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Biomedical subjects

M D Goldman

Publications and source records attributed to M D Goldman.

At least 19 recordsLinked to original sources
PubMed1995

Inspiratory fall in systolic pressure in normal and asthmatic subjects.

We used a noninvasive monitor of arterial pressure to determine whether respiratory changes in arterial pressure were closely correlated with airflow obstruction in asthmatic patients during bronchial challenge with methacholine. To validate the noninvasive measurement of respiratory changes in arterial pressure, a preliminary study in 6 subjects with normal cardiovascular and respiratory systems was done during cardiac catheterization for suspected coronary artery disease. There were no significant differences between inspiratory falls in systolic pressure measured noninvasively and those measured from intraaortic pressure. In 11 otherwise healthy asthmatic patients we measured finger arterial pressure, end-expiratory lung volume (FRC), and forced expired volume (FEV1) during baseline and bronchial challenge in the supine posture. Finger arterial pressure was also measured in 11 normal control subjects seated and supine. Normal subjects had an inspiratory fall in systolic pressure (IFSP) of 3.2 mm Hg supine and 5.1 mm Hg seated (p < 0.01). Asthmatic patients when bronchodilated (seated FEV1 = 83 +/- 7% of predicted) had an IFSP of 5.9 mm Hg supine (p < 0.01 compared with supine normal subjects). During bronchial challenge (average fall in FEV1 = 22%), IFSP increased to 16.1 mm Hg (p < 0.001 compared with baseline). In asthmatic subjects, there was a significant correlation between IFSP and FEV1 (mean r = -0.92 +/- 0.05, p < 0.01), and the average change in IFSP/change in FEV1 was -0.38 mm Hg per percentage change in FEV1. During subsequent bronchodilation, IFSP decreased with a similar time course as relaxation of airway smooth muscle, assessed by the breath-to-breath fall in FRC.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1994

Time course of postoperative hypoxaemia.

OBJECTIVE: To study the time course of nocturnal episodic and constant hypoxaemia during the first five nights after a major abdominal operation in patients not given supplementary oxygen. DESIGN: Open study. SUBJECTS: 17 patients undergoing major elective operations and with no recognised risk factors. MAIN OUTCOME MEASURES: Arterial oxygen saturation measured by pulse oximetry. RESULTS: The level of constant hypoxaemia was lowest during night 2 (p < 0.01) as was the time spent below 90% saturation (p < 0.01) compared with the other four postoperative nights. Episodic hypoxaemia was most common during night 3 (p < 0.05). It was not possible to predict the postoperative occurrence of hypoxaemia from the preoperative spirometric measurements. Preoperative awake arterial oxygen saturation correlated significantly with mean constant hypoxaemia on postoperative nights 1, 3, 4, and 5, but not with episodes of sudden desaturation after operation. Preoperative overnight oximetry correlated significantly with constant hypoxaemia on all five postoperative nights and with episodic hypoxaemia on nights 3 and 4. CONCLUSION: In the light of these results which show the natural history of postoperative hypoxaemia without supplementary oxygen, and because postoperative hypoxaemia may be associated with dysfunction of organ systems after major operations, controlled studies of supplementary oxygen in the late postoperative period are warranted.

Abdomen↗
PubMed1994

Surveillance policy for early detection of failing arteriovenous fistulae for haemodialysis.

We have developed a programme of surveillance for arteriovenous fistulae. Indications for investigation were a reduction of thrill or pulsation on the fistula, decreasing flow (< 200 ml/min) and/or increased venous return pressure (> 150 mmHg.) when on haemodialysis. Between March 1992 and February 1993 we performed intravenous digital subtraction fistulograms in 17 patients. These investigations demonstrated vein stenosis in 11 patients, nine with primary arteriovenous fistulae and in two with secondary access. There was disease of the arterial inflow in one, and no evidence of anatomical problems in the remaining five. As a result revision surgery was performed in 10 cases and percutaneous transluminal angioplasty in the remaining two cases. Five patients underwent dialysis the following day on the same site, avoiding temporary access. Sixteen patients (94%) are still using the same site for haemodialysis at mean follow-up time of 6.1 months (range 2-12 months) and one failed subsequently. Close surveillance of arteriovenous fistulae leads to detection of stenosis prior to occlusion and intervention increases patency, preserves alternative access sites, and prevents central venous cannulation for temporary access.

