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Biomedical subjects

R H Bower

Publications and source records attributed to R H Bower.

At least 37 records · Page 2Linked to original sources
PubMed1985

Warfarin absorption after massive small bowel resection.

Small bowel resection is often accompanied by malabsorption and nutritional deficiencies. Malabsorption of drugs may also occur; however, few reports have been published. We treated five patients with oral warfarin for thrombotic problems after substantial small bowel resection. All five had a documented hypoprothrombinemic response to the warfarin (patient prothrombin time: control greater than 1.5). Maintenance warfarin doses were up to 10 mg/day. Oral warfarin appears to be well absorbed after removal of the majority of the jejunum and ileum. This may indicate a proximal site of warfarin absorption.

Adult↗
PubMed1983

Hepatic complications of parenteral nutrition.

Hepatic dysfunction is a common metabolic complication of parenteral nutrition in both the pediatric and adult age groups. In infants, elevation of the serum direct bilirubin reflects intrahepatic cholestasis. In the adult lesion, elevation of alkaline phosphatase and transaminases reflect fatty infiltration. Although the causes are unknown, they are probably multifactorial and involve imbalances of administered nutrients. Hepatic dysfunction is nearly always self-limited and resolves following cessation of parenteral nutrition. Further research into assessment of exact nutrient requirements and a better understanding of the cellular effects of parenteral nutrition should lead to prevention of this complication.

Adult↗
PubMed1982

Association between microorganism growth at the catheter insertion site and colonization of the catheter in patients receiving total parenteral nutrition.

Catheter-related sepsis is one of the major complications of total parenteral nutrition (TPN) therapy. The relationship between microbial colonization of the skin at the site of catheter insertion and colonization of the central venous catheter was investigated in 74 catheters used to administer TPN therapy in 53 patients. Semiquantitative culture specimens were obtained from the insertion site and intravascular and subcutaneous catheter segments at the time of catheter removal. Bacteria and/or fungi were recovered from 19 catheters and 19 insertion sites; of the 19 colonized catheters, 6 had sterile insertion sites. Organisms isolated from the remaining 13 catheters were isolated concurrently from the insertion site. Catheter-associated bacteremia or fungemia was observed in 10 of the 19 patients with colonized catheters. The association between colonization of catheters and the presence of more than 10(3) bacterial or fungal colony-forming units at the insertion site was significant (P less than 0.005). These results demonstrated that colonization of catheters by organisms present on the skin at the site of catheter insertion occurred twice as frequently as colonization by the hematogenous route. The results also suggested that colonization of catheters by organisms present at the insertion site occurred only after a threshold number of organisms was reached.

Adult↗
PubMed1982

The effect of a new branched chain--enriched amino acid solution on postoperative catabolism.

Branched-chain amino acids (BCAAs) may regulate muscle amino acid flux. Metabolic studies of both experimental animals and humans utilizing comparatively large amounts of BCAAs infused with hypocaloric glucose have shown that catabolism and proteolysis can be blunted. These studies suggested that the nitrogen-sparing properties of amino acid solutions used in postoperative trauma or sepsis might be improved by increasing the amount of BCAAs. This hypothesis was tested on ten patients undergoing operations of moderate severity utilizing a peripheral amino acid mixture with a branched-chain:non-branched-chain ratio of 45:55% given in 5% dextrose. The patients received 1.7 gm of protein equivalent/kg of ideal body weight in 5% dextrose-crystalloid solution with a concentration of 3.5% amino acids for the first 5 postoperative days. Nitrogen balance, 3-methylhistidine excretion, blood chemistries, and plasma amino acid profile tests were done daily. The results showed that nitrogen equilibrium was maintained for 5 postoperative days without any untoward effects on patients, their surgical wounds, or hepatic function. Plasma amino acids showed no significant changes from baseline with the exception of elevations of the BCAAs. We conclude that this 45% BCAA-enriched solution may be safely administered to patients with postoperative traumatic injury and results in nitrogen equilibrium over a 5-day period.

Adolescent↗
PubMed1981

Comparison of distal and proximal splenorenal shunts: a randomized prospective trial.

