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Biomedical subjects

M D Kerstein

Publications and source records attributed to M D Kerstein.

At least 145 records · Page 8Linked to original sources
PubMed1989

Randomized double-blind, multicenter study of prostaglandin E1 in patients with the adult respiratory distress syndrome. Prostaglandin E1 Study Group.

Prostaglandin E1 (PGE1) was compared to placebo in a 100-patient (50 PGE1, 50 placebo) randomized, double-blind, clinical trial to determine whether PGE1 therapy enhances survival of patients with adult respiratory distress syndrome (ARDS) when infused through a central line at 30 ng/kg/min continuously for seven days. At 30 days postinfusion, 30 PGE1 and 24 placebo patients had died. Total deaths judged to be related to the syndrome were 32 and 28 in the PGE1 and placebo groups respectively at six months. We conclude that PGE1 did not enhance survival in patients with established ARDS. PGE1 augmented the hyperdynamic circulation of these patients by reducing systemic and pulmonary vascular resistance, which resulted in a reduction of blood pressures and increased stroke volume, cardiac output, and heart rate. An improvement in oxygen availability and oxygen consumption was observed with PGE1 therapy. PGE1 was associated with an increased incidence of diarrhea (six patients in the PGE1 group vs one in the placebo group, p less than 0.05). Other adverse effects included hypotension (ten patients in the PGE1 group vs seven in the placebo group), fever (six patients in the PGE1 group vs three in the placebo group), and non-fatal dysrhythmias (ten in the PGE1 group vs five in the placebo group).

Alprostadil↗
PubMed1989

An early test of survival in patients with the adult respiratory distress syndrome. The PaO2/FIo2 ratio and its differential response to conventional therapy. Prostaglandin E1 Study Group.

Patients with established adult respiratory distress syndrome (ARDS) have a mortality rate that exceeds 50 percent. We analyzed the magnitude of hypoxemia as manifest by the PaO2/FIO2 ratio and its early response to conventional therapy including positive end-expiratory pressure (PEEP) in the placebo group of a large multicenter study. The PaO2/FIO2 ratio was not different at the time of diagnosis of ARDS in those patients who lived compared to those who subsequently died. After one day of conventional therapy including PEEP, those patients who survived increased their PaO2/FIO2 ratio. The nonsurvivors did not improve over a seven-day course. The difference in the PaO2/FIO2 ratio was significant throughout the seven-day observation period. We conclude that the early response to conventional therapy picks a patient population with a good prognosis and can be used as a test of likely survival from ARDS.

Alprostadil↗
PubMed1989

Cost effectiveness of regional anesthesia in carotid endarterectomy.

The purpose of this prospective study was to assess safety, efficacy, and hospital costs (excluding medications) and laboratory tests related to general (GA) and regional anesthesia (RA) for carotid endarterectomy (CEA). One hundred patients underwent CEA; 50 received GA and 50 received RA. Thirty-eight men (eight diabetic) and 12 women (two diabetic), with an average age of 62.4 (47 to 79) years comprised the GA group; 35 men (six diabetic) and 15 women (one diabetic), with an average age of 64.1 (51 to 74) years comprised the RA group. Twenty-one patients (17 men, 4 women) in the GA and 24 patients (19 men, 5 women) in the RA group had hypertension. Every patient had some stigmata of cardiac disease. Patients receiving GA for CEA spent an average of 1.2 days in the surgical Intensive Care Unit (ICU) and 6.1 days in a regular hospital bed, for an average cost of $4547. The patients who underwent CEA under RA had an average of 0.1 ICU days and 4.1 regular hospital days, for a cost of $2067. RA saved $2480 per patient and $124,000 in our study group, with no increase in mortality or morbidity rates (P less than 0.001). RA is superior to GA in cost-effectiveness for patients undergoing CEA.

Anesthesia, Conduction↗
PubMed1989

Benefits of HIV testing during military exercises.