Adult↗
PubMed1993

Repetitive nocturnal arterial oxygen desaturation and silent myocardial ischemia in patients presenting for vascular surgery.

OBJECTIVE: To determine whether nocturnal respiratory abnormality (cyclic oxygen desaturation and tachycardia) is associated with nocturnal myocardial ischemia in older individuals with ischemic heart disease. DESIGN: Non-invasive monitoring on a single occasion. SETTING: Tertiary care referral hospital. PATIENTS: Thirty four consecutive older (68.5 +/- 6 yrs) patients referred for elective abdominal or carotid reconstructive vascular surgery. RESULTS: Seven patients (21%) had moderately severe nocturnal respiratory abnormality, defined by more than 50 dips in arterial oxygen saturation and increases in heart rate during the night. Two of these seven had clinical risk factors for ischemic heart disease and had nocturnal myocardial ischemia. Ten patients (29%) developed ischemia at some time during the study, of whom seven hand known ischemic heart disease, hypertension, and/or angina. Those with increased nocturnal ischemia showed very low frequency (1-2 cycles per minute) cyclic heart rate oscillations and repetitive nocturnal episodes of arterial oxygen desaturation, similar to patients with sleep apnea. CONCLUSION: Repetitive nocturnal cyclic arterial desaturation and cyclic increases in heart rate are associated with nocturnal myocardial ischemia in individuals with clinical risk factors for ischemic heart disease. Further investigation in a large patient sample utilizing non-invasive monitoring of saturation, heart rate, and blood pressure may provide definitive evidence regarding causation of some of the nocturnal myocardial ischemia occurring in older individuals with vascular disease.

Aged↗
PubMed1993

Comparison of thoracoabdominal calibration methods in normal human subjects.

In 19 normal subjects in the supine posture, we compared accuracy and precision of calibration methods that utilized different ranges of tidal volumes and thoracoabdominal partitioning: spontaneous quiet breathing (QB), isovolume maneuvers, and voluntary efforts to breathe with variable tidal volume and thoracoabdominal partitioning. Thoracic and abdominal movements were measured with the respiratory area fluxometer. Calibration methods utilizing one or more types of respiratory efforts were applied to three measurement situations: QB, variable breathing (volume and thoracoabdominal partitioning), and simulated obstructive apnea (isovolume efforts). Qualitative diagnostic calibration (QDC) included QB data only. The isovolume method (ISOCAL) included isovolumetric efforts at end expiration (functional residual capacity) and QB. Multilinear regression analyses were performed on data sets that included 1) voluntary efforts to breathe with variable volume and thoracoabdominal partitioning (CAL 1), 2) QB in addition to variable volume and partitioning (CAL 2), and 3) isovolume maneuvers in addition to QB and variable volume and partitioning efforts (CAL 3). When calibration data included a wide range of tidal volume, variable thoracoabdominal partitioning, and isovolume efforts (CAL 3), a stable calibration with small bias and scatter during all respiratory patterns was obtained. Excluding isovolume maneuvers (CAL 2) and QB (CAL 1) did not diminish accuracy. Limiting data to isovolume efforts at functional residual capacity plus QB (ISO-CAL) caused a significant increase in scatter during variable breathing patterns. Limiting calibration data to that portion of QB with small variation in the uncalibrated sum of thoracic and abdominal movements (QDC) caused significant increases in scatter in both isovolume efforts and variable breathing.

Abdomen↗
PubMed1992

Postoperative hypoxaemia after major abdominal vascular surgery.

We have studied the severity and duration of nocturnal hypoxaemia before operation and for the first five nights after operation after elective major abdominal vascular surgery. Oxygen supplementation was almost 100% effective in keeping oxygen saturation greater than 90% during the early postoperative period; however, 50% of patients spent prolonged periods with an SpO2 less than 85% during at least one night after operation. The risk of severe hypoxaemia persists well beyond the current prescription of supplementary oxygen in these high risk patients. A significant association exists between the mean preoperative overnight saturation value and the nocturnal saturation observed subsequently in the later postoperative period.

