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Biomedical subjects

R W Busuttil

Publications and source records attributed to R W Busuttil.

At least 271 records · Page 15Linked to original sources
PubMed1988

Can clinical evaluation and noninvasive testing substitute for arteriography in the evaluation of carotid artery disease?

The objective of this study was to prospectively assess the value of combining clinical assessment and noninvasive testing in predicting the spectrum of carotid bifurcation pathology, as subsequently proven by arteriography, in order to determine the safety and accuracy of performing carotid endarterectomy without angiography. A panel of eight specialists representing vascular surgery, neurology, and neurosurgery were presented with the history, physical findings, and noninvasive test results (GEE-OPG and duplex scan) of 85 patients. They were asked to make an anatomic prediction of the status of each carotid artery (170 arteries) as to whether the bifurcation was normal, ulcerated, had a hemodynamically significant stenosis, or was occluded. The predictions were then prospectively evaluated and correlated with angiographic findings; 159 of 170 (93.5%) carotid arteries were accurately characterized; 73 of 80 (91%) symptomatic carotid arteries and 86 of 90 (95.5%) asymptomatic arteries were correctly characterized; 61 of 61 (100%) stenoses of hemodynamic significance, nine of 14 (64.3%) ulcerations without stenosis, and 18 of 18 (100%) of total occlusions were accurately identified by the panel. Twenty-nine patients have subsequently had 32 carotid endarterectomies without angiography, and the predicted lesion was confirmed at the time of exploration. The combination of clinical assessment and noninvasive testing, particularly duplex scanning, when performed in a laboratory with validated accuracy may with defined qualification be safely used as a substitute for contrast angiography.

Aged↗
PubMed1988

Liver transplantation at UCLA: a report of clinical activities.

Liver transplantation has become a widely accepted form of therapy for many life-threatening liver illnesses. Since the introduction of CsA in 1980, numerous centers have opened and now more than 800 liver transplants are performed in the United States per year. In most large series, a 70% 5-year survival rate is seen. However, in terms of survival, hepatic transplantation for carcinoma continues to lag behind other diseases. In the absence of an available alternative treatment for this group of patients, vigorous investigation into prevention of recurrences following OLT is needed. Despite the proliferation of liver transplant programs, optimization of postoperative care remains a major challenge for those physicians who care for these patients. Too often, the diagnosis of rejection in contrast to infection is guided by clinical suspicion rather than firm evidence. Reversal of multiorgan dysfunction is often aggravated by the very immunosuppressants which allow transplantation. Maximizing graft acceptance and organ function while minimizing infectious complications remains the ultimate goal for transplant surgeons and is the key to further success.

Adolescent↗
PubMed1987

Interval gangrene occurring after successful lower-extremity revascularization.

Four patients experienced a rare but devastating complication of peripheral vascular reconstructive surgery in which gangrene occurred in the presence of a functioning graft and palpable pulse. Three patients underwent bypass procedure for limb-threatening ischemia. Despite a "satisfactory" postoperative result of a well-perfused distal extremity and strongly palpable pulse, each of these patients developed progressive ischemic gangrene in an area proximal to the distal anastomosis and eventually required amputation. These patients demonstrate the importance for maintaining collaterals to perfuse bypassed segments of the lower extremities. In a patient with inadequate collateral circulation or in whom the profunda perigeniculate collateral pathway has been disrupted or is absent due to disease, it is necessary to revascularize sequential vascular beds.

Aged↗
PubMed1987

Variables influencing the outcome following orthotopic liver transplantation.

Seventy-two patients who underwent orthotopic liver transplantation (OLT) were studied to identify perioperative variables that would predict survival and intraoperative blood loss. Survival and intraoperative blood loss were not affected by encephalopathy, length of donor liver ischemia, or any of the preoperative laboratory values studied. Survival was significantly decreased in patients requiring postoperative dialysis (41%) and in patients who had severe rejection requiring retransplantation (33%). Intraoperative blood loss was significantly greater in patients over 50 years of age (11.6 blood volumes) and patients with biliary atresia (8.7 blood volumes). These results may aid in choosing future recipients for orthotopic liver transplantation and in anticipating the postoperative support needed.

