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Biomedical subjects

M D Kerstein

Publications and source records attributed to M D Kerstein.

At least 91 records · Page 5Linked to original sources
PubMed1994

Adverse outcome of nonoperative management of intimal injuries caused by penetrating trauma.

PURPOSE: The objective of this study was to determine adverse outcomes associated with the nonoperative management of intimal injuries. METHODS: A five-year retrospective review of 118 patients admitted with soft signs of vascular injury to two level I trauma centers was conducted. All injuries evaluated were isolated penetrating injuries. The number of major arteries at risk were 16 axillary, 31 brachial, 36 common femoral, 22 superficial femoral, and 13 deep femoral. Twenty-three angiographic abnormalities were identified in 23 limbs. Seven injuries were categorized as "minor" intimal flaps and treated with observation alone. The remainder were explored during operation. RESULTS: During the follow-up period, six of the seven patients treated without operation returned to either the outpatient clinic or emergency department with acute onset of pain or paresthesia in the previously injured limb. The following abnormalities were identified with angiography: one axillary artery thrombosis, one brachial artery pseudoaneurysm, two common femoral thromboses, two superficial femoral artery/superficial femoral vein fistulas, and one deep femoral artery pseudoaneurysm. All the abnormalities were repaired with operation. CONCLUSION: The benign nature of intimal injury identified with angiography may be overemphasized. The results of long-term follow-up in patients with this type of injury must be reviewed before "observation alone" can be recommended as standard treatment.

Adolescent↗
PubMed1994

The role of echocardiography in blunt chest trauma: a transthoracic and transesophageal echocardiographic study.

Previous studies assessing the value of transthoracic echocardiography (TTE) in blunt chest trauma are limited because patients with severe chest wall injury often have suboptimal echocardiographic findings. Transesophageal echocardiography (TEE) can provide high quality images when the transthoracic image quality is poor. To provide complete echocardiographic assessment of cardiac structure and function we prospectively performed TTE in 105 patients with severe blunt chest trauma and TEE in 20 of the 105 patients (19%) whose TTE examination results were suboptimal. Myocardial contusion was diagnosed in 31 patients (30%), 22 by TTE and nine by TEE. Cardiac complications developed in 8 of 31 patients (26%) with myocardial contusion compared with 2 of 74 patients (3%) with normal echocardiographic findings (p = 0.001). Cardiac complications required treatment in only four patients. Echocardiography was of value in detecting severe right ventricular dysfunction as the cause of hypotension in two patients with suspected cardiac tamponade. Four patients with myocardial contusion died compared with two patients with normal echocardiographic findings (p = NS). No death was related to the cardiac status. In addition, TEE detected aortic injury in five patients, four with focal intimal tears and one with an aortic transection. We conclude that myocardial contusion is common following blunt chest trauma, rarely requires treatment, and is associated with a favorable prognosis. Only patients who develop cardiac complications benefit from echocardiography. Transesophageal echocardiography is of value when the TTE examination results are suboptimal and when aortic injury is suspected.

Abbreviated Injury Scale↗
PubMed1994

Primary aortoenteric fistulas: a case report.

Primary aortoenteric fistulas are rare vascular entities. Their recognition involves astute clinical observation. Diagnostic testing is frequently nonconfirmatory and usually impedes urgently needed operative intervention. We present a case of primary aortoenteric fistula and emphasize the necessity for immediate surgical evaluation.

Aged↗
PubMed1994

Evaluation of multiple vascular reconstructive procedures with synthetic graft occlusions.

