Radiology and surgery in the treatment of the complications of acute pancreatitis.
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Acute Disease↗
Biomedical subjects
R Rutledge
Publications and source records attributed to R Rutledge.
Cholelithiasis in sickle cell anemia: surgical considerations.
Gallstones are frequently found in patients with sickle cell anemia. The differentiation between acute calculous biliary tract disease and sickle cell crisis can be difficult and should be based on the clinical presentation, comparison with previous episodes of abdominal pain, and judicious use of hepatobiliary radionuclide scanning. Emergency cholecystectomy is associated with a high morbidity and should be avoided if possible. Elective cholecystectomy is associated with a lower but still significant risk of complications. We believe patients with sickle cell anemia and symptomatic cholelithiasis should have elective cholecystectomy. Careful management is essential to minimize the danger of postoperative complications.
Acute Disease↗
Massive transfusion.
Massive transfusion is a potentially serious problem associated with a number of complications, including changes in coagulation factor and platelet concentration, nonmechanical bleeding, hypothermia, pulmonary dysfunction, hypokalemia and hyperkalemia, hypocalcemia, hypomagnesemia, acidosis and alkalosis, immune suppression, blood transfusion reactions, and transmission of infectious diseases. The pathophysiology and management of massive transfusion are reviewed in this article.
Blood Coagulation Disorders↗
Physician use of on-line databases.
All in all, the amount of information and the potential use to the physician are difficult to overstate. Still, possibly one of the most amazing things about this area of computers in medicine is that this is only the beginning.
Humans↗
Experience with the variable axis knee prosthesis.
In an evaluation of 245 variable axis total knee arthroplasties, no significant deterioration of results were found five to nine years after implantation. The patellar problems originally reported diminished with the use of a patellar button, widening of the flange on the femoral component and the increased use of lateral retinacular release. The local complications were: severe patellar problems, 6.9%; ligamentous laxity, 2.9%; aseptic loosening, 1.2%; deep infections, 2.0%; supracondylar fractures, 1.2%; peroneal nerve palsy, 1.6%.
Aged↗
Candida species. Insignificant contaminant or pathogenic species.
The pathogenicity of Candida species cultured from peritoneal fluid or from an intra-abdominal abscess is unknown. A review of cultures at NCMH from 1978 to 1983 showed that Candida species were cultured from the peritoneal fluid of 39 patients and from intra-abdominal abscesses in 24 patients. The average age was 49 (range 6 months to 102 years); there were 38 men and 25 women. None of the 39 patients with Candida species grown from the peritoneal fluid was treated with Amphotericin B and only 1 (2.6%) subsequently developed an abscess. This patient was treated by surgical drainage without Amphotericin B and recovered. Twenty-four patients had Candida cultured from an intra-abdominal abscess. Of these, 21 (87.5%) also grew other bacterial organisms. Twenty of these 24 patients were treated with surgical drainage and antibacterial antibiotics without Amphotericin B. Six (30%) died, but only one death was felt to be directly related to the Candida infection. The remaining four were treated with surgical drainage, appropriate antibacterial antibiotics, and Amphotericin B. Two of these four (50%) died; one of the two deaths was related to Candida infection. Candida species grown from the peritoneum were not related to later Candida infection. Treatment of patients with contamination of the peritoneum by Candida with Amphotericin B appears unnecessary and because of Amphotericin renal toxicity, may be potentially harmful. Patients with polymicrobial intra-abdominal abscesses that contain Candida species should be treated with surgical drainage and appropriate antibacterial antibiotics. The value of adding Amphotericin B therapy in patients with polymicrobial abscess containing Candida was not demonstrated in this study, and its role is unclear.
Abdomen↗
Genomic heterogeneity of AIDS retroviral isolates from North America and Zaire.
In an analysis of the genomic variation of AIDS retroviral isolates from patients living in New York, Alabama, and Zaire, restriction maps were constructed by using seven enzymes, each known to cleave the proviral DNA more than once, in conjunction with Southern blot analysis. The maps of LAV, HTLV-III, and ARV-2 as deduced from their published nucleotide sequences were included in this analysis. The results demonstrated that (i) several "signature" restriction sites were common to all isolates; (ii) with the exception of LAV and HTLV-III, the North American and European isolates were all different from one another and showed no geographical specificity; (iii) the African isolates as a group were more diverse than those from North America and Europe; and (iv) the genomic variability was concentrated within the env gene.
Acquired Immunodeficiency Syndrome↗
Actuarial analysis of the risk of prosthetic valve endocarditis in 1,598 patients with mechanical and bioprosthetic valves.