Controversy still surrounds the place of portalsystemic shunting in the therapy of bleeding esophageal varices. Recently, a selective shunt, the distal splenorenal shunt, has achieved some degree of popularity and, apparently, is associated with less chronic encephalopathy. Because of this, a trial was initiated at the Massachusetts General Hospital and continued at the University of Cincinnati Medical Center, prospectively randomizing central and distal splenorenal shunts in consecutive elective cases of patients with established variceal bleeding. Preoperative evaluation included endoscopic examination at the time of hemorrhage, angiography and upper gastrointestinal series, emphasis on mental function including EEG, amino acids, neurologic examination, as well as standard liver chemistries. Nineteen patients underwent central splenorenal shunts and 23 distal splenorenal shunt. There was one operative death from hemorrhagic pancreatitis in a Child's Class A patient with distal splenorenal shunt. Four late deaths, from gunshot wound, auto accident, overwhelming pneumonitis similar to postsplenectomy syndrome, and metastatic carcinoma (2.5 years after operation), have been recorded in the distal splenorenal shunt group, and none in the central splenorenal shunt group. On follow-up angiographic examination, six shunts have clotted, with three patients requiring reoperation, generally mesocaval shunt. There has been no chronic encephalopathy, three individual episodes of encephalopathy, two in the central splenorenal shunt group and one in the distal splenorenal shunt group, two associated with gastrointestinal bleeding and one with intercurrent infection and overdiuresis. Follow-up liver chemistries and amino acids which may be useful as an indicator of hepatic function suggest that although the distal shunt group had a better amino acid pattern before operation, branched-chain amino acids tend to become lower in the distal group while remaining the same in the central group. Aromatic amino acids increase post shunt, equally in the two groups. The results do not support the contention that distal splenorenal shunt is associated either with greater survival or freedom from encephalopathy than central splenorenal shunt, a small side-to-side shunt. Ascites seems better controlled by the central splenorenal shunt.

Adult↗
PubMed1979

Cushing's disease: megadose dexamethasone suppression in a case refractory to medical therapy.

A patient with Cushing's disease failed to show complete suppressibility of adrenal function with conventional "high" doses of dexamethasone (8 mg per day). Higher doses were required to achieve suppression. Pituitary irradiation and medical therapy (cyproheptadine, metyrapone, and aminoglutethimide) failed to control the disease, necessitating bilateral adrenalectomy. The diagnostic and therapeutic implications of megadose dexamethasone suppression have not been clearly addressed in the medical literature. It is possible that adrenal suppression achieved only with unconventionally high doses of steroids may be predictive of refractoriness to nonsurgical therapy.

17-Hydroxycorticosteroids↗
PubMed1977

Cyclic adenosine monophosphate and human gastric acid secretion.

This report concerns gastric juice, plasma, and urinary levels of adenosine 3',5'-monophosphate (cAMP) in 27 subjects undergoing routine gastric analysis under maximum stimulation with betazole or pentagastrin. Cyclic AMP was measured by sensitive and specific radioimmunoassay. No increase in concentration of cAMP was noted in gastric juice, plasma, or urine following either betazole or pentagastrin stimulation. Betazole-stimulated human gastric acid secretion was associated with an increased cAMP output into the gastric juice (P less than 0.05). There was no change in cAMP output following pentagastrin stimulation. The peak acid output produced by pentagastrin and betazole was similar. The lack of increase in cAMP concentration lends support to the concept that cyclic AMP is not a primary mediator in the stimulation of gastric acid secretion by betazole or pentagastrin in the human. The physiologic significance of the increase in cAMP output following betazole stimulation remains unresolved.

Betazole↗
PubMed1976

Nephrogenous cyclic AMP levels in primary hyperparathyroidism.

The clinical utility of urinary cyclic adenosine-3',5'-monophosphate (cAMP) determinations has been limited by the overlap between hyperparathyroid and normal patients. We evaluated the potential of the parathyroid hormone (PTH)-dependent, nephrogenous cAMP in the diagnosis of hyperparathyroidism. Twenty-three patients with primary hyperparathyroidism and 19 control subjects had two-hour urine collections and blood sampling at midpoint. Nephrogenous cAMP level was calculated as total urinary cAMP excretion minus the amount filtered. The total urinary cAMP excretion (micromols per gram of creatinine) was higher in hyperparathyroid patients (6.8 +/- .5 SE), but overlapped with values obtained in controls (2.9 +/- .15). The level of nephrogenous cAMP (percent of total) was also higher in hyperparathyroid patients (72.5 +/- 1.8) than controls (26.3 +/- 4.1) and clearly separated the groups. Determination of nephrogenous cAMP levels may be useful in the diagnosis of hyperparathyroidism.

