Biomedical subjects

R W Busuttil

Publications and source records attributed to R W Busuttil.

At least 307 records · Page 17Linked to original sources

PubMed1984

Determinants of failure in the treatment of ruptured abdominal aortic aneurysm.

One must identify those fatal errors in the treatment of patients with ruptured abdominal aortic aneurysms (AAAs) to improve future treatment and reduce mortality. Our vascular registry identified 29 patients with ruptured AAAs who died following admission to the UCLA Hospital, Los Angeles, and the Sepulveda (Calif) Veterans Administration Hospital between 1971 and 1981. Review of the records identified four categories of error that contributed to death. These included failure to proceed with elective aneurysmectomy in 12 patients with known AAAs, error in the diagnosis of aortic rupture that led to delay in getting nine patients to the operating room, intraoperative technical error that produced venous injury in eight patients, and undue delay in anesthetic induction in four patients. Following the outline of a careful treatment approach should further reduce the mortality in the treatment of patients with ruptured AAAs.

Aged↗

PubMed1984

Survival of alcoholic v nonalcoholic patients after portasystemic shunts.

Controversy persists over the comparative survival of alcoholic v nonalcoholic cirrhotic patients who have had portasystemic shunts for therapeutic variceal decompression. We performed a matched retrospective study of 20 alcoholic cirrhotic patients and 20 nonalcoholic cirrhotic patients to determine any difference in survival between these groups and whether this correlated to the results of liver function tests. Patients were matched for age, urgency of operation, number of prior bleeding episodes, and Child's classification. Preoperative levels of albumin, bilirubin, alkaline phosphatase, and prothrombin time were similar in both groups. Operative mortality was 5% in the alcoholic cirrhotic group and 15% in the nonalcoholic group. Average long-term survival was 36 months in the alcoholic group and 43 months in the nonalcoholic group. Preoperative liver function parameters did not correlate with survival. Based on this data, we concluded that the results of preoperative liver tests did not correlate with survival in either group, long-term survival is similar in both groups after portasystemic shunts, and the difference in survival previously reported after a portasystemic shunt may pertain only to high-risk patients.

Adult↗

PubMed1984

Cutaneous extramedullary hematopoiesis following splenectomy for idiopathic myelofibrosis.

A 50-year-old man with idiopathic myelofibrosis had development of extensive cutaneous extramedullary hematopoiesis after undergoing splenectomy. Treatment with hydroxyurea was not effective, but electron-beam irradiation controlled the cutaneous infiltration. This rare clinical manifestation of idiopathic myelofibrosis can be confused with cellulitis, and diagnosis depends upon biopsy.

Aged↗

PubMed1984

Selective and nonselective shunts for variceal bleeding. A prospective study of 103 patients.

Based on the experience reported herein, the following conclusions have been made: (1) Although nonoperative means, including sclerotherapy, have an important role in the management of bleeding varices, they are not definitive means of treating recurrent variceal hemorrhage. (2) Because of the maintenance of hepatopetal flow and splanchnic venous hypertension, a selective shunt is associated with a lower incidence of encephalopathy and provides a better quality of life than does a nonselective shunt. Thus, an elective distal splenorenal shunt is the elective operation of choice for recurrent variceal hemorrhage. (3) Nonselective shunts can be performed with similar expectation of patient survival as selective shunts, but because of increased encephalopathy, should be reserved for emergency operations, in cases of unsuitable venous anatomy, and in those patients with intractable ascites. (4) A well-conceived elective shunt procedure can be performed with low operative mortality and long-term patency, results in significant survival, and is still considered the "gold standard" for treatment of variceal bleeding.

Adult↗

PubMed1984

Splenectomy for hematologic disease. The UCLA experience with 306 patients.

Between 1956 and 1981, 306 splenectomies for hematologic diseases were performed at the UCLA Medical Center. Of these operations, more than 75% were performed for therapeutic reasons to control anemia, thrombocytopenia, neutropenia, or painful symptoms of splenomegaly. Of the 65 patients who had idiopathic thrombocytopenic purpura, 77% showed an excellent response, and of the 39 patients who had hereditary spherocytosis, 90% responded. Other diseases with predictably good response rates were autoimmune hemolytic anemias, Felty's syndrome, and hairy cell leukemia. Forty patients with Hodgkin's disease had splenectomies for diagnostic purposes the last 10 years. The overall morbidity and mortality were 24% and 6%, respectively, the most common complications being pneumonia, wound infections, and local postoperative bleeding, and the most common cause of death being sepsis. The review supports the thesis that in carefully selected patients, therapeutic splenectomy can have desirable palliative effects and that diagnostic splenectomy has a sufficiently low risk to warrant its consideration in patients with Hodgkin's disease.

