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Biomedical subjects

R J Marcus

Publications and source records attributed to R J Marcus.

At least 19 recordsLinked to original sources
PubMed2006

Safety of paracentesis in inpatients.

INTRODUCTION: Prior research has suggested that paracentesis is free from complications such as acute renal failure (ARF) providing albumin is administered. Actual safety of paracentesis > 1,000 ml was assessed at a tertiary care hospital. METHODS: 300 inpatient paracenteses performed between 12/99 and 4/04 were identified by coding records, of which 40 procedures were excluded due to lack of pre- or post-procedure lab values. Charts were reviewed for serum creatinine (Scr) before and after procedures, ascites volume, and clinical outcomes. RESULTS: 44 deaths occurred after 260 paracenteses (16.9%). Among 33 patients with ARF, 13 (39.4%) died. Only 31/227 patients without ARF (13.7%) died (p < 0.001). Serum creatinine (Scr) > 1.6 mg/dl prior to paracentesis predicted a 22.5% rate of ARF, compared to 8% for Scr < 1.0 (p = 0.002). ARF increased as volume increased (9.9%, 12.4%, and 14.9%, for volumes of < 2,300, 2,300 - 3,200, and > 3,200 ml) but this trend did not have statistical significance (p = 0.426). ARF occurred in 11/69 (15.9%) of patients receiving albumin, compared to 22/191 (11.5%) of patients who did not (p = 0.462). CONCLUSIONS: Paracentesis in inpatients has significant rates of ARF and death. Scr > 1.6 prior to paracentesis predicts an increased rate of ARF. Development of ARF is associated with an increased rate of death. No advantage was demonstrated with administration of albumin. Pre- and post-paracentesis labwork should be routine in inpatients.

Acute Kidney Injury↗
PubMed2005

The cost of steroid-free protocols in primary cadaver kidney transplantation.

Steroid-free immunosuppression regimens have been enjoying recent success in clinical transplantation. The use of antibodies required for such protocols can be an economic burden. We proposed to study their cost in our center. This retrospective study involved 147 consecutive patients subjected to 4 protocols of immunosuppression. The first received triple therapy. The second group received induction with basiliximab, whereas the third received Basiliximab plus cyclosporine (CSA) plus mycophenolate mofetil (MMF), and the fourth received Thymoglobulin plus CSA plus MMF in conjuction with only 4 days of steroid. Rejection episodes were treated with Solumedrol. Six-month charges were obtained from computerized records of the finance department, the in-house laboratories, and the transplantation service registry. All charges were expressed in 2004 dollars. Statistical analyses were obtained using chi-square, analysis of variance (ANOVA) and Kaplan-Meier tests. The 4 groups were similar with regard to donor and/or recipient gender, race, panel reactive antibodies, cold ischemia, dialysis requirements length of stay and readmission, graft survival, and function. Charges were significantly higher in the last 2 groups as compared with triple therapy.

Adult↗
PubMed2004

Ascites reinfusion dialysis (ARD) for renal failure with refractory ascites.

BACKGROUND: Dialysis is difficult for patients who have simultaneous liver and kidney failure. Effective mobilization of ascites is rare, and hypotension is common. Combining repeated paracentesis with continuous renal replacement therapy can achieve effective volume removal with hemodynamic stability, but requires intensive care unit resources. Large amounts of albumin are lost from the body in the drained ascites. Combining ascites reinfusion with hemodialysis is a potential alternative therapy. METHODS: Eight treatments were undertaken in 3 patients with refractory ascites in the setting of acute onset renal failure. Hemodialysis was unsuccessful due to hypotension in each case. Two patients were treated twice, and 1 patient was treated 4 times. Each patient underwent hemodialysis with reinfusion of ascites directly into the blood inlet of the dialysis machine. Weight, blood urea nitrogen, albumin and platelet counts were measured before and after treatment. Hemodynamic tolerance was assessed, and patients were observed for the development ofencephalopathy, disseminated intravascular coagulation, infection and hemodynamic decompensation. RESULTS: All patients survived. There was 1 episode of transient hemoperitoneum, but no encephalopathy, GI bleeding or infection. One patient recovered renal function, and the other 2 were discharged ambulatory to chronic hemodialysis programs. Blood pressure was supported easily during therapy, despite removal of 3-8 kg of fluid. Platelet counts decreased by 27,000 +/- 13,000, and albumin increased by 0.5 +/- 0.2 g/dl. All values returned to baseline over the next 1-4 days. CONCLUSIONS: Ascites recirculation with dialysis is a safe and effective therapy for patients with refractory ascites and severe renal failure, which can be carried out in routine inpatient and outpatient settings. Hemodynamic tolerance was good and thrombocytopenia was modest.

Acute Kidney Injury↗
PubMed2002

Pulmonary volume recruitment restores pulmonary compliance and resistance in anaesthetized young children.