During U.S. Marine Corps Reserve summer 2-week active duty for training periods, 6,482 people were tested for human immunodeficiency virus (HIV). Testing at an initial exercise, Solar Flare, trained a cadre of contact teams to, in turn, train other personnel in phlebotomy and the HIV protocol at three other exercises (141 Navy Reserve and Inspector-Instructor hospital corpsmen were trained). Corpsmen could be trained with an indoctrination of 120 minutes and a mean of 15 phlebotomies. After 50 phlebotomies, the administration, identification, and labeling process plus phlebotomy could be completed in 90 seconds. HIV testing during military exercises is both good for training and cost-effective.

AIDS Serodiagnosis↗
PubMed1989

Penetrating thoracic aortic injuries: rare but potentially salvageable sequelae of urban warfare.

Penetrating injuries of the thoracic aorta are rare and often fatal. Victims of such wounds rarely survive to reach the emergency department. Those patients who do arrive will display one of two symptom complexes--either continuing hemorrhage or seeming hemodynamic stability with a widened mediastinum on chest roentgenography. As the results of our study of six such patients show, at least 50% of those who arrive with any signs of life may be salvaged by aggressive surgical management.

Adolescent↗
PubMed1989

Abdominal aortic aneurysms.

The diagnosis and management of abdominal aortic aneurysms has improved greatly since the first report of Matas. Improved awareness of the diagnosis and advances in diagnostic techniques have allowed the diagnosis to be made earlier in the course of disease. Improved operative skills and peri-operative management have significantly decreased the morbidity and mortality rates associated with surgical intervention.

Aorta, Abdominal↗
PubMed1989

Amaurosis fugax: carotid endarterectomy without an angiogram.

The risks of carotid angiography--technical, allergic, cardiac, renal, or emotional--may be lessened or absented by the use of real-time B-mode ultrasound to evaluate carotid artery disease. A patient with amaurosis fugax, a positive fluorescein angiogram, ulceration on ultrasound, and an unremarkable computed tomography scan was operated on without angiography. The pathology was correct and the patient did well.

Aged↗
PubMed1989

Lower limb embolus: a near-lethal disease after age 75 years.

Because it has been suggested that embolectomy increases morbidity and mortality, we reviewed our experience with lower-extremity embolectomy in an elderly high-risk population. Of 153 consecutive patient records reviewed, 69 were sufficiently complete for analysis. Of these patients, 45 were men with a mean age of 80.7 years (range, 75 to 91 years); 24 were women with a mean age of 76.9 years (range, 75 to 81 years). Records were reviewed for patient age, sex, race, acute myocardial infarction or atrial fibrillation upon admission, history of smoking, diabetes, and cardiac disease (acute and chronic), admission blood pressure, role of postoperative echocardiography, and New York Heart Association classification (NYHA class). All patients were hemodynamically stable at the time of operation. Forty-two of the 69 patients had a history of smoking, nine were diabetic, and 48 (33 men and 15 women) had hypertension (blood pressure greater than 140/90 mm Hg) on admission. Twelve deaths occurred within the perioperative period. Nine patients had an acute myocardial infarction and 12 had arrhythmias on admission. Thirty patients (15 men and 15 women) were in NYHA class III. A total of 30 patients had died by six months postoperatively, 27 of cardiovascular causes. The perioperative mortality was 12/69 (17%), and long-term mortality was 30/69 (43%). Simultaneous embolus and myocardial infarction was associated with 100% mortality for the patients surviving the operation; 15 patients required another operation for amputation (nine above-knee and six below-knee).

Age Factors↗
PubMed1989

Penetrating injury to the carotid artery. A reappraisal of management.

Penetrating trauma remains the most common cause of cervical carotid artery injury. Controversy persists regarding proper management of these injuries, especially in the presence of a neurologic deficit. Recent experience with 24 patients over a 5-year period is reviewed. In patients with preoperative neurologic deficits, neither repair nor ligation of the injured vessel altered outcome. Outcome correlated only with preoperative neurologic status. All patients without preoperative neurologic deficits should have repair attempted when technically feasible. Although controversial, this study supports carotid artery repair except in comatose patients who have profound neurologic deficits.

Adult↗
PubMed1988

Does intracranial dye study contribute to evaluation of carotid artery disease?