Cyclic AMP↗
PubMedDate not supplied

Cholangiography during laparoscopic cholecystectomy--cumulative sum analysis of an institutional learning curve.

The ability to perform intraoperative cholangiography during laparoscopic cholecystectomy is an essential skill for the laparoscopic biliary surgeon. The volume of experience required to be able to consistently obtain a cholangiogram during laparoscopic cholecystectomy has not been determined. Cumulative sum analysis is a statistical technique which generates a graphical display that identifies periods of performance that fall below a predetermined standard for a given task. The cumulative sum (S(n)) for a series of observations is defined as: S(n)= summation operatorX(I) - X(o), where X(I) = 0 for a success, X(I) = 1 for a failure, and X(o) is the acceptable failure rate for the process under study. This function is plotted against the number of observations to create a curve. When the curve has a positive slope, the acceptable failure rate is being exceeded. When it reaches a plateau, the observed failure rate is equal to the acceptable failure rate. When the curve has a negative slope, the observed failure rate is lower than the acceptable failure rate. We performed a cumulative sum analysis of the first 97 intraoperative cholangiograms attempted during lap-aroscopic cholecystectomy at our institution. The results demonstrated that 46 cases were required to reach a level of proficiency where a cholangiogram could be obtained in 95% of attempts. Success rates of 85% and 90% were achieved at 16 and 25 cases, respectively. This form of analysis is a useful tool for estimating the number of attempts required to achieve a desired success rate when learning new procedures.

Adult↗
PubMedDate not supplied

Familial ovarian dysgenesis in 46,XX females.

Three phenotypic female sisters in a sibship of four sisters and one brother were found to have pure ovarian dysgenesis, which was confirmed by the finding of streak gonads at laparotomy in two of the three sisters who presented with amenorrhea and lack of secondary sexual characteristics. No evidence of any other congenital anomaly was found in any of these sisters. Pure gonadal dysgenesis syndrome distinguishes a group of women with primary gonadal failure with amenorrhea whose heights are over 152 cm and who are without either webbed necks or any of the other somatic anomalies that are characteristic of Turner's syndrome. Cytogenetic studies revealed a normal female (46,XX) karyotype in all the affected members. Endocrine studies indicated that the affected sisters had elevated FSH and LH values with decreased plasma estradiol and urinary estrogen determinations. This is the second report of a family with 46,XX karyotype that meets all the criteria for the pure gonadal dysgenesis syndrome. The multiple affected sibs suggests an autosomal recessive mode of inheritance.

Adolescent↗
PubMedDate not supplied

Disease-specific amino acid infusion (F080) in hepatic encephalopathy: a prospective, randomized, double-blind, controlled trial.

Seventy-five patients with acute hepatic decompensation superimposed on chronic alcoholic cirrhosis were prospectively randomized for a blinded trial of the treatment of hepatic encephalopathy. The control group received 4 g of enteral neomycin daily along with 25% dextrose by a central venous catheter. The experimental group received a placebo resembling neomycin and isocaloric dextrose plus a modified amino acid mixture enriched with branched-chain amino acids to 36% and deficient in aromatic amino acids and methionine. Thirty patients in the F080 group and 29 in the control group completed the trial. The group receiving the modified amino acid mixture demonstrated a statistically significant improvement in encephalopathy as compared to the neomycin group, while maintaining nitrogen equilibrium. Survival and discharge from the hospital were statistically greater in the group treated with the modified amino acid solution and hypertonic dextrose. Treatment of hepatic encephalopathy in the presence of hepatic decompensation with an amino acid solution formulated for its treatment seems to produce faster, more complete recovery with improved capacity for nutritional support.

Adolescent↗
PubMedDate not supplied

Warfarin resistance associated with intravenous lipid administration.

Intravenous lipids have been shown to have varying effects on coagulation parameters. A patient with short bowel syndrome and recurrent thrombotic episodes who required both intravenous lipids and anticoagulation is described. A constant infusion of a soybean oil emulsion (Intralipid) in his parenteral nutrient solution was demonstrated to interfere with the anticoagulant effect of warfarin. Termination of the infusion and rechallenge with warfarin resulted in prolongation of his prothrombin time to the therapeutic range. Reinstitution of a lipid-free parenteral nutrition regimen has allowed for successful continuation of warfarin therapy.

Adult↗