BACKGROUND: Oxygenation and gas exchange are impaired after induction of general anaesthesia. A timed re-expansion inspiratory manoeuvre (TRIM) improves pulmonary compliance and reverses haemoglobin oxygen desaturation rapidly in lambs. METHODS: Twenty children of less than 2 years of age were given a standardized ventilated general anaesthetic. After 15 min of anaesthesia they were randomized to receive either a TRIM or 100% oxygen for 3 min. Dynamic pulmonary compliance and airway resistance were measured. RESULTS: Pulmonary compliance fell by 12% and airway resistance rose by 12% during 15 min of ventilated general anaesthesia. 100% oxygen caused a further fall of 9% in compliance (P=0.016), whilst TRIM resulted in a 30% increase in compliance (P < 0.01). The changes in airway resistance with 100% oxygen and TRIM were not statistically significant. CONCLUSIONS: This study shows that TRIM increases pulmonary compliance during standardized ventilated general anaesthesia.

Airway Resistance↗
PubMed2001

Interaction of local anaesthetic agents with the endogenous norepinephrine transporter in SH-SY5Y human neuroblastoma cells.

Use of intravenous guanethidine for the treatment of complex regional pain syndrome type I is of variable efficacy. Guanethidine injection is painful, so local anaesthetic is co-administered. We hypothesize that local anaesthetic inhibits uptake of guanethidine and hence reduces its efficacy. In this study we have examined the effects of a range of local anaesthetic agents on the uptake of [3H]norepinephrine ([3H]NE) (as a surrogate for guanethidine) and the binding of [3H]nisoxetine to the NE transporter in cultured SH-SY5Y human neuroblastoma cells. All local anaesthetic agents inhibited NE uptake with a rank order cocaine>tetracaine>procaine(esters), dibucaine > bupivacaine > prilocaine > lidocaine (amides). In addition all anaesthetic agents displaced [3H]nisoxetine with a rank order cocaine > tetracaine > dibucaine > procaine > prilocaine > bupivacaine > lidocaine. There was a positive correlation between [3H]NE uptake and [3H]nisoxetine binding. Our data suggest that when local anaesthetic and guanethidine are co-administered the former may reduce uptake of the latter and hence reduce the clinical efficacy of guanethidine.

Anesthetics, Local↗
PubMed2001

Long-term outcomes of revascularization for peripheral vascular disease in end-stage renal disease patients.

The occurrence of peripheral vascular disease (PVD) and atraumatic lower-extremity amputations is significantly greater in patients with end-stage renal disease (ESRD) than those with normal renal function. Moreover, the mortality for dialysis patients undergoing atraumatic lower-extremity amputations is far greater. Because PVD requiring amputation is an extreme form of PVD, we tested the hypothesis that mortality and intermediate outcomes for patients with ESRD undergoing lower-extremity revascularization, a less extreme form of PVD, would be equivalent to that for patients without ESRD. This is a retrospective case-control analysis of lower-extremity revascularization in patients with ESRD. Procedures in patients with ESRD were matched with procedures in non-ESRD controls for patient age, sex, race, diabetes mellitus, and hospital setting. Patient survival, graft survival, and limb salvage rates were determined using Kaplan-Meier analysis. Subjective interpretation of functional and symptomatic improvement was determined by telephone interviews with patients or relatives. Thirty-one procedures were performed on 20 patients with ESRD and 64 matched procedures were performed on 57 patients without ESRD. In the ESRD group, median patient survival was 1.72 years compared with 5.17 years for the control group (P < 0.001). Time to 50% limb loss was 1.24 years in the ESRD group and longer than 5.65 years in the control group (P < 0.001). Time to 50% graft patency loss was 0.70 years in the ESRD group and longer than 5.5 years in the control group (P < 0.05). Subjective improvement was less in patients with ESRD. Outcomes of lower-extremity revascularization in patients with ESRD are inferior to those in non-ESRD controls. The mortality rate for patients with ESRD who undergo revascularization is extremely high. Patient-related variables (eg, increased prevalence of hypertension and cardiovascular disease) and/or provider-specific factors (eg, timing of surgery in the course of PVD) may be responsible for poorer outcomes.

Adult↗
PubMed2000

Anaesthesia for manipulation of forearm fractures in children: a survey of current practice.

Despite recent recommendations that all children presenting for urgent or emergency surgery should be treated as though they have a full stomach, a local audit had shown a wide variation in technique used for anaesthesia in children after trauma. Therefore, a postal questionnaire was sent to 500 anaesthetists regarding their preferred anaesthetic technique for a 6-year-old child requiring manipulation of a forearm fracture. Four clinical situations were presented differing in the timing of surgery in relation to the injury, starvation times before injury and the administration of opioid analgesia. Rapid sequence induction and tracheal intubation was preferred by 83% of all anaesthetists for surgery on the day of injury if the child had eaten 2 h prior to injury and had received opioid analgesia, but the percentage was significantly lower in experienced anaesthetists (P < 0.05) compared with trainees, and was 34.5% overall if surgery was delayed until the following day. Only 19.3% would perform a rapid sequence induction for surgery on the day of injury if the child had not eaten for 6 h before the injury. We conclude that not all anaesthetists believe that rapid sequence induction is necessary for anaesthesia after forearm fractures, despite recent recommendations.