The objective of this study was to evaluate the efficiency of multiple vascular reconstructive procedures in the presence of an occluded synthetic graft. Over a four year period seventy-seven occluded synthetic grafts were treated with urokinase and reconstruction. Follow-up ranged from 1 to 1627 days (4 years, 5 1/2 months). Kaplan-Meier and generalized Wilcoxon test were used to determine patency and limb salvage rates. The cases were divided into three groups according to the number of previous reconstructive events. Group I consisted of patients that had undergone one previous vascular reconstructive procedure. Group II consisted of patients that had undergone two previous vascular reconstructive procedures. Group III consisted of patients who had undergone three or more previous reconstructive procedures. In Group I, the one, two, and three year patency rates were 48.6%, 34.7%, and 26.0% and the limb salvage rates were 76.2%, 67.9%, and 67.9% for one, two, and three years respectively. The Group II patency rates were 41.9%, 24.4%, and 16.3% and the limb salvage rates were 73.7%, 66.3%, and 66.3%. The Group III patency rates were 31.8%, 5.5%, and 5.5% and the limb salvage rates were 76.6%, 54.8%, and 54.8%. The patency rate was significantly reduced when Group III was compared to Group I (p < 0.01). There was no statistically significant difference in limb salvage rates between any of the groups. These results indicate that the number of secondary vascular reconstructive procedures combined with thrombolysis had no correlation with the prognosis of limb salvage.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗
PubMed1994

Fasciotomy in vascular trauma: is it too much, too often?

Fasciotomy has been used as a prophylactic measure against development of compartment syndrome and as a treatment modality when the syndrome has developed in patients suffering vascular trauma. The hospital records of 36 patients who underwent surgical repair of their traumatic vascular injuries were reviewed. All 36 patients had at least one indication for fasciotomy at the time of repair; i.e., ischemic time of more than 6 hours or combined arterial and venous injury. Prophylactic fasciotomies were performed in 18 of the patients at the time of vascular repair; 18 did not have fasciotomies performed at the time of initial repair. The decision to perform a fasciotomy was made by the operating surgeon based on well-defined criteria. Hospital stay was significantly longer for the fasciotomy group. Four of the fasciotomy-related complications were infective in nature. Only one patient who did not undergo fasciotomy at the time of original repair developed a compartment syndrome during the postoperative period. Selective fasciotomy based on well-defined criteria instead of serial physical examinations or measurement of compartment pressures will effectively save limbs; there is an increased hospital stay.

Adolescent↗
PubMed1994

Role of computed tomography scan in evaluating the widened mediastinum.

Thirty-eight blunt trauma patients with a suspicion of thoracic aortic injury were assessed by computed tomography (CT) scan, aortography, and chest x-ray. Twenty-eight of the 38 patients had widened mediastinum by chest x-ray; four of 13 CT scans were abnormal. No patient with a negative CT scan had aortic injury by aortogram. A normal, non-dynamic CT scan of the chest should influence one's decision-making in the need for aortography.

Aorta, Thoracic↗
PubMed1993

'Routine' radiologic evaluation of the thoracolumbar spine in blunt trauma patients: a reappraisal.

A retrospective review of 756 blunt trauma cases at a level I trauma center was conducted to determine the role of thoracolumbar (TL) spine roentgenograms in the management of asymptomatic patients. Thoracolumbar spine films were obtained on 106 patients. The charts from 99 patients were available for thorough review. Fifty-five patients had negative clinical evidence of TL spine injury; all of these (100%) had negative radiographic evidence of fracture or dislocation on the TL spine films. Twenty-four patients had positive clinical evidence of TL spine injury; 14 (58%) had corresponding radiographic evidence of TL spine injury. Of the 20 patients in whom the clinical examination was equivocal, one (5%) had radiographic evidence of TL spine injury. We conclude that physical examination is reliable for assessing the TL spine, and that in the absence of clinical evidence of injury, TL spine films are unnecessary. In patients with equivocal examinations, TL spine films should be obtained because 7% (one of 15) of the injuries were identified in this group.

Adult↗
PubMed1993

Moonlighting in a university surgical training program.

The impact of house officer moonlighting on training performance was assessed through a faculty questionnaire and house officer survey distributed in the Department of Surgery at Tulane University School of Medicine. Responses were obtained from 30 house officers and 15 faculty members. Most house officers who moonlighted did so one or two times each month; most were employed in emergency departments. Yearly earnings from moonlighting averaged approximately $10,000. Although many house officers were in debt from medical school, debt was not the primary reason for moonlighting. Many faculty members disapproved of moonlighting, but agreed to monitoring by clinical performance and American Board of Surgery In-Training Examination. A statistically significant relationship was found between yearly income from moonlighting and decreasing scores on the American Board of Surgery In-Training Examination.