One thousand consecutive cerebral arteriograms for suspected carotid artery disease were retrospectively evaluated for the intracranial disease component. Only 784 patients (78 percent) had arteriograms of the intracranial circulation. Forty-six patients (6 percent) had siphon stenosis in the range of 5 to 70 percent. No patient had a lesion encompassing more than 75 percent of the vessel diameter. Thirteen patients (2 percent) had intracranial aneurysms. All patients were asymptomatic from the standpoint of their aneurysms and none required surgical intervention. One additional patient was noted to have an intracranial tumor, which was confirmed by computerized tomography. In this patient population, intracranial dye study did not provide information that altered management.

Adult↗
PubMed1988

Subclavian-external carotid bypass for symptomatic severe cerebral ischemia from common and internal carotid artery occlusion.

Occlusion of the common and internal carotid arteries in a patient with symptomatic severe cerebral ischemia, with or without contralateral carotid disease, portends a poor prognosis. The present study has described our experience with subclavian and external carotid artery revascularization for symptomatic severe cerebral ischemia from common and internal carotid artery occlusion. Nine patients (five men and four women) with a mean age of 62 (range 41 to 82 years) were diagnosed as having symptomatic severe cerebral ischemia. All patients had ipsilateral hemispheric symptoms, seven had amaurosis fugax, and two had associated syncope. Four patients (three men and one woman) were hypertensive, four (two men and two women) had diabetes, eight smoked, and all had a history of coronary artery disease. All of the patients had noninvasive laboratory studies and preoperative angiography, and three had postoperative angiography. Five patients were successfully revascularized to a patent external carotid artery despite nonvisualization by angiography. Six patients had unilateral and three bilateral occlusion of the common and internal carotid arteries appropriate to their symptoms. Using regional anesthesia, four patients underwent a subclavian-external carotid bypass with polytetrafluoroethylene; saphenous vein was used in five; and three had concomitant axilloaxillary bypass grafting with polytetrafluoroethylene. Neurologic improvement (that is, no subsequent deficit and no progression of symptoms) was noted in all nine patients with a follow-up of 4 to 28 months (mean 11.2 months). Two patients died from myocardial infarction 4 and 7 months after operation. Subclavian-external carotid artery bypass is a safe addition to the options for the treatment of symptomatic severe cerebral ischemia with occlusion of the common and internal carotid arteries, visualization of a superior thyroid collateral vessel on the recipient end, and nonvisualization of the external carotid artery.

Adult↗
PubMed1988

Measurement of impotence by laser Doppler flowmetry and conventional methodology.

The problem of vasculogenic impotence was evaluated by laser Doppler flowmetry with the LD5000 capillary perfusion monitor to determine cutaneous penile blood flow in 25 men defined previously as impotent by Doppler ultrasound with penile brachial ratios of 0.63 +/- 0.14. Erotic visual stimulation for 1, 2 and 4 minutes did not statistically change the cutaneous flow as measured by laser Doppler flowmetry from its baseline of 20 mv. The dynamics of skin microcirculation in the penis may reflect changes in the deeper vessels and represent an alternate, dependable method to evaluate capillary perfusion.

Adult↗
PubMed1988

Financing residency training in urology.

Five educators concerned with changes occurring in the financing of medical education and care reviewed the present status of residency programs and their financing. Future support depends on political decisions as well as demonstrable needs. The effects of anticipated reductions in funding for residents and their programs may be countered by the development of alternative sources and the restructuring of present programs for more efficient operation. The need for leadership is clear.

Costs and Cost Analysis↗
PubMed1988

Assessment of the use of transfusion therapy perioperatively in patients with sickle cell hemoglobinopathies.