Analgesics, Opioid↗
PubMed2000

Comparison of ketamine and morphine for analgesia after tonsillectomy in children.

In a double blind study we compared the effects of i.m. ketamine with morphine on postoperative analgesia in children undergoing tonsillectomy. Eighty children (aged 6-15 yr) were randomized to receive either i.m. morphine 0.1-0.15 mg kg-1 or ketamine 0.5-0.6 mg kg-1, after induction of a standard general anaesthetic. Pain scores 30 min after extubation were higher (P < 0.05) in the ketamine group, but were similar thereafter to the morphine group. Mean (SD) times to recovery from anaesthesia were 20.1 (SD 6.5) min in the ketamine group compared to 14.2 (5.6) min in the morphine group (P < 0.01). There were no differences in supplemental analgesia requirements, or the incidence of vomiting or dreaming between the groups. We conclude that ketamine 0.5 mg kg-1 i.m. may be an alternative analgesic for children undergoing tonsillectomy.

Adolescent↗
PubMed1997

Elevated soluble interleukin 2 receptor levels found among kidney transplant recipients.

Although previous studies have not demonstrated a clear correlation between interleukin (IL) 2 receptor levels and immunological events after transplantation, many still suggest that these levels have clinical utility. A total of 759 serial measurements of both IL-2R and creatinine were compared over time and correlated with rejection episodes, clinical course, and immunosuppression. The profiles for the 40 patients showed several patterns, including correlation with changes in creatinine levels or with renal dysfunction, peaks in the absence of clinical findings, and discordant IL-2R and creatinine levels. Wide baseline variations in IL-2R levels confounded comparison of mean values and definition of a statistically significant rise. While tending to correlate with immunological events, elevations in IL-2R also occurred in clinically normal patients. IL-2R appears to lack specificity for immunological events. Thus, we conclude that IL-2R measurement does not have clinical diagnostic utility for monitoring renal transplant recipients.

Cadaver↗
PubMed1994

Renal transplantation at Allegheny General Hospital with special reference to the use of extreme-age cadaveric donors.

We report our experience with 25 living-donor and 427 cadaveric-donor kidneys followed for over 6 years. Patient survival exceeds 90% at 5 years for all recipients. Overall one-year and 5-year graft survival rates were 82.7% and 65.5%, respectively. Approximately one-third of CAD were of extreme age (eg, < or = 10 and > or = 60 years old). One-year and 5-year GS rates of this group were 72.2% and 54.8%, respectively. Kidneys from elderly donors probably should be given to age-matched recipients. Infant en bloc kidneys had good GS. They also adapted well their growth and function to adult recipients and should be used more frequently to alleviate the organ shortage problem. HLA mismatches, transplant PRA level, original kidney disease, and immunosuppressive regimens significantly affected the GS. Race, sex, cytomegaloviral antibody states, unacceptable antigens, length of pretransplant dialysis, and CAD cold ischemic time had no significant effect on GS.

Adolescent↗
PubMed1981

Clinical pharmacists' contribution to patient care on a gynecological unit.

A retrospective study of the contributions of clinical pharmacists on a gynecological unit was undertaken, based on an examination of the clinical pharmacists' interventions in and recommendations for drug therapy. Intervention or recommendations were classified as to type and as to probable result had the pharmacist not intervened or made recommendations. Over an eight-month period, the clinical pharmacist intervened in or made recommendation in 227 instances (0.8% of all medication orders). It was considered that two of the orders would probably have caused death had they been carried out, six could have caused toxicity and possible death, and 39 could have led to serious toxicity. The quality of patient care seemed to have been positively affected by having the clinical pharmacist in the patient care area.

California↗
PubMed1977

Thyrotropin-releasing hormone content of rat brain and hypothalamus: results of endocrine and pharmacologic treatments.

Studies of hypothalamic and regional brain TRH content in the rat after administration of various hormonal and pharmacologic agents were performed. No consistent changes in TRH content in the hypothalamus or brain followed thyroidectomy, hypophysectomy or administration of thyroxine or dexamethasone. There was a significant fall in hypothalamic forebrain and brain stem TRH content 60 min after insulin administration and in brain stem TRH at 30 and 120 min as well. Administration of alpha-methyl-paratyrosine, parachlorophenylalanine or reserpine, in varying doses and for varying periods, did not alter hypothalamic or regional brain TRH content. Thus, little evidence that hypothalamic or brain TRH content is dependent on hormonal milieu or neurotransmitter content was found.

Animals↗