Adolescent↗
PubMed1987

A prospective study on the use of monoclonal anti-T3-cell antibody (OKT3) to treat steroid-resistant liver transplant rejection.

Conventional treatment of acute liver allograft rejection has included high doses of corticosteroids and antithymocyte globulin. Urgent retransplantation was the only option for patients who failed to respond. We report our initial experience with the use of monoclonal anti-T3-cell antibody (OKT3) in 25 patients with acute hepatic allograft rejection that was resistant to steroid and/or antithymocyte globulin therapy. Twenty-four of 25 patients had a response to OKT3, which was complete in 14 and partial in ten. With a mean follow-up of 8.2 months, allograft salvage has been 80% and patient survival 88%; two patients underwent successful retransplantation. Side effects have been mild and well tolerated. Repeated rejection has occurred in 40% of patients, but these episodes have responded to steroid therapy. We conclude that OKT3 is well tolerated and highly effective in reversing severe episodes of acute hepatic allograft rejection that is resistant to high-dose steroid therapy.

Acute Disease↗
PubMed1987

Incidence and mechanism of post-carotid endarterectomy hypertension.

Hypertension following carotid endarterectomy occurs frequently but is poorly understood. Its occurrence has been correlated with an increased incidence of neurologic complication. We identified those factors that correlate with an increased incidence of post-carotid endarterectomy hypertension. The records of 100 patients who underwent carotid endarterectomy at UCLA Medical Center from November 1981 to September 1983 were examined. One hundred fifty variables were surveyed to determine those factors associated with this problem. Fifty-eight percent of the study patients developed post-carotid endarterectomy hypertension (an increase in systolic blood pressure greater than 35 mm Hg over baseline, and/or blood pressure requiring treatment with sodium nitroprusside). Of patients who developed this problem, 93% had diabetes mellitus, 75% received isoflurane anesthesia, 71% had peripheral vascular occlusive disease, 71% underwent ipsilateral transient ischemic attacks, and 65% had high-grade ipsilateral carotid stenosis. These variables have in common the loss of or interference with cerebral autoregulation. Central dysautoregulation may set the stage for a positive feedback mechanism that results in increased blood pressure. Anesthetic agents that do not interfere with cerebral autoregulation may reduce the incidence of this complication, and an aggressive treatment program may prevent neurologic complications.

Adult↗
PubMed1987

Fulminant hepatic failure: the role of liver transplantation as primary therapy.

Fulminant hepatic failure is a clinical syndrome with a high mortality rate when traditional supportive therapy is used as treatment. Orthotopic liver transplantation has been proposed as a therapeutic option. Clinical and logistic difficulties include the rapid deterioration of the patients, unpredictable recovery, and the immediate need for a donor organs. Including this series, a total of 41 patients with fulminant hepatic failure have been transplanted, with a survival rate of 61 percent. We have reported eight liver transplantations carried out in six patients. Four of the patients survived (66 percent). Death was due to irreversible neurologic dysfunction in one patient and fungal sepsis in one patient. These results indicate that orthotopic liver transplantation is a practical therapeutic option for fulminant hepatic failure which should be considered early, before neurologic deterioration becomes irreversible.

Acute Disease↗
PubMed1987

The effects of in vivo antibiotics on neutrophil (PMN) activity in rabbits with peritonitis.

