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Biomedical subjects

T Kirby

Publications and source records attributed to T Kirby.

At least 19 recordsLinked to original sources
PubMed1998

Cytomegalovirus infection is a risk factor for invasive aspergillosis in lung transplant recipients.

Invasive aspergillosis (IA) remains a major cause of morbidity and mortality following solid organ transplantation. To assess the incidence of IA following lung transplantation and to identify risk factors for its occurrence, we performed a case-control study involving 101 patients undergoing lung transplantation at our institution from 1990 to 1995 and reviewed the findings. Fourteen patients (14%) developed IA. The mean time from transplantation to diagnosis was 15 months. Nine patients died; the mean time to death from diagnosis was 13 days. Risk factors associated with developing IA included concomitant cytomegalovirus (CMV) pneumonia or viremia and culture isolation of Aspergillus species from a respiratory tract specimen after lung transplantation. Optimal strategies to prevent IA in lung transplant recipients remain to be determined, but prevention of aspergillus airway colonization and CMV viremia and disease after transplantation may be important targets for prophylactic interventions.

Aspergillosis↗
PubMed1998

Central nervous system complications after lung transplantation.

PURPOSE: This study describes the central nervous system (CNS) events after lung transplantation. METHODS: A chart review of all lung transplant recipients (LTR) to collect the clinical and neuroimaging data for CNS events defined as seizures, severe headaches, confusion, or stroke. RESULTS: Twenty-six patients of 100 LTRs from 1990 through 1995 had a CNS event; more than one event occurred in 5 patients for a total of 32 events. Severe headache was most common, occurring in 14 patients, followed by seizures in 10, stroke in 5, and confusion in 3. The CNS event was related to infection in three of the 26 patients. Of all evaluations performed, magnetic resonance imaging (MRI) identified the most abnormalities, the most common being white matter changes consistent with cyclosporine toxicity. Cyclosporine levels were elevated in slightly more than half of the patients. Hypomagnesemia was present in three of 10 patients with seizures. Prognosis for recovery from these complications was good, with only five patients having ongoing problems with headaches, one requiring long term anticonvulsant therapy, three having minor or no limitations from stroke and no long-term problems with confusion. One patient with seizures resulting from an aspergilloma died. CONCLUSION: CNS events occur commonly in LTRs, mostly related to cyclosporine toxicity or infection. MRI identifies more abnormalities than computed tomography. These events were not consistently associated with documented high cyclosporine levels and hypomagnesemia. In spite of significantly abnormal MRIs, the functional outcome is favorable.

Adolescent↗
PubMed1995

Ocular globe topography in radiotherapy.

PURPOSE: Ocular lens, retina, and olfactory bulb exposure are common concerns in contemporary radiotherapy practice. Methods to clinically localize soft tissue structures (i.e., lens and retina) are varied and often imprecise. We hypothesized that eyelid markers constituted a better reference point than the commonly used lateral canthus marker for lateral beam simulations, unless diagnostic computed tomography or ultrasound examinations were available and/or used. METHODS AND MATERIALS: Sixty-six pre-Magnetic Resonance Image, normal, orbital computed tomography scans from adult patients were used to measure (a) sagittal distances from eyelid to posterior lens surface, from lateral canthus to posterior lens surface and to the globe's posterior pole, (b) supero-inferior distances in the lateral projection from the lens to the cribriform plate, and (c) common dimensions to establish internal validity of the measurements. RESULTS: The eyelid to lens and retina topography is individually more constant than that from the canthus. There is little if any supero-inferior separation between the lens and the cribriform plate lateral projections. CONCLUSIONS: The lateral canthus does not specify lens or retina locations. Eyelid markers of known size provide more accurate anatomical information. Lateral beam ocular globe shielding has to be individualized. Lens shielding is questionable if the olfactory bulb needs to be irradiated by a lateral beam.

Adult↗
PubMed1994

Changes in regional ventilation during histamine bronchial challenge in stable asthma.