Adolescent↗

PubMed1984

Imipenem therapy of Pseudomonas aeruginosa and other serious bacterial infections.

Imipenem is the first of a new class of beta-lactam antimicrobial agents with remarkable and extremely potent in vitro activity against most commonly isolated bacterial pathogens, including Staphylococcus aureus, enterococcus, members of the family Enterobacteriaceae, Pseudomonas aeruginosa, Bacteroides fragilis, and Hemophilus influenzae. The clinical efficacy and toxicity of imipenem were evaluated in 35 patients with 38 different infections. The overall clinical response was favorable (infections cured or improved) in 89% of the infections (34 of 38). Of the 17 infections with P. aeruginosa, 15 were cured or improved. However, P. aeruginosa isolates resistant to imipenem emerged during the therapy of six infections, and two cases of P. aeruginosa septicemia later relapsed after imipenem therapy. Gastrointestinal toxicity (nausea with or without emesis) occurred in 17% of the patients (6 of 35) but was ameliorated by slowing the rate of intravenous infusion or lowering the dose of imipenem. Except for certain severe P. aeruginosa infections, imipenem is effective and relatively safe therapy for infections caused by susceptible organisms.

Adolescent↗

PubMed1984

A report of iris neovascularization: an indication for carotid endarterectomy.

The combined use of goniophotocoagulation and carotid endarterectomy may be an important mode of treatment of iris neovascularization caused by carotid insufficiency. Carotid operation alone in cases of iris neovascularization has not been successful in controlling the concomitant or ensuing neovascular glaucoma. When more severe symptoms of carotid occlusion occur, such as transient ischemic attacks or visual loss, it may be too late to reverse the damage of neovascular glaucoma. In this case report, early detection of the iris neovascularization, goniophotocoagulation, and carotid operation were successful in the prevention of neovascular glaucoma and blindness.

Aged↗

PubMed1984

A comparative study of cefamandole versus gentamicin plus clindamycin in the treatment of documented or suspected bacterial peritonitis.

Our data support the premise that antimicrobial therapy for peritonitis must be individualized. In the patient with minimal and moderate contamination who is not suppressed and who will undergo prompt and correct surgical therapy, then a single antimicrobial agent, such as cefamandole or perhaps even a first generation cephalosporin, such as cefazolin, will be adequate therapy even in instances of polymicrobial peritonitis when anticipated resistant organisms are present. In this situation, a single drug will be just as effective and safer when compared with the combination of an aminoglycoside and a specific antianaerobic agent. On the other hand, in the patient with immunosuppression, who is late to come to treatment or who has hospital acquired sepsis with probably a large contamination of resistant organisms, either a third generation cephalosporin with extended coverage or triple drug therapy, including a broad spectrum penicillin, an aminoglycoside and an anaerobic effective agent, should be the treatment of choice. Also, for infections with a culture proved overwhelming anaerobic flora, an antimicrobial specific for these pathogens should be used. The dictum, however, that all instances of peritonitis mandate double or triple drug therapy is a clinical impression based upon experimental models which do not correctly simulate the clinical situation.

Adolescent↗

PubMed1984

Bleeding esophageal varices and portal vein thrombosis after pancreatic mixed-cell autotransplantation.

A patient with chronic pancreatitis caused by congenital pancreatic duct atresia underwent total pancreatectomy and mixed-cell pancreatic autotransplantation by portal vein embolization. Two years later she developed massive upper gastrointestinal bleeding from gastroesophageal varices and required a mesocaval H graft. The cause of the portal hypertension was portal vein thrombosis caused by portal vein infusion of pancreatic homogenate, and it represents a serious complication of the procedure. Although this is the second report of portal hypertension that required portasystemic shunting after islet cell autotransplantation, it is the first reported case of the development of bleeding esophageal varices caused by portal vein thrombosis after pancreatic islet cell transplantation.

Adult↗

PubMed1984

Topical versus systemic cephalosporin administration in elective biliary operations.