Adult↗
PubMed1992

Neoadjuvant PFL augmented by methotrexate and piritrexim followed by concomitant chemoradiotherapy for advanced head and neck cancer: a feasible and active approach.

To increase the complete remission (CR) rate achieved with two cycles of cisplatin, continuous infusion fluorouracil (5-FU) and oral leucovorin (PFL) we added two antifolate drugs, methotrexate (MTX) and the lipophilic piritrexim (PTX), to the combination (PFL-MP). Twenty-eight patients with previously untreated Stage IV squamous cell carcinoma of the head and neck received 2 cycles of cisplatin 100 mg/m2 on day 1 followed by a 5-day continuous infusion of 5-FU at 800 mg/m2/day and 100 mg of leucovorin administered orally every 4 hours. MTX was administered at 40 mg/m2 IV on day 15 and PTX at 75 mg orally twice daily on days 22 to 26, with cycle 2 starting on day 36. After 2 of the first 5 patients had tumor progression between days 15 and 35, the regimen was intensified to MTX 50 mg/m2, PTX 100 mg twice daily and a cycle duration of 28 days. Local therapy consisted of surgery and/or radiotherapy with concomitant 5-FU and hydroxyurea (FHX) administered every other week. Eleven patients (39%, 95% confidence intervals 21-57%) had a CR, 9 (32%) had a PR, and four patients had no response. Four patients were unevaluable for response to PFL-MP. Patients with poor performance status or N3 disease were less likely to achieve a CR. Mucositis following PFL was the dose-limiting toxicity. Local therapy included surgery in 15 patients and FHX chemoradiotherapy in 19 patients. The administration of FHX in this setting proved feasible and the regimen was given near the intended dose intensity in the majority of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1992

Late postoperative nocturnal dips in oxygen saturation in patients undergoing major abdominal vascular surgery. Predictive value of pre-operative overnight pulse oximetry.

Twenty-four patients (23 male) who presented for aortic reconstructive surgery were studied with pulse oximetry on a pre-operative night and during the first five postoperative nights. Patients with five or more dips in oxygen saturation of greater than 4% (with a prompt recovery back toward baseline of 3% or more) per hour of monitoring were classified as having a significant abnormality of respiration. Pre-operatively, four of 24 patients (17%) demonstrated such an abnormality. Postoperatively, 12 patients (50%) met these criteria on at least one of the first five postoperative nights and six of these had two or more nights with severe episodic hypoxaemia. Frequent severe episodic dips in arterial oxygen saturation (to less than 85% saturation) occurred in the late postoperative period at a time when oxygen therapy would usually have been discontinued. Pre-operative overnight pulse oximetry studies fail to predict the development of abnormal respiratory patterns in the postoperative period in the majority of patients.

Adult↗
PubMed1992

Vascular access surgery: a 2-year study and comparison with the Permcath.

The results of a 2-year prospective study of primary and secondary vascular access surgery for haemodialysis have been compared with a retrospective study of central venous access via a flexible silicone catheter (Permcath). Cumulative patency for 61 primary fistulae in 57 patients was 64.8% at 1 year and 57.7% at 2 years. The patency of 55 secondary procedures in 43 patients was 48.1% at 1 and 2 years. Cumulative survival of 64 Permcaths inserted into 51 patients was 74% at 1 year and 43% at 2 years. Surgical complications included explorations for bleeding (2), haematomas (4), swollen arms (4), and inadequately dilated veins (4). Permcath complications included explorations for bleeding (3) and a temporary recurrent laryngeal nerve palsy (1). Exit site infection and septicaemia rates were 4.95 and 3.36 per 1000 catheter days respectively, but 20.6% of septicaemic episodes occurred in a patient who refused catheter removal. For haemodialysis, the Permcath is comparable with secondary vascular access. The Permcath may have a primary access role in patients with limited life expectancy.