We reviewed the charts of 1,598 patients undergoing valve replacement at the National Institutes of Health, Bethesda, Md, from 1956 through 1981. Retrospective analysis disclosed that 43 patients had prosthetic valve endocarditis (PVE). Twelve patients had early (less than 60 days after operation) and 31 patients had late (greater than 60 days after operation) endocarditis. The cumulative risk was 3% at five years and 5% at ten years. We also calculated the interval risk of PVE. The high risk of early PVE development peaked 15 days after operation. The peak risk was 45 episodes per 100,000 patient days. The risk then declined rapidly and from 150 days to 20 years remained stable at approximately one episode per 100,000 patient days. Nine hundred fifty-two patients had valve replacement with a Starr-Edwards prosthesis and 363 patients had valve replacement with a bioprosthetic valve; there was no significant difference in the risk of PVE in either group. Neither the valve make, position, model, nor the number of valves implanted affected the frequency of PVE or the mortality. Actuarial techniques disclosed the high early risk of PVE, the prolonged risk of PVE up to 150 days after operation, and the low but persistent risk late after operation. There was no significant difference in the risk of PVE in patients with bioprosthetic v mechanical valves.
Actuarial Analysis↗
Mediastinal infection after open heart surgery.
Mediastinal infection occurred in 29 of 2031 patients (1.4%) who underwent median sternotomy for cardiac operation at the National Heart, Lung and Blood Institute between 1956 and 1981. Factors associated with the development of mediastinitis included postoperative complications such as low cardiac output, respiratory insufficiency, reoperation for bleeding, repeat median sternotomy, and triple valve replacement. Factors that were not significantly associated with the development of mediastinitis included preoperative functional class, preoperative cardiac index, age, sex, weight, or presence of diabetes mellitus. The mortality rate in patients who developed mediastinitis was 52%. Factors associated with death included preoperative functional class III or IV, type of operation, type of organism involved, and the development of pneumonia. The mortality rate was significantly lower (35% versus 73%) in the patients who underwent mediastinal exploration for treatment. There was no difference in survival whether the wound was closed over drainage tubes or packed open. Hospital stay, however, was significantly prolonged in the patients whose wounds were packed open.
Adolescent↗
The use of barium enema in the evaluation of patients with possible appendicitis.
Patients with right lower quadrant pain and possible appendicitis may present a difficult diagnostic dilemma to the surgeon. Barium enema has been used as an adjunctive test in the evaluation of patients with right lower quadrant pain in whom the diagnosis is unclear. The authors retrospectively reviewed their experience with 33 patients to determine the value of barium enema. The average age was 32 years (range, 2-89 years). Twenty-five patients had nonfilling of the appendix; nine of these patients had a mass effect on the cecum. Three patients had partial filling of the appendix and five patients had a normally filled appendix. Of the 16 patients who had nonfilling of the appendix without a filling defect of the cecum, 14 patients underwent operation. Eleven patients had appendicitis and three patients had a normal appendix. Two patients with nonfilling did not undergo operation and did well. All patients with a filling defect of the cecum on barium enema had appendicitis. All patients with partial filling of the appendix had appendicitis. Of five patients with normal appendices on barium enema, one patient had a diverticular abscess and underwent operation, and another patient had Meckel's diverticulitis which was excised. Barium enema can provide information to aid in the management of patients in whom the diagnosis of appendicitis is not clear. It can prevent unnecessary operation in some, and assist in earlier operation in others.
Adolescent↗
The relation of serum calcium and immunoparathormone levels to parathyroid size and weight in primary hyperparathyroidism.
This study was designed to determine whether the serum calcium or immunoparathormone (iPTH) level would be of value in predicting the size or weight of the parathyroid gland in patients with single-gland enlargement caused by primary hyperparathyroidism. Ninety-two patients who underwent parathyroidectomy with removal of a single enlarged gland at the North Carolina Memorial Hospital (1974 to 1984) were reviewed. The preoperative calcium and immunoparathormone levels were correlated to the weight and calculated volume of the removed gland. The calcium level was found to be significantly associated with parathyroid gland weight and volume (p less than 0.001), as determined by linear regression analysis. Despite the statistical association, the correlation coefficient (calculated with the Pearson correlation matrix) was low, 0.16 for the relation of calcium to gland weight and 0.25 for the relation of calcium to calculated gland volume. The calculated coefficients of correlation of iPTH (three different assays) to gland weight and volume were similarly low. These findings demonstrate a variable relationship between the preoperative serum calcium level or the iPTH level to the weight or volume of the enlarged hyperfunctioning parathyroid gland. Identification of the pathologic parathyroid gland(s) in primary hyperparathyroidism cannot be based on a perceived relation of preoperative calcium or iPTH levels to the size of the enlarged glands.
Adolescent↗
Intraoperative Doppler ultrasonographic localization of a colonic arteriovenous malformation.
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Adult↗
Actuarial analysis of the risk of undergoing repeat cardiac valve replacement.