Antibiotics play an important role in helping the host fight infection; however, the direct cellular effect of antibiotics on polymorphonuclear cells remains undefined. Adherence, chemotaxis, phagocytosis, and superoxide anion production are important steps in the cascade of events initiated by the polymorphonucleocyte in bacterial killing. Previous studies have shown inhibition as well as stimulation of neutrophil antibacterial therapy by antibiotics. Peritoneal and blood polymorphonuclear neutrophils (PMN) respond differently to peritonitis and to external agents. The purpose of this study was to investigate the effects of in vivo clindamycin and netilmicin on infected rabbit peritoneal and blood polymorphonuclear adhesiveness, phagocytosis, chemotaxis, and superoxide anion production. Peritoneal and blood PMNs were obtained from rabbits which had undergone appendiceal devascularization 18 hr earlier: antibiotics were administered intramuscularly 1 hr prior to appendectomy and every 8 hr postoperatively for 5 days; these PMNs were compared to infected rabbits which did not receive antibiotics. Clindamycin and netilmicin in vivo cause significant inhibition of phagocytosis, peritoneal adhesiveness, and, when used in combination, blood adhesiveness and peritoneal superoxide anion production. No effects were seen on chemotaxis. Based on this data we conclude that antibiotics, while vitally important in fighting infections, may in and of themselves be agents of immunosuppression at the cellular level.

Animals↗
PubMed1987

The effect of dexamethasone in vivo on blood and peritoneal neutrophils (PMN) in rabbits with peritonitis.

Neutrophils play an essential role in the host's defense against infection. Our previous studies have shown that blood and peritoneal neutrophils (PMN) have different basal activities and responses to infection. We also demonstrated that peritonitis produces divergent changes in the cellular function of PMN both in the blood and in the peritoneal fluid. Steroids are well documented to cause immunosuppression both clinically and, more variably, at the cellular level. Understanding the mechanism of steroid-induced immunosuppression in surgical infection may impart insight on the management of this condition. Using a model of surgical peritonitis, we studied the effects of immunosuppression on rabbit blood and peritoneal PMN. Blood and peritoneal PMNs were harvested after the development of fibrinopurulent peritonitis. Rabbits were divided into two groups: immunosuppressed and control. Immunosuppression was accomplished by intramuscular injection of dexamethasone (2 mg/kg) for 10 days preoperatively and 10 days postoperatively. Purified PMNs were studied for phagocytosis, adhesiveness, superoxide anion production and chemotaxis from both groups. Survival was computed from the number of days the rabbit survived after the operation up to a total of 10 at which time they were sacrificed. Immunosuppression with dexamethasone resulted in inhibition of peritoneal phagocytosis and peritoneal adhesiveness; there were no changes in blood adhesiveness nor blood phagocytosis. Also, there was no significant change in superoxide anion production nor in chemotaxis. Survival of the rabbits was significantly reduced when treated with dexamethasone.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1987

The first 100 liver transplants at UCLA.

A clinical program in liver transplantation was begun at UCLA in 1984 after a period of laboratory investigation. The first 100 orthotopic liver transplants (OLT) were performed in 83 patients (43 adults and 40 children) between February 1, 1984 and November 1, 1986. Donors and recipients were matched only for size and ABO blood group compatibility, with OLT performed across blood groups in 28 patients. Standard operative techniques were used, including venous-venous bypass in adults. Arterial reconstruction was performed using an aortic Carrel patch or "branch patch" in 65% of cases and by end-to-end or aortic conduit techniques in the remainder. The hepatic artery thrombosis rate was 5%. Biliary reconstruction was choledochocholedochostomy in 67 OLT and Roux-en-Y choledochojejunostomy in 33 (complication rate of 24% and 24%, respectively). Average lengths and ranges of donor liver ischemia, operating time, and blood replacement were 4 hours (range: 1-10 hours), 7.6 hours (range: 4-15 hours), and 17 units packed cells (range: 2-220 units). Immunosuppressive regimen was cyclosporine-steroid combination, with monoclonal anti-T-cell antibody (OKT3) used for refractory rejection. All patients had one or more complications: pulmonary (78%), infectious (51%), renal dialysis (25%), neurologic (22%). All patients had at least one episode of acute rejection, and 3.6% had chronic rejection. Retransplantation was needed in nine patients once and in four patients twice. The overall retransplant survival rate was 54%, and two of four patients who received a second retransplant are alive. Sixty-three of the 83 patients (76%) are alive (adults 72%, children 80%). The 1- and 2-year actuarial survival rate is 73% (adults 68%, children 78%). Thirty-eight of 43 patients (88%) who had transplantation in the past year are alive. Of 14 perioperative variables assessed as predictors of early mortality, only postoperative dialysis (p less than 0.0005) and presence of severe rejection (p less than 0.01) had statistical significance. Seventy per cent of adults returned to work, and 84% of children had normal or accelerated growth. A new program in liver transplantation provides a dramatic option in patient care and an academic stimulus to the entire medical center.