Actuarial Analysis↗
PubMed1991

Haemodynamic effects of periodic ventilation: abolition with supplementary oxygen.

A 63-yr-old man was noted to breathe with a periodic pattern of ventilation during sleep, both before and after operation for coronary artery grafting, and 6 weeks later after aortic aneurysm repair. Periodic ventilation was associated with cyclic oxygen desaturations and increases in heart rate and arterial pressure. Administration of oxygen was found to abolish consistently the periodic pattern and the associated haemodynamic changes.

Hemodynamics↗
PubMed1991

Postoperative myocardial ischaemia: temporal association with nocturnal hypoxaemia.

Three patients presenting for elective aortic surgery were studied before operation and for up to 3 days after operation with ambulatory electrocardiographic monitoring and nocturnal pulse oximetry. Supplementary oxygen was administered for the first 2 days after operation and withdrawn on the 3rd morning after operation. Heart rate remained increased for the first 3 days after operation. Two patients developed episodes of myocardial ischaemia during the first 48 h after operation while their arterial oxygen saturation remained greater than 90%. On the third day, and during the third night after operation, both the severity and duration of myocardial ischaemia increased markedly, associated with arterial hypoxaemia. A temporal relationship between decreases in oxygen saturation and fluctuations in ST segment level were observed in the three patients.

Aged↗
PubMed1991

Postoperative obstructive sleep apnoea. Haemodynamic effects of treatment with nasal CPAP.

A 74-year-old man presenting for aortic reconstructive surgery showed severe, previously undiagnosed obstructive sleep apnoea during overnight oximetry monitoring before operation. Postoperatively, in the first 4 hours following extubation, he suffered 238 episodes of respiratory obstruction. These events were associated with frequent arousals, large fluctuations in systolic and diastolic blood pressure. Administration of nasal continuous positive airways pressure abolished the obstructions and allowed an uninterrupted night's sleep, with a significantly reduced blood pressure. Subsequent dips in oxygen saturation as a result of respiratory obstruction recurred on the fifth postoperative night. We conclude that pre-operative overnight oximetry may be useful in identifying those patients at risk of postoperative upper airway obstruction. Use of nasal continuous positive airway pressure may prevent the occurrence of early postoperative obstruction and the associated haemodynamic changes.

Aged↗
PubMed1991

The incidence and value of rectal examination in children with suspected appendicitis.

Rectal examination is considered an important part of the examination of patients presenting with abdominal pain. However, children find anal digitation unpleasant and it was our impression that doctors were becoming less insistent on performing a rectal examination. We performed an audit of rectal examination and assessed whether this made any difference to the management of children with acute abdominal pain. We looked at the records of 48 children from 1989 and 49 children from 1985 presenting with abdominal pain. We found that the rate of rectal examination was halved in this time. Diagnostic accuracy was similar in the two groups, and the morbidity rate was the same. These findings call into question the need for routine rectal examination in children with suspected appendicitis.

Abdomen, Acute↗
PubMed1990

A randomized study comparing two regimens of neoadjuvant and adjuvant chemotherapy in multimodal therapy for locally advanced head and neck cancer.