Our objective was to examine the changes in regional ventilation during histamine-induced bronchoconstriction in stable asthma. We measured regional ventilation by a new method which measures regional distribution of inhaled 127Xe during tidal breathing by a gated method and, by simultaneously measuring 99mTc counts from labelled macroaggregates, allowed for changes in lung shape during the breathing cycle. We studied 10 asthmatic patients [forced expiratory volume in 1 s (FEV1 2.04-4.37 litres)] and measured, in addition to the regional ventilation, oxygen saturation (SaO2), minute ventilation (VE) and tidal volume (Vt) before and after inhaling enough histamine to lower FEV1 by > 20% and/or SaO2 by > 4%. Histamine inhalation reduced FEV1 by 0.44-1.15 liters and SaO2 by 0-4%. It increased VE and functional residual capacity (FRC) in 8 of the 10 patients. The FEV1 fall did not correlate with the SaO2 fall, VE or FRC changes. Histamine inhalation increased apical ventilation in most patients, but the changes in regional ventilation in the left and right lungs were asymmetrical in 17 out of the 30 lung regions studied (upper, middle and lower paired regions in 10 patients). These results demonstrate that histamine bronchial challenge causes uneven regional ventilation. Any resultant change in ventilation-perfusion balance may be the underlying mechanism of oxygen desaturation seen in this procedure and in spontaneous attacks of asthma.

Adult↗
PubMed1993

High-grade malignant stricture is predictive of esophageal tumor stage. Risks of endosonographic evaluation.

BACKGROUND: Endosonography is very accurate for the preoperative staging of esophageal carcinoma. Approximately 20-38% of patients with esophageal carcinoma present with high-grade malignant strictures that preclude passage of the dedicated echoendoscope. In patients with such strictures, endosonographic staging of esophageal tumors may be performed after aggressive esophageal dilatation. However, aggressive dilatation and passage of the echoendoscope in patients with high-grade malignant strictures is not without risk. A detailed assessment of the tumor stage in patients presenting with high-grade malignant stenoses has not been previously reported to the authors' knowledge. METHODS: Seventy-nine patients with esophageal carcinoma were staged preoperatively using endosonography. The results of preoperative staging were compared with the pathologic stage of the esophagectomy specimen when available or the surgical stage (detection of adjacent organ involvement [Stage T4] or metastatic disease [Stage M1] at the time of surgery). RESULTS: Twenty-one patients (26.6%) presented with high-grade malignant strictures precluding endosonographic examination without prior esophageal dilatation. Nineteen of the 21 patients (91%) with high-grade malignant stricture had Stage III or IV disease by histopathologic examination of the surgical specimen. Five of these 21 patients (24%) sustained an esophageal perforation as a result of either wire-guided dilatation, or as a direct consequence of the endosonographic staging procedure. The discovery of metastatic lymph nodes proximal to the stricture resulted in successful staging (assessment of depth of tumor penetration and lymph node involvement) in only 2 of these 21 patients before esophageal dilatation (incomplete staging). Staging of the proximal aspect of the tumor was obtained in the remaining 19 patients before dilatation; however, the accuracy for such incomplete staging was only 33%. CONCLUSIONS: The majority of patients with esophageal carcinoma presenting with high-grade malignant strictures precluding endoscope passage without prior dilatation have a relatively advanced stage of disease (Stage III or IV) compared with those patients presenting with less severe stenoses. There is a significant risk for esophageal perforation (24%) when patients with high-grade malignant esophageal strictures undergo preoperative staging using endosonography. Patients with high-grade malignant strictures, therefore, present a relative contraindication to endosonography using the dedicated echoendoscope.

Carcinoma↗
PubMed1993

Concentric tracheal and subglottic stenosis. Management using the Nd-YAG laser for mucosal sparing followed by gentle dilatation.

Treatment of tracheal stenosis varies with the type and extent of the disease. Tracheostomy with stents, end-to-end anastomosis, or extensive reconstructive procedures often is required, especially when tracheomalacia is present. High recurrence rate is associated with relatively less invasive endotracheal treatments, such as bougie dilatation or total laser ablation. Mucosal sparing technique using Nd:YAG laser photodissection (LPD) and gentle dilatation (GD) can provide durable successful results in selected patients with benign concentric tracheal stenosis (CTS). In our study of 18 patients with CTS, 12 were successfully treated with Nd:YAG LPD and GD. Of these patients, eight required a single treatment while four required two or more treatments. No patients required new tracheostomy to carry out the procedure. Follow-up periods ranging from 2 to 85 months (mean: 32.6 +/- 1.5 months) for 12 successfully treated patients have revealed no recurrence of their stenosis. Lengthy scars (> 1 cm) and tracheomalacia were the clinical features common to those patients who failed the treatment. We advocate the use of Nd:YAG LPD in conjunction with "gentle" rigid bronchoscopic dilatation as the initial treatment of CTS.

