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Biomedical subjects

R K Tompkins

Publications and source records attributed to R K Tompkins.

At least 91 records · Page 5Linked to original sources
PubMed1977

Operative choledochoscopy. Results of a prospective study in several institutions.

A prospective study from six surgical units utilizing choledochoscopy in conjunction with primary choledocholithotomyand cholangiography resulted in an incidence of less than 2 per cent unsuspected residual biliary calculi. Total reliance on choledochoscopy without associated operative cholangiography is not justified and fraught with error. When there are no calculi in the common duct, the choledochoscope allows the surgeon to shorten exploration time with confidence that the postexploratory cholangiogram will confirm his negative findings. The choledoschoscope is of additional value in the extraction of calculi. Certain considerations in the management of biliary tract tumors also can be helped by the addition of choledochoscopy. The simultaneous presence of calculous disease and biliary tract neoplasm can coexist can be brought to light by the use of the choledochoscope. The incorporation of choledochoscopy, using a rigid Berci-Shore choledochoscope, as part of routine common duct exploration, appears to be warranted.

Adolescent↗
PubMed1977

Enhancement of biliary phospholipid radioactivity by intestinal administration of labeled precursors of hepatic lecithin synthesis.

An animal model is used to study the effects of different radioactive precursors of lecithin, administered intestinally, upon biliary lecithin synthesis. Choline caused greater biliary lecithin radioactivity than choline-labeled lecithin or palmitic acid. The clinical application of this finding is discussed with relation to patients with gallstones or potentially lithogenic bile. Oral administration of choline may increase biliary lecithin concentration and, thus, cholesterol-holding capacity in this patient group, thereby changing the character of the bile to a non-lithogenic state.

Animals↗
PubMed1977

Eelvated postoperative renal clearance of amylase without pancreatitis after cardiopulmonary bypass.

Two postoperative cardiopulmonary bypass patients who had pancreatitis within a two week period provided the impetus for pursuing this study. Amylase-creatinine clearance ratios (ACCR) were measured in a series of ten thoracic surgery patients: six coronary artery bypass patients with cardiopulmonary bypass (cardiac group), and four exploratory thoracotomy patients (pulmonary group). These ratios were obtained in the preoperative, recovery room, and postoperative periods. Comparisons were made among the following data: clinical history, pre- and postoperative medications, intraoperative vital signs, drugs, and anesthetics. The preoperative mean ACCR was 3.34 per cent. All cardiac patients had a significantly elevated ACCR in the recovery room with a mean of 17.36 per cent (p less than 0.05). The ACCR had returned to preoperative levels by the second postoperative day in five of six cases. There were no elevated ACCR levels in the pulmonary group. All patients were asymptomatic for pancreatitis. The intraoperative course of the cardiac patients involved four common factors, besides cardiopulmonary bypass, which were not present in the pulmonary group. These similarities included transfusion of citrated fresh whole blood activated by calcium chloride, hypotension treated with ephedrine, administration of mannitol, and intraoperative morphine analgesia. The mechanisms of increased amylase secretion by calcium chloride or ephedrine administration and transient sphincter of Oddi constriction by morphine or the alpha-adrenergic response of ephedrine are considered with the theoretical implications toward pancreatitis. The background and significance of the ACCR are also analyzed, especially in association with the osmotic diuresis of mannitol and a subsequent low urine creatinine level.

Aged↗
PubMed1977

The effectiveness and cost of acute respiratory illness medical care provided by physicians and algorithm-assisted physicians' assistants.

The medical management of patients with acute respiratory illnesses was analyzed at two different clinics during a 14- to 21-month period. Patients received care from either physicians or physician-supervised physician's assistants (PA). The PAs used respiratory illness clinical algorithms to guide their choice of diagnostic tests and treatment. Illness outcome, patient satisfaction, and medical care cost data were obtained for all patients approximately two weeks after the index illness. Despite significant differences in patient population characteristics, illness outcomes were similar, regardless of the provider's educational background. Medical care costs, however, were highest for the physician's patients. For all patients, diagnostic tests contributed about one-third of the total direct costs, mainly because of chest x-ray and throat culture use. Sixty to eighty per cent of medication costs were due to nonprescription drugs used principally for symptom relief. The data demonstrate that the medical care delivered by these physician's assistants was as effective and less costly than the care provided by physicians. Reducing chest x-ray and throat culture use would have a significant economic impact, without adversely affecting medical care effectiveness.