The role of prophylactic antibiotic lavage in elective biliary tract operations is controversial. To investigate this question, a prospective, randomized study was undertaken between 1979 and 1983. All patients more than 18 years of age who underwent elective biliary operations were included. Eighty-eight patients were enrolled in the study and were stratified into the following antibiotic groups: (1) cefamandole nafate 2 gm administered intravenously preoperatively and 6 hours postoperatively in four doses; (2) cefamandole nafate 0.4% solution: 250 ml to irrigate the abdominal wound on opening, 500 ml to irrigate the peritoneal cavity, and 250 ml to irrigate the wound on closing; and (3) systemic plus topical administrations as in Nos. 1 and 2. Age, sex, type of operation, and underlying diseases were comparable in all groups. The patients were then evaluated for postoperative infections. In the intravenous cefamandole group there was only one patient who developed a urinary tract infection after operation. In the topical cefamandole group there were four postoperative infections: wound-one, urinary tract--two, and cholangitis--one. In the intravenous plus topical cefamandole group there were four postoperative infections: wound--one, urinary tract--two, and pneumonia--one. No deaths occurred in any group. Blood, subcutaneous, and peritoneal drug levels were sampled 1 hour after opening and before closing. Therapeutic serum levels of cefamandole are 1 to 16 micrograms/ml and adequate serum levels were achieved in all groups. However, higher levels were obtained in the subcutaneous tissue and peritoneum when topical cefamandole was used. We conclude: (1) Topical cefamandole lavage alone is adequate prophylaxis in elective biliary operations and achieves comparable results as perioperative systemic administration; (2) topical cefamandole resulted in higher subcutaneous tissue and peritoneal levels than intravenous cefamandole and also achieved therapeutic serum levels; and (3) there is no advantage to the use of systemic plus topical antibiotics in elective biliary operations.

Administration, Topical↗

PubMed1984

Bacteriologic and surgical determinants of survival in patients with mycotic aneurysms.

Mycotic aneurysms are a fulminant infectious process frequently resulting in rupture and death if not properly treated. A review of the University of California, Los Angeles, medical records identified 10 patients with extrathoracic, extracranial mycotic aneurysms. In addition, a search of the English literature revealed 178 patients with 243 mycotic aneurysms. These patients were reviewed to identify the aneurysm location, etiology, bacteriology, and modality of treatment in order to determine the relationship between these factors and the outcome. The femoral artery was the most common site (38%), followed by the abdominal aorta (31%). Arterial trauma was the primary etiology in 42% of mycotic aneurysms. In 25% no clear source of infection could be identified. Staphylococcus aureus was cultured from 28% of mycotic aneurysms, and Salmonella from 15%. A trend toward the involvement of more gram-negative aerobes and anaerobes is noted. Aortic aneurysms were repaired with in situ Dacron in 61% of patients with a 32% mortality rate and 16% reinfection rate. Simple ligation of femoral artery mycotic aneurysms resulted in a 34% incidence of ischemia necessitating amputation. Methods of treatment of superior mesenteric, carotid, iliac, and peripheral arteries are also analyzed. On the basis of these data, specific surgical procedures are recommended for the treatment of mycotic aneurysms.

Adolescent↗

PubMed1984

Impact of routine arteriography on management of penetrating neck injuries.

We evaluated the impact of routine arteriography on the management of 105 patients with penetrating injuries to the neck and upper chest. Of 72 patients with bullet wounds and 33 with knife wounds, surgical exploration on an emergency basis was performed in three patients because of shock; the remaining 102 underwent aortic arch or selective arteriography. Surgical exploration was performed in 18 patients because of abnormal arteriograms and in 13 (10 with normal arteriograms) because of shock or suspected hemorrhage. Operative findings confirmed the angiographic interpretation in 26 of the 31 patients who were explored. The angiogram underestimated the arterial injury in two patients and failed to identify an associated venous injury in three. Seventy-two patients with negative arteriograms received expectant treatment without subsequent complications. Routine arteriography is integral to expeditious triage and accurate diagnosis of patients with brachiocephalic trauma. A negative study in almost 80% of patients permits safe nonoperative management, whereas a positive study allows the surgeon to plan his operative approach more judiciously. Endoscopic procedures are important adjuncts in selected patients.

Adolescent↗

PubMed1984

The limitations of predictability of success of femoral-popliteal bypass grafts.

This study was carried out to determine whether we could develop a model to identify predictive factors for success of femoral-popliteal (FP) bypass grafts. In a retrospective review of 199 operations, 24 factors influencing outcome were selected by stepwise logistic regression analysis, a sophisticated, multifactorial computer program. The top five indicators (excluding intraoperative technical problems) were runoff status, previous ipsilateral FP bypass, preoperative prediction of potential amputation level, concurrent proximal vascular reconstruction, and site of the distal anastomosis. We chose to validate the predictive model developed before applying it clinically. Data from 67 subsequent cases were presented to the computer without the known outcome, and the probability of 30-day patency was calculated. The model predicted 11 failures; there were actually eight thromboses in the 67 grafts. However, only three of the failures were predicted correctly, and eight cases of computer-anticipated thromboses were patent at 30 days. The high false positive rate makes the clinical application of the predictive model inappropriate. The success of FP bypass grafts appears to be related to factors that cannot be assessed preoperatively, such as technical problems during surgery. Even those which seem to have a poor runoff and other high-risk factors may succeed; thus an aggressive approach is justified in lower extremity reconstructions.