Adult↗
PubMed1993

Lung transplantation in New Jersey.

Single- or bilateral-lung transplantation is an effective treatment for end-stage pulmonary diseases. Refinements in the surgical technique and postoperative management of recipients have resulted in a return to normal function in most cases and a one-year survival in 70 percent of patients.

Adult↗
PubMed1987

Effect of acute diaphragm paralysis on ventilation in awake and sleeping dogs.

The mechanisms responsible for hypoventilation during rapid-eye-movement (REM) sleep in patients with diaphragmatic weakness are not clear. Therefore, we studied the effects of unilateral (UDP) and bilateral (BDP) diaphragmatic paralysis on ventilation during wakefulness (W), slow-wave sleep (SWS), and REM sleep. Studies were performed in 3 trained dogs in which small silicone cuffs had been implanted surgically around the phrenic nerves. Reversible diaphragmatic paralysis was induced during wakefulness or sleep by bathing the phrenic nerves in local anesthetic injected through a catheter attached to the phrenic cuffs. The UDP reduced abdominal expansion and increased rib cage expansion, but had no effect on minute volume of ventilation (VI) or end-tidal PCO2 (PACO2). The BDP produced marked abdominal paradox, but did not reduce VI during W or SWS and had no effect on tidal volume or respiratory frequency. In contrast, during REM sleep, VI was decreased by an average of 21% mainly because of a fall in tidal volume, and PACO2 increased by 2.4 mm Hg compared with that during the intact state. Furthermore, addition of extra dead space to the breathing circuit, which was well tolerated in intact dogs, led to a progressive increase in PACO2 during BDP and to arousal from sleep. The findings indicate that acute BDP does not impair ventilation during quiet W or SWS, but reduces ventilation during REM sleep, supporting the concept that during REM sleep maintenance of ventilation is critically dependent on diaphragmatic compensation for intercostal and accessory muscle inhibition.

Animals↗
PubMed1984

Fusion of the first metatarsophalangeal joint in forefoot arthroplasty.

Forefoot arthroplasty is often recommended for the management of metatarsalgia secondary to rheumatoid arthritis. Concurrently, the first metatarsophalangeal (MP) joint can be fused rather than excised. The results in 37 patients with 64 arthroplasty operations (34 with fusion and 30 with excision of the first joint) show that fusion produced a better cosmetic appearance of the foot, facilitated fitting with normal shoes, and improved overall balance. Pedobarograph measurements during gait indicated that relatively more weight was transmitted through the medial ray when the first metatarsophalangeal joint was fused. Residual pain in the foot was often caused by irregular trimming of the metatarsals. There was no difference in relief of pain between fused and unfused patients. Failure of fusion at the first metatarsophalangeal joint generally was painless. Radiologic degeneration of the interphalangeal (IP) joint of the great toe was relatively common following fusion. MP joint fusion is inadvisable if there is already disease in the IP joint.

Adult↗
PubMedDate not supplied

Bullectomies for bullous sarcoidosis.

A 36-year-old woman presented with respiratory insufficiency due to cystic sarcoidosis. She had been previously treated with multiple courses of prednisone without improvement. Enlarging blebs involving both lower lobes impaired the function of the relatively spared upper lobes. Bilateral lower lobectomies were performed in one step via median sternotomy without complications, with prompt subjective and objective improvement of her respiratory status. One-stage bilateral upper-lobe bullectomy for bullous emphysema has been previously reported, but to our knowledge this is the first performance of one-stage bilateral lower-lobe bullectomies for cystic sarcoidosis. The immediate benefits were evident; long-term results will depend on the course of the underlying disease.

Adult↗
PubMedDate not supplied

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Personnel Management↗