Acute Disease↗
PubMed1977

An analysis of the cost-effectiveness of pharyngitis management and acute rheumatic fever prevention.

The cost-effectivness of preventing primary acute rheumatic fever attacks by oral or benzathine penicillin treatment was analyzed for both epidemic and endemic streptococcal pharyngitis situations. Decision analysis was used: the probabilities and the outcome values were calculated from published data. Three penicillin strategies were compared: (A) treating only patients with group A streptococci-positive throat cultures; (B) treating all patients; (C) treating none of the patients. In the epidemic situation it is medically most effective and least costly to treat all patients with penicillin (Strategy B). In the endemic situation, Strategy B is also most cost-effective when oral penicillin is used in patient populations where the positive throat culture yield is at least 20%. Strategy A is optimal when the yield is between 5% and 20%; below a 5% yield, Strategy C is appropriate. For any individual patient, it is possible that choice of the most cost-effective treatment strategy could be based on the patient's clinical findings.

Cost-Benefit Analysis↗
PubMed1977

Absence of mucosal atrophy in human small intestine after prolonged isolation.

Light and electron microscopic evaluation of segments of human jejunum (bypassed for 3 1/3 years in treatment of morbid obesity) and ileum (bypassed for 6 years as a Thirty-Vella fistula in treatment of postsurgical fistula) showed no obvious evidence of widespread mucosal atrophy. The findings contrast with those reported in experimental animals and in most human patients with ileal urinary conduits, where atrophy of the isolated segment is the rule. Perhaps nonluminal factors in the human subject are sufficient to maintain small intestinal mucosa for long periods in the absence of intestinal chyme.

Atrophy↗
PubMed1976

Benign hepatic tumors and their association with oral contraceptives.

The growing number of reports of benign hepatic tumors occurring in young women who have been receiving oral contraceptive steroids has led us to review the 33 patients reported in the literature and to cite two additional case reports. By presenting two reports, one describing focal nodular hyperplasia and the other multiple hepatic cell adenomas, we hope to emphasize the pathological differentiation between these two lesions in order to calrify further reporting. Twelve of the 35 patients had massive intraperitoneal bleeding; two other patients had less severe hemoperitoneum. Five deaths have been reported. Although the frequency of use of these agents has become such that a direct relationship between them and benign hepatic tumors is not proved, the clinician should bear the association in mind when presented with women taking oral contraceptives who have abdominal pain. The review is made in the hope of stimulation further case reporting and microscopical and ultrastructural analysis. We trust that three will clarify the possible role of contraceptive steroids as predisposing or etiologic agents.

Adult↗
PubMed1976

Operative endoscopy in the management of biliary tract neoplasms.

Operative endoscopy of the biliary system has been employed with ever increasing frequency at the UCLA Hospital during the last three years. In addition to its established value with respect to disclosing unsuspected stones in the bile ducts, choledochoscopy has been of great value in terms of more accurate diagnosis and staging of periampullary and bile duct neoplasms. It has been observed that many biliary tract carcinomas are multicentric in origin and that cholangiography is not adequate to identify small intrahepatic ductal lesions. More than one cell type of bile duct carcinoma may be present in the same patient. Choledochoscopy should be used in addition to the conventional criteria for resectability in all patients with ductal or periampullary carcinoma. Use of this technic will spare some patients needless radical procedures and should improve long-term cure rates by identifying those patients with truly localized disease for curative resections.

Adenocarcinoma↗
PubMed1976

Ischemia of the colon.

Ischemic colitis is a disease complex that presents as a continuum of mucosal and submucosal hemorrhage, late stricture formation and frank gangrene. The exact form depends upon the degree, site and duration of the vascular occlusion, the presence of collateral vessels and the intraluminal pressure in the colon. In a study group of 19 women and seven men, the majority of whom were in the seventh to eighth decades of life, most frequent symptoms were crampy abdominal pain and abdominal distention associated with bloody diarrhea. Ischemic colitis occurred with increased colonic intraluminal pressure, generalized decreased vascular flow and embolic phenomenon. The predominating predisposing causes were atherosclerosis, shock and congestive heart failure as well as leukemia. The results of barium enema studies showed a pathognomonic condition that included thumbprinting, mucosal ulcerations and sacculations. Arteriography, generally, was not helpful, and results of sigmoidoscopy were invariably negative, since the rectum seldom is involved in ischemic colitis. Conservative treatment should include intestinal rest, low molecular weight dextran and antibiotics. Early operative intervention is recommended when conservative therapy fails or signs of peritoneal irritation become evident.