Attitude of Health Personnel↗
PubMed1993

External iliac artery occlusion due to pelvic fracture: management with a cross-femoral bypass graft.

Vascular injury is not uncommon in cases of major pelvic trauma. Venous injury is by far the most common associated problem and may lead to exsanguinating hemorrhage. Arterial injury is less common, but certainly not without associated morbidity and mortality. It can lead to persistent bleeding after fixation and stabilization of the pelvic girdle, and occlusion of major pelvic arteries can cause limb ischemia and limb loss. The potential problems with revascularizing the ischemic extremity are (1) other life-threatening injuries that may be present and (2) a retroperitoneal hematoma that can interfere with an anatomic approach. Our solution to the latter problem, as presented here, is placement of a cross-femoral bypass graft, which rapidly and safely restores blood flow in the presence of pelvic fracture and an occluded external iliac artery. The pelvic hematoma is avoided, thereby restoring circulation more quickly, with less blood loss and greater ease.

Adult↗
PubMed1993

End-stage renal disease with venous occlusion in both upper extremities.

We studied 27 patients with venographically documented bilateral subclavian vein occlusion thrombosis after the use of dual lumen hemodialysis catheters. Immediate venous access was severely limited because all patients had previously had multiple access failures. The rate of venous pressure rise between hemodialysis treatments is inconsistent in suggesting imminent thrombosis as the sole explanation for venous thrombosis, yet it is a signal to investigate vein patency. Venography may be the best method, pending further development of duplex ultrasonography. The lack of clinical symptoms warrants early use of duplex ultrasonography and venography to document subclavian vein occlusion thrombosis so that heparin and thrombolytic therapy may be initiated. Length of time between onset of pressure increase and initiation of therapy did not affect successful outcome.

Arm↗
PubMed1993

Potential of overuse of the inferior vena cava filter.

To examine indications for, and morbidity and mortality rate of, inferior vena cava filter insertion at a community hospital, the records of 69 patients who received inferior vena cava filters were reviewed. Patients were assigned to three groups--group 1, 45 patients with pulmonary embolism or deep venous thrombosis and a contraindication to anticoagulation; group 2, 14 patients with a diagnosis as in group 1, who received filters without consideration to anticoagulation, and group 3, ten patients with clinically suspected deep venous thrombosis and no objective assessment of the process. Indications for filter placement were recorded. Morbidity and in-hospital mortality rates were 29 and 49 percent, 43 and 36 percent and 10 and 30 percent for groups 1, 2 and 3, respectively (29 and 43 percent overall). Only patients in group 1 had documented indications for caval interruption. Results compared unfavorably with complication and mortality rates reported previously. Non-selective use of inferior vena cava filters is associated with unacceptable morbidity and mortality rates. Strict indications for filters must be well documented.

Adult↗
PubMed1993

Heparin treatment enhances the recovery of neoendothelial acetylcholine-induced vascular relaxation after balloon catheter injury in the rabbit aorta.

BACKGROUND: After catheter injury, the neoendothelium that grows is abnormal in morphology and in acetylcholine-induced generation of endothelium-derived relaxing factor (EDRF). Heparin has been shown to have stimulatory effects on vascular endothelial growth in vitro. Its effect in vivo on neoendothelial cell morphology and metabolism after injury has not been described. We investigated the effect of heparin treatment on the neoendothelium formed after injury. METHODS AND RESULTS: Four groups of New Zealand White rabbits were studied. Group 1 rabbits underwent catheter denudation and were killed 4 weeks after injury without receiving treatment (NO Tx, n = 8). Groups 2 and 3 underwent similar aortic injury, received 2 weeks of treatment with either heparin (n = 7) or low molecular weight heparin (LMWH, n = 5), and were killed at 4 weeks. Group 4 underwent sham operation (SHAM, n = 8). EDRF generation was determined by the relaxation of precontracted aortic rings in an organ bath in response to acetylcholine. The heparin-treated group exhibited a significant improvement in acetylcholine-induced relaxation (27%) versus both LMWH-treated (14%, P = .035) and untreated groups (11%, P = .004), although relaxation was only 50% of that observed in the uninjured control vessels (52%, P = .001). The neoendothelium formed in the heparin-treated group exhibited a more normal histological appearance and was aligned with the direction of blood flow as compared with that observed in the untreated or LMWH-treated groups. CONCLUSIONS: These results demonstrate that in vivo heparin administration enhanced the recovery of EDRF generation and augmented normalization of the morphologic appearance of the neoendothelium.