During the period of 1978 to 1986, 66 patients (31 men, 35 women) with a mean age of 28.4 years and various sickle cell hemoglobinopathies underwent 82 surgical procedures; 28 were emergencies. Fifty of the 66 patients had HbSS, 13/66 had HbSC, and 3/66 had HbS-thalassemia. All 66 patients received transfusions, although not for all procedures. In 48 patients, transfusion therapy was only administered preoperatively. Simple transfusions (1 to 10 units) were administered in 31 of 48 procedures. Exchange transfusions (1 to 6 units) were performed in nine of 48 procedures. Preoperative hematocrit ranged from 7.0% to 54.2%; of those receiving transfusions the hematocrit ranged from 22.6% to 53.7%. Intraoperative transfusions (1 to 10 units) were performed in 14 of 82 procedures; postoperative transfusions (1 to 6 units) were performed in 13 of 82 procedures. No advantage was noted in preoperative exchange transfusion as measured by a decrease in postoperative complications; a slight increase was seen in atelectasis in this group of patients with preoperative transfusions. An increase was reported in the complication rate of patients with an hematocrit of less than 30%. The type of transfusion (preoperative, intraoperative, or postoperative) administered did not appear to be related to postoperative morbidity rates. The complication rate for simple transfusions was 51.6% and for multiple transfusions, 55.6%. HbSS hemoglobinopathy had the higher complication rate. The hepatitis B surface antigen was demonstrated in four of 66 (6.1%) patients; ten of 66 (15.2%) developed alloantibodies. The benefits of transfusion therapy should be judged according to clinical needs; not all sickle cell patients need exchange or preoperative transfusion.

Adult↗
PubMed1988

Impotence following pelvic fracture.

A group of 42 men (mean age, 26.7 years) with pelvic fractures as the result of motor vehicle accidents were evaluated for impotence 48 hours after injury. Hormone levels were normal in all patients tested. One half (21/42) of the patients had abnormal penile:brachial arterial ratios. Of this group, 13/21 had abnormal bulbocavernosus reflex (BCR): four patients were paraplegic and nine had urethral injuries. Followup of available patients to 20 months reflects persistent impotence in those who experienced vasculogenic trauma. Only 2/21 patients with normal tests (vascular, hormonal, neurologic) complain of impotence (followup at 23 months); one of these patients is in litigation.

Adolescent↗
PubMed1988

Tortuosity of the right common carotid artery simulating aneurysm.

Among the problems that confront the vascular surgeon, a pulsatile, right-sided neck mass requires a careful and logical evaluation. It has long been known that tortuosity of the right common carotid artery, frequently associated with advanced hypertension, can physically mimic a right carotid aneurysm. The question, then, is whether carotid angiography, with a higher attendant risk of morbidity and mortality, is preferable to less invasive diagnostic modalities such as computerized tomography (CT) and ultrasonography for initial evaluation. In our study, 31 consecutive patients with a pulsatile right neck mass, indistinguishable on physical examination from a carotid aneurysm, were evaluated using CT scan of the neck and either radionuclide scan or angiography. In all of the patients, the masses were confirmed to be tortuous right common carotid arteries and not aneurysms. Because a kinked carotid artery simulating an aneurysm occurs so frequently, noninvasive diagnostic techniques, such as CT and ultrasonography, should precede angiography. We also discuss demographic characteristics commonly associated with tortuosity of the right common carotid artery.

Aged↗
PubMed1988

Role of intraoperative fibrinolytic therapy in acute arterial occlusion.

Nineteen patients with acute onset of ischemia affecting the lower extremities were studied from January 1985 to March 1987. Patients with preoperative Doppler and angiographic studies consistent with arterial occlusions subsequently underwent a thromboembolectomy using a Fogarty catheter. All patients were given a bolus injection of 5,000 units of heparin intravenously at the start of the surgical procedure. In all patients studied, a clot was retrieved on the first pass, but after two additional passes, total distal blood flow was not shown to be restored on angiogram. Intraoperative angiograms showed distal emboli. All patients underwent intraoperative fibrinolytic therapy by local bolus infusion. Streptokinase, ranging from 50,000 to 200,000 units, was administered in 50,000 unit injections in ten to 15 minute intervals. Repeat attempts at thromboembolectomy with the Fogarty catheter resulted in an additional clot retrieved in all 19 patients with intraoperative angiographic, Doppler and clinical improvement. No perioperative or postoperative complications were observed, including anaphylactic reactions, uncontrollable bleeding or amputation. Four patients had nonacute femoropopliteal bypass operations within the next six months. Intraoperative fibrinolytic therapy can be a safe and effective adjunct in acute arterial embolic occlusion requiring balloon catheter thromboembolectomy.

Acute Disease↗