Blood Vessel Prosthesis↗

PubMed1983

Congenital arteriovenous malformations. The role of transcatheter arterial embolization.

We treated 11 patients with congenital arteriovenous malformations (AVMs) with staged transcatheter arterial embolization of their lesions. In nine patients, the AVM involved an extremity. One patient had multiple pulmonary AVMs, another an AVM of the pancreas. Embolization was performed using polyvinyl alcohol sponge (Ivalon) particles and Gianturco-Wallace colls. Nine patients had a systemic response to embolization, characterized by pain, fever, leukocytosis, and elevated enzyme levels. Complications (three major, two minor) developed in five patients. A total of 28 staged embolizations were performed, with follow-up to 36 months. We found transcatheter embolization a useful palliative therapy in treating congenital AVMs. It should be considered as a therapeutic alternative for patients with unresectable AVMs, those for whom amputation would be required, and those who are otherwise poor surgical candidates.

Adolescent↗

PubMed1983

Risk of renal failure after major angiography.

In 400 patients who underwent major aortography, acute renal dysfunction (ARD) occurred in 11.3%. Of the group with normal renal function before the procedure, 8.2% had ARD and 0.8% required dialysis. Patients with prior abnormal renal function had a 41.7% incidence of ARD, and 8.3% required dialysis as a result of angiography. Vigorous intravenous hydration was used in all patients but did not completely prevent renal problems. Two risk factors not previously emphasized were the injection site (higher risk with abdominal aortic studies) and presence of congestive heart failure requiring treatment with digoxin. Other notable risk factors included contrast load and age. These results emphasized that even with modern contrast agents and application of current concepts of treatment, there remains a risk of renal injury with major angiography.

Acute Kidney Injury↗

PubMed1983

Cause and noninvasive detection of restenosis after carotid endarterectomy.

The incidence of significant restenosis after carotid endarterectomy was studied with ocular pneumoplethysmography. Of 105 operations, symptomatic restenosis occurred in 4.8 percent and asymptomatic restenosis in 6.6 percent. No preoperative factors were identified to be associated with subsequent recurrence. However, technical problems with the end-point of the endarterectomy were associated with restenosis. Half of the restenoses occurred in the first 6 months of operation. The results focus on the need for special attention to the technical management of end-point problems and the need for early noninvasive follow-up to detect a substantial proportion of early restenoses.

Arterial Occlusive Diseases↗

PubMed1983

Fate of aortic graft removal.

Reoperation to remove an aortic graft was performed in 18 patients. The need for removal was infection in the majority. A changing flora was seen in aortic graft infection with gram-negative organisms predominating. Despite a standardized approach with total graft removal, aortic closure, and extraanatomic reconstruction, amputation and mortality rates remain unacceptably high. A new approach to this problem is needed, and further trials with autogenous reconstruction appear warranted.

Aged↗

PubMed1983

Aortic saddle embolus. A twenty-year experience.

Clinical experience with aortic saddle embolus (ASE) is not extensive due to the relative infrequent lodging of emboli at the aortic bifurcation. During the period 1962-1982, 26 patients (mean age, 56 years) were treated at the UCLA Medical Center for ASE and followed from 2 to 158 months (mean, 45 months). These cases were reviewed in order to identify features of diagnosis, anticoagulation, and operation which impact on results. All 26 patients presented with bilateral lower extremity ischemia with or without extension of clot to the iliac bifurcation. Ninety-six per cent of emboli were of cardiac origin and one-third occurred in patients who had previous symptoms of chronic lower extremity ischemia. Rest pain and motor/sensory deficits were main complaints in 92% of the patients, but did not become manifest until more than 6 hours, unlike more distal emboli which have an earlier presentation. Preoperative angiography, even in the patient with a history of claudication, has a small role in planning the surgical approach to patients with ASE and, although performed in 11 patients, it influenced operation in only two. Operation within the "golden period" of 6 hours after embolization did not significantly influence outcome after ASE, since 20 patients were operated on more than 6 hours after embolization, with results similar to six patients who were operated on less than 6 hours after embolization. Early high-dose heparinization, used in all patients and maintained for a mean of 12 days, may have contributed to this effect. In 22 patients (85%) Forgarty catheter extraction via bilateral groin approaches was used with a mortality of 14%; only one death was directly attributed to the catheter embolectomy. In 15% of patients, a direct approach on the aorta was selected with a zero mortality rate. Postoperative functional result was excellent with an amputation rate of only 2% (one limb). Re-embolization occurred in seven patients (27%) after discharge, five of whom had not been maintained on Coumadin and two who were not anticoagulated adequately. The authors conclude that the keys to successful treatment of ASE include high dose heparin which is maintained through the perioperative period, embolectomy without preoperative angiography, and maintenance of long-term oral anticoagulation.

Adult↗