One thousand five hundred ninety-eight patients who underwent cardiac valve replacement were reviewed. One hundred fifty-two patients (10 percent) required a second valve replacement. The indications for repeat valve replacement were prosthetic valve dysfunction in 53 patients (35 percent), development of a new valvular lesion in 46 patients (30 percent), simple closure of a perivalvular leak in 14 patients (9 percent), change of the valve poppet in 13 patients (8 percent), severe hemolysis or emboli in 21 patients (14 percent), and prosthetic valve endocarditis in 5 patients (3 percent). The mean preoperative New York Health Association functional class improved from 3 to 1.5 in the nonreoperated patients and from 2.9 to 1.8 in patients who underwent a second valve replacement. Similarly, the mean cardiac index improved from 2.5 to 2.9 and from 2.5 to 2.8 in nonreoperated and reoperated patients, respectively. The operative mortality rate was 14 percent in the nonreoperated patients and 16 percent at second operation in the reoperated patients. Using actuarial techniques, the risk of repeat valve replacement was 1 to 4 percent per year. Long-term survival was compared between groups. Using actuarial techniques, the estimated survival rates at 1, 5, and 10 years were 89 percent, 69 percent, and 52 percent, respectively in nonreoperated patients and 87 percent, 60 percent, and 37 percent in reoperated patients. This study has documented the excellent improvement in functional and hemodynamic state after second cardiac valve replacement. The operative mortality and long-term survival rates were similar to those of the nonreoperated patients. Patients having repeat cardiac valve replacement can expect good improvement in length and quality of life.
Actuarial Analysis↗
Enteral alimentation using fluoroscopically placed catheters.
Proximal gastrointestinal disease or injury that prevents adequate enteral alimentation is a difficult management problem. Recently, total parenteral nutrition has been shown to be important in maintaining these patients and the management of these problems. However, central intravenous hyperalimentation is associated with well-described problems and has other advantages. This article describes a technique for catheterizing a distal portion of the gastrointestinal tract for the provision of adequate enteral alimentation using an angiographic catheter and fluoroscopy.
Adult↗
Rifampin and cefazolin as prophylactic agents. A comparison in an animal model of vascular graft infection.
We investigated rifampin and cefazolin sodium as prophylactic agents in a dog model of vascular graft infection. A 1-cm segment of 3-mm-diameter polytetrafluoroethylene (Gore-tex) graft was sewn into the right carotid artery of each dog, and prior to closure, 10(3) Staphylococcus organisms sensitive to both cefazolin and rifampin were injected over the graft. The dogs were killed five days after surgery and the grafts cultured. Infection occurred in 100% of controls, 58% of cefazolin-pretreated dogs, and 17% of rifampin-pretreated dogs. Mean blood levels of antibiotics were assayed as follows: cefazolin, 50.1 micrograms/mL; rifampin, 2.9 micrograms/mL. Both were well above the minimal inhibitory concentration. Thus, rifampin proved to be more effective than cefazolin in this animal model.
Animals↗
Mitral valve replacement after closed mitral commissurotomy.
Closed mitral commissurotomy (CMC) was performed at the National Heart Institute in 303 patients (73% women, 27% men; mean age 40 years) with acquired isolated mitral stenosis between 1954 and 1980. The average mean mitral valve gradient decreased from 14.2 +/- 0.4 to 5.3 +/- 0.4 mm Hg (p less than 0.001), and mitral valve area index increased from 0.7 +/- 0.03 to 1.4 +/- 0.9 cm2/m2 (p less than 0.001). The perioperative mortality was 2%. Ninety-two percent of patients improved one or more functional classes after CMC. Actuarial survival was 95%, 82% and 70% at 5, 10 and 15 years after CMC, respectively. Fifty-four patients (18%) required mitral valve replacement (MVR) a mean of 9.6 years after commissurotomy (range 1-26 years). Before CMC, factors associated with later MVR included preoperative functional class, calcification of the mitral valve, and the absence of an opening snap. After CMC, poor functional improvement, congestive heart failure, atrial fibrillation, and the necessity for a repeat CMC were associated with late MVR. Catheterization after CMC showed that patients who later required MVR had a smaller decrease in left atrial pressure (p less than 0.001), more mitral regurgitation (p less than 0.001), and were more likely to have pulmonary hypertension (p less than 0.05). The indications for MVR were residual stenosis with or without mild mitral regurgitation in 33 patients (61%), restenosis in 15 (28%), and moderate-to-severe regurgitation in six (11%). Perioperative mortality for valve replacement was 13%. Among survivors, 88% improved at least one functional class after valve replacement. Actuarial survival was estimated to be 95% at 5 years and 74% at 10 years after MVR. This study confirms that CMC provides excellent long-term hemodynamic and clinical improvement in appropriately selected patients. When symptomatic deterioration occurs late after CMC, MVR restores clinical and hemodynamic improvement in many patients. CMC continues to be performed at the National Heart Institute in selected patients with acquired mitral stenosis.
Adult↗
The challenge of moving.
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Health Facilities↗
Synthesis and diuretic profile of 3-(3-amino-1,2,4-oxadiazol-5-yl)-5-chloro-2,6-pyrazinediamine, an amiloride-type diuretic.
The synthesis of an analogue of amiloride in which the acylguanidine moiety has been replaced by a 1,2,4-oxadiazol-3-amine unit is described. This substance (3, CGS 4270) exhibited a diuretic profile similar to that of amiloride when evaluated in the rat and the dog. In the rat, combination with hydrochlorothiazide increased diuresis and saluresis and returned potassium levels to control values. A series of 5-aryl-1,2,4-oxadiazol-3-amines not directly related to amiloride was prepared, but these substances had no diuretic activity.
Animals↗