Two regimens of neoadjuvant chemotherapy for previously untreated patients with locally advanced head and neck cancer were compared with the goal of identifying a regimen with a greater than 50% complete response (CR) rate. Patients with a performance status of 0 to 2 and normal end-organ function were randomized to receive either four cycles of neoadjuvant methotrexate, cisplatin, and continuous infusion 5-fluorouracil (5-FU) (MPF) (arm A), or four cycles of bleomycin, cisplatin, and methotrexate (PBM) alternating with cisplatin and 5-FU (PF) (arm B). Patients with a performance status of greater than 2 or a carbon monoxide diffusion capacity of less than 50% of the predicted value were assigned to the arm A regimen but were analyzed separately (arm C). Local therapy consisted of surgery (for patients with resectable disease) or radiation therapy followed by two cycles of adjuvant chemotherapy with the regimen that was administered initially. Of the 42 patients who were evaluated, 16 were randomized to arm A, 13 to arm B, and 13 to arm C. The clinical CR rate was 19% on arm A (95% confidence interval, 0% to 38%), 39% on arm B (95% confidence interval, 12% to 66%) (P = 0.41), and 54% on arm C (95% confidence interval, 27% to 81%). At a median follow-up time of 35 months, the 2-year actuarial survival rate was 61% on arm A, 69% on arm B (the P value was not significant), and 38% on arm C. The 2-year survival rate for all 42 patients who were treated was 57% and the median survival time was 31 months. Toxicities of neoadjuvant chemotherapy on all arms consisted of mild to moderate myelosuppression and renal toxicity. The incidence of moderate to severe mucositis was significantly higher on arm A than arm B (P = 0.02). Two cycles of adjuvant chemotherapy were administered to only 11 of 42 patients due to patient refusal or cumulative toxicity. In conclusion, both neoadjuvant chemotherapy regimens resulted in similar response and survival rates, but mucositis was more severe with arm A. However, since neither regimen was likely to cause a CR rate of greater than 50%, this study was closed to further patient accrual.

Adult↗
PubMed1990

Is there central respiratory depression after intravenous administration of propranolol?

Beta-adrenergic blockers have been reported to depress central ventilatory drive. The authors investigated this possibility in a double-blind, randomized fashion in 12 healthy volunteers who received 0.1 mg.kg-1 of propranolol and normal saline intravenously at two separate study sessions. A modified Read rebreathing technique was used. Both ventilatory and occlusion pressure responses to CO2 were measured to help separate peripheral (airway) from central mechanisms. Significant beta blockade was demonstrated by statistically lower heart rate responses to CO2 rebreathing after propranolol, but not normal saline. Nevertheless, propranolol exerted no significant effect on resting end-tidal CO2 or the ventilatory and occlusion pressure responses to CO2. Although health subjects appear to have minimal alterations in their ventilatory response to CO2 after beta-adrenergic blockade, patients with airway disease may still experience significant changes in ventilation. In addition, drug interaction studies may give further insight into the presence or absence of any respiratory effects of propranolol.

Adult↗
PubMed1989

Hydroxyurea, fluorouracil, and concomitant radiotherapy in poor-prognosis head and neck cancer: a phase I-II study.

Hydroxyurea and fluorouracil (5-FU) are active cytotoxic drugs in head and neck cancer and have shown synergistic activity in vitro. Both drugs also act as radiosensitizers. Therefore, we administered radiotherapy at daily fractions of 180 to 200 cGy with simultaneous continuous infusion 5-FU at 800 mg/m2/d and escalating daily doses of hydroxyurea for five days. Cycles were repeated every other week until completion of radiotherapy. Thirty-nine inoperable patients were treated at six dose levels of hydroxyurea ranging from 500 mg to 3,000 mg orally daily. Little effect of hydroxyurea on the WBC or platelet count was noted in patients receiving less than 2,000 mg daily, whereas both parameters decreased progressively in patients receiving 2,000 mg daily or more. Mucositis occurred at all dose levels, requiring frequent dose reduction of 5-FU; however, in patients receiving a daily hydroxyurea dose of 2,000 mg or less, the median weekly 5-FU dose administered was 1,725 mg/m2 (86% of the intended 5-FU dose), whereas at daily hydroxyurea doses exceeding 2,000 mg, the median weekly 5-FU dose decreased to 1,133 mg/m2 (57%) (P = .001). Of 15 evaluable patients with recurrent disease after prior local therapy only one failed to respond; six had a complete response (CR), and eight a partial response (PR). Of 17 evaluable patients without prior local therapy, 12 had a CR, with no patient developing recurrence in the irradiated field to date; five patients had a PR. We conclude that the recommended dose of hydroxyurea in this regimen is 2,000 mg daily. That dose will cause mild to moderate myelosuppression and will allow for delivery of greater than 80% of the intended 5-FU dose. The activity of this regimen in poor-prognosis head and neck cancer exceeds 90%; its further investigation in previously untreated patients is warranted.

Adult↗