Adolescent↗
PubMed1976

The hepatorenal syndrome.

The hepatorenal syndrome is defined as the spontaneous onset of progressive renal failure in patients with far advanced hepatic disease, usually on the basis of cirrhosis. The clinical characteristics of the syndrome include azotemia, oliguria, hyponatremia, low urinary sodium excretion and the absence of abnormal findings in the urinary sediment. Although the results of a large number of studies suggest that abnormal histologic features in the kidneys are infrequent, changes such as glomerulosclerosis, degeneration of tubular cells and alterations in the basement membranes have been described. Theories on the pathophysiologic aspects of the syndrome, including reduced plasma volume, inferior vena cava hypertension and active renal vasoconstriction, are presented. The last of these is currently the most widely accepted theory in which there is a selective redistribution of blood flow away from the cortical nephrons to the medullary nephrons on the basis of selective cortical vasoconstriction. The role of the synpathetic nervous system, as well as that of plasma renins in the cause of this condition is explored. Therapy for the hepatorenal syndrome generally has failed to ameliorate extremely unfavorable mortality rates. Such factors as the effects of plasma volume expansion; various pharmacologic agents, including dopamine, Octopressin and metaraminol; portacaval shunt; transplantation of the liver, and steroids are discussed. Regardless of specific therapy, the few patients who do survive tend to demonstrate a significant reversible component with respect to hepatic disease.

Diagnosis, Differential↗
PubMed1975

Canine gallbladder bile. Effects of proximal gastric vagotomy, truncal vagotomy, and truncal vagotomy with pyloroplasty on volume and composition.

Three groups of four dogs each underwent proximal gastric vagotomy, truncal vagotomy, or truncal vagotomy with pyloroplasty. Two dogs had sham operations. Gallbladder bile was aspirated and measured. Aliquots were cultured and assayed for cholesterol, phospholipid, and bile salts initially and at subsequent laparotomies. Both truncal vagotomy groups showed marked increases in aspirate volume at subsequent laparotomies. The sham and proximal gastric vagotomy groups showed a small initial decrease in mean aspirate volume without further significant changes. When the bile assay data were plotted on triangular coordinates, all point for all groups remained well within the area of cholesterol solubility. Nevertheless, two dogs in each truncal vagotomy group were found to have gallstones. No stones were found in the sham and proximal gastric vagotomy groups. Proximal gastric vagotomy appears to preserve fasting gallbladder bile volume and does not alter bile composition in the dog.

Animals↗
PubMed1975

Lesions of the segmental and lobar hepatic ducts.

Despite reports to the contrary, unobstructed drainage of 50% of an otherwise normal liver through either the right or left uninfected hepatic duct is adequate to restore normal liver function, even if the obstructed lobe remains in place. An undrained liver lobe, if present, may require no further treatment. As long as it is completely obstructed and uninfected, it will undergo a progressive asymptomatic atrophy. Cholangitis invariably develops behind a partial lobar ductal obstruction, producing jaundice, pruritus, and fever. Unless unobstructed, uninfected biliary flow can be achieved through a segmental or lobar duct, it is better that the duct be completely obstructed and the affected liver parenchyma allowed to atrophy, provided there is normal biliary flow from the residual 50% of liver. This concept is important in the management of injured anomalous segmental or lobar hepatic duct and in the palliative treatment of bile duct carcinoma. Localized intrahepatic infections communicating with abnormal biliary ducts will require hepatic resection of the infected parenchyma and ducts for cure. The abnormality may be saccular dilatation of the intrahepatic ductal system with abscess formation or intrahepatic abscess associated with stenosis of the ductal system from trauma to the duct, to the duct and liver, or to retained intrahepatic stones. Diffusely situated intrahepatic abscesses secondary to ductal abnormalities can be treated with systemic antibiotics, local drainage of a dmoninant abscess, and efforts to improve biliary drainage.

Adolescent↗