Acetylcholine↗
PubMed1993

Parathyroid carcinoma: case report.

Parathyroid carcinoma is a rare entity, representing less than 1% to 5% of patients with primary hyperparathyroidism. Parathyroid carcinomas are often symptomatic, have markedly elevated calcium levels, have palpable masses, are equally distributed between the sexes, and present 10 years younger than their benign counterparts. Parathyroid carcinoma is often undiagnosed preoperatively, suspected intraoperatively, and only confirmed postoperatively. When diagnosed, the treatment of choice is an en-bloc resection of the tumor.

Aged↗
PubMed1993

Venous insufficiency: a late sequelae of four-compartment fasciotomy in the lower extremity?

Four-compartment fasciotomies used to relieve abnormally high compartment pressures necessitate interruption of the ensheathing fascial membrane. In the calf, this is considered an important component in maintaining a viable musculovenous pump and preventing venous hypertension, a leading cause of venous insufficiency. Through postoperative physical examination and photoplethysmography evaluation of 47 patients who underwent this procedure, no indication exists that division of the fascial component leads to calf pump dysfunction and chronic venous insufficiency. Of the patients studied, 92 per cent had unchanged musculovenous pump function upon photoplethysmography reevaluation at 19 weeks compared with the initial values recorded 6 weeks postoperatively; 6 per cent had improved venous flow, while only one of the 47 (2%) had venous recovery measurements consistent with diminished venous flow.

Adolescent↗
PubMed1993

Impact of anesthetic agents on patients with sickle cell disease.

Fifty-two surgical procedures were performed on 45 patients with sickle cell anemia. All patients were managed perioperatively with hydration and were kept warm and well oxygenated. Patients were anesthetized with either halothane (n = 16), enflurane (n = 22), isoflurane (n = 6), or intravenous narcotics (n = 4). Four patients had epidural anesthesia. Perioperative morbidity was assessed using the criteria of atelectasis, urinary tract infection, wound infection, thrombophlebitis, drug reaction, hypotension, and vaso-occlusive crisis. The overall perioperative complication rate in this study was 45 per cent. Patients anesthetized with isoflurane and enflurane had postoperative morbidity rates of 83 and 59 per cent, respectively, while the patients anesthetized with halothane had a complication rate of 25 per cent. In all three groups, atelectasis was the main cause. No complications occurred in the epidural group. In the intravenous anesthesia group, one patient developed sickle cell crisis. It appears that the types of anesthetic agents used do not impact on postoperative morbidity in patients with sickle cell anemia more than any other type of patient.

Adult↗
PubMed1992

Comparative effects of endothelin (ET-1) and U46619 on human saphenous vein and gastroepiploic artery, sources of human autologous grafts.

The effects of endothelin (ET-1) on smooth muscle contractile activity were investigated and compared in human saphenous vein and gastroepiploic artery, vessels frequently used in revascularization procedures. ET-1 contracted saphenous vein and gastroepiploic artery in a concentration-dependent manner. The peptide produced a greater maximal effect in the vein than in the artery and, in both preparations, ET-1 was less efficacious than U46619, an agent which mimics the actions of thromboxane A2 at the thromboxane A2/prostaglandin H2 receptor. The contractile response to ET-1 declined spontaneously at a more rapid rate in the artery than in the vein. The present data indicate that ET-1 has significant contractile activity in both vessels which are used for coronary arterial bypass surgery and suggest that although, a weaker vasoconstrictor than U46619, the peptide could induce vasospasm in both graft vessels.

Arteries↗