Adolescent↗
PubMed1987

Operations upon the biliary tract during transplantation of the liver.

Operation upon the biliary tract is a discipline within transplantation of the liver. There exists a background of basic science information concerning anatomy and physiology, an historical evolution of surgical techniques, a divergence of contemporary opinion regarding preferred approaches and a body of well described complications. The complication rate, once more than one-half with substantial contribution to mortality rates, now ranges from approximately 15 to 25 per cent. Current practice in most institutions is to use choledochocholedochostomy with T-tube stent when a recipient duct is present and Roux-en-Y choledochojejunostomy with internal stent when a suitable recipient duct is absent. Hepatic arterial thrombosis is an important cause of complications of the biliary tract. The overlap of symptoms and signs of rejection with those of biliary sepsis and other complications of the biliary tract underscores the need for algorithmic use of diagnostic modalities in the post-transplant period.

Biliary Tract Surgical Procedures↗
PubMed1987

Hepatic hemangiomas: evaluation by magnetic resonance imaging and technetium-99m red blood cell scintigraphy.

A study was performed to evaluate and compare the sensitivity of magnetic resonance imaging (MRI) and radionuclide blood-pool scanning in the detection of hepatic hemangiomas. All patients had known hemangiomas which were first detected on either ultrasound or computed tomography. Sixteen patients with a total of 23 lesions were investigated. Eleven patients had both MRI and blood-pool scans performed. In the group studied by both modalities, 18 lesions were detected ranging in size from 1 to 11 cm. All lesions were detected by both techniques. However, two of the 18 lesions had an atypical appearance on MRI. Our experience to date indicates that the anatomic location and specific diagnosis of hemangiomas can be made with a high degree of certainty when both MRI and blood-pool scanning techniques are utilized.

Adult↗
PubMed1987

Selective surgical therapy of the Budd-Chiari syndrome provides superior survivor rates than conservative medical management.

The Budd-Chiari syndrome is an unusual form of portal hypertension caused by hepatic vein occlusion, which results in centrilobular congestion and necrosis. Its overall mortality rate exceeds 50% at 2 years, and optimal treatment remains controversial. To determine optimal therapy on the basis of clinical and angiographic data, we retrospectively analyzed 30 patients with this disease treated at the University of California, Los Angeles or the University of Southern California School of Medicine between 1955 and 1985. Twelve patients were treated conservatively with diuretics, anticoagulants, paracentesis, and/or peritoneal-venous shunt. Eighteen patients were treated by definitive surgery: side-to-side portocaval shunt (four), mesocaval shunt (four), side-to-side splenorenal shunt (one), liver transplantation (two), transatrial membranotomy (TM) (two), TM followed by inferior vena cava reconstruction (IVCR) (one), TM followed by mesocaval shunt (one) simultaneous IVCR and side-to-side portocaval shunt (one), IVCR (one), and azygousatrial shunt followed 4 years later by a splenopulmonary shunt (one). Overall the surgical group had survival rates superior to the medical group, with a 2-year survival rate of 54% for the surgical group vs. 9% for the medical group (p less than 0.089). On the basis of these data we conclude that surgical therapy is superior to medical therapy for the Budd-Chiari syndrome. However, the operation must be tailored to treat the specific anatomic and clinical abnormality. Guidelines to select the proper surgical procedure are given.

Actuarial Analysis↗