↗
PubMed1987

Fulminant hepatic failure: the role of liver transplantation as primary therapy.

Fulminant hepatic failure is a clinical syndrome with a high mortality rate when traditional supportive therapy is used as treatment. Orthotopic liver transplantation has been proposed as a therapeutic option. Clinical and logistic difficulties include the rapid deterioration of the patients, unpredictable recovery, and the immediate need for a donor organs. Including this series, a total of 41 patients with fulminant hepatic failure have been transplanted, with a survival rate of 61 percent. We have reported eight liver transplantations carried out in six patients. Four of the patients survived (66 percent). Death was due to irreversible neurologic dysfunction in one patient and fungal sepsis in one patient. These results indicate that orthotopic liver transplantation is a practical therapeutic option for fulminant hepatic failure which should be considered early, before neurologic deterioration becomes irreversible.

Acute Disease↗
PubMed1987

The first 100 liver transplants at UCLA.

A clinical program in liver transplantation was begun at UCLA in 1984 after a period of laboratory investigation. The first 100 orthotopic liver transplants (OLT) were performed in 83 patients (43 adults and 40 children) between February 1, 1984 and November 1, 1986. Donors and recipients were matched only for size and ABO blood group compatibility, with OLT performed across blood groups in 28 patients. Standard operative techniques were used, including venous-venous bypass in adults. Arterial reconstruction was performed using an aortic Carrel patch or "branch patch" in 65% of cases and by end-to-end or aortic conduit techniques in the remainder. The hepatic artery thrombosis rate was 5%. Biliary reconstruction was choledochocholedochostomy in 67 OLT and Roux-en-Y choledochojejunostomy in 33 (complication rate of 24% and 24%, respectively). Average lengths and ranges of donor liver ischemia, operating time, and blood replacement were 4 hours (range: 1-10 hours), 7.6 hours (range: 4-15 hours), and 17 units packed cells (range: 2-220 units). Immunosuppressive regimen was cyclosporine-steroid combination, with monoclonal anti-T-cell antibody (OKT3) used for refractory rejection. All patients had one or more complications: pulmonary (78%), infectious (51%), renal dialysis (25%), neurologic (22%). All patients had at least one episode of acute rejection, and 3.6% had chronic rejection. Retransplantation was needed in nine patients once and in four patients twice. The overall retransplant survival rate was 54%, and two of four patients who received a second retransplant are alive. Sixty-three of the 83 patients (76%) are alive (adults 72%, children 80%). The 1- and 2-year actuarial survival rate is 73% (adults 68%, children 78%). Thirty-eight of 43 patients (88%) who had transplantation in the past year are alive. Of 14 perioperative variables assessed as predictors of early mortality, only postoperative dialysis (p less than 0.0005) and presence of severe rejection (p less than 0.01) had statistical significance. Seventy per cent of adults returned to work, and 84% of children had normal or accelerated growth. A new program in liver transplantation provides a dramatic option in patient care and an academic stimulus to the entire medical center.

Adolescent↗
PubMed1987

The importance of nonoperative trauma management in postgraduate surgical education.

The activities of a trauma service in a university hospital were analyzed to test the hypothesis that operative caseload alone does not adequately measure the trauma experience of a surgical resident. Over a 2-year period, 378 victims of major trauma (blunt in 79%) were admitted to the service. Only 41% of them required a major operation by the Trauma Service. The patients spent an average of 2.8 days in the intensive care unit and often presented complex challenges in surgical critical care, including ventilator support and hemodynamic monitoring. A trauma service in a university center manages significant numbers of patients with multisystem injuries who never undergo a general surgical procedure. This experience constitutes such an important component of surgical education in trauma that it should be recognized by agencies accrediting residents and training programs. Completion of surgical residency should also imply competence in critical care of surgical patients.

Academic Medical Centers↗
PubMed1987

Operations upon the biliary tract during transplantation of the liver.

Operation upon the biliary tract is a discipline within transplantation of the liver. There exists a background of basic science information concerning anatomy and physiology, an historical evolution of surgical techniques, a divergence of contemporary opinion regarding preferred approaches and a body of well described complications. The complication rate, once more than one-half with substantial contribution to mortality rates, now ranges from approximately 15 to 25 per cent. Current practice in most institutions is to use choledochocholedochostomy with T-tube stent when a recipient duct is present and Roux-en-Y choledochojejunostomy with internal stent when a suitable recipient duct is absent. Hepatic arterial thrombosis is an important cause of complications of the biliary tract. The overlap of symptoms and signs of rejection with those of biliary sepsis and other complications of the biliary tract underscores the need for algorithmic use of diagnostic modalities in the post-transplant period.

Biliary Tract Surgical Procedures↗
PubMed1987

Percutaneous aspiration of peripancreatic fluid collections: a safe method to detect infection.

During the past 5 years, we have used percutaneous aspiration of peripancreatic fluid collections guided by computed tomography (CT) or ultrasonography (US) to facilitate diagnosis of infection in selected cases. Fifteen of 18 patients undergoing guided needle aspiration had persistent fevers (greater than 38.3 degrees C). The three afebrile patients all had abdominal pain and leukocytosis, and two of the three also had elevated serum amylase levels. Percutaneous aspiration was guided by CT in 14 patients and by US in four. On the basis of aspirate Gram stains and cultures, as well as surgical (15) and percutaneous drainage (1) findings, the final diagnosis was pancreatic abscess in nine patients, infected pseudocyst in four, uninfected pseudocyst in four, and cystadenoma in one. Diagnosis based on percutaneous aspiration was correct in 17 of 18 patients (94%), and no complications could be directly attributed to the procedure. We conclude that CT- or US-guided percutaneous aspiration is a safe and accurate diagnostic procedure for patients with peripancreatic fluid collections in whom secondary infection is suspected.

Abscess↗