Mycotic superior mesenteric aneurysm.
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Adult↗
Biomedical subjects
David Rosenthal
Publications and source records attributed to David Rosenthal.
Opiate users' knowledge about overdose prevention and naloxone in New York City: a focus group study.
BACKGROUND: Drug-induced and drug-related deaths have been increasing for the past decade throughout the US. In NYC, drug overdose accounts for nearly 900 deaths per year, a figure that exceeds the number of deaths each year from homicide. Naloxone, a highly effective opiate antagonist, has for decades been used by doctors and paramedics during emergency resuscitation after an opiate overdose. Following the lead of programs in Europe and the US who have successfully distributed take-home naloxone, the Overdose Prevention and Reversal Program at the Lower East Side Harm Reduction Center (LESHRC) has started providing a similar resource for opiate users in NYC. Participants in the program receive a prescription for two doses of naloxone, with refills as needed, and comprehensive training to reduce overdose risk, administer naloxone, perform rescue breathing, and call 911. As of September 2005, 204 participants have received naloxone and been trained, and 40 have revived an overdosing friend or family member. While naloxone accessibility stands as a proven life-saving measure, some opiates users at LESHRC have expressed only minimal interest in naloxone use, due to past experiences and common misconceptions. METHODS: In order to improve the naloxone distribution program two focus groups were conducted in December 2004 with 13 opiate users at LESHRC to examine knowledge about overdose and overdose prevention. The focus groups assessed participants' (i) experiences with overdose response, specifically naloxone (ii) understanding and perceptions of naloxone, (iii) comfort level with naloxone administration and (iv) feedback about increasing the visibility and desirability of the naloxone distribution program. RESULTS: Analyses suggest that there is both support for and resistance to take-home naloxone, marked by enthusiasm for its potential role in reviving an overdosing individual, numerous misconceptions and negative views of its impact and use. CONCLUSION: Focus group results will be used to increase participation in the program and reshape perceptions about naloxone among opiate users, also targeting those already prescribed naloxone to increase their comfort using it. Since NYC is advancing toward a citywide naloxone distribution program, the LESHRC program will play an important role in establishing protocol for effective and wide-reaching naloxone availability.
Journal Article↗
Comparison of the epidemiology and co-morbidities of heart failure in the pediatric and adult populations: a retrospective, cross-sectional study.
BACKGROUND: Heart failure is a clinical syndrome that is associated with a significant number of interventional procedures and has received a large amount of scrutiny in the adult literature; however, the epidemiology in children is less well described. METHODS: We analyzed two large, commercially available inpatient datasets collected in 1997 by the Agency for Healthcare Research and Quality: the Kids' Inpatient Database and the National Inpatient Study, accounting for 50% of the U.S. pediatric discharges and 20% of the U.S. adult discharges in 1997. RESULTS: The database contained 5,610 children and 732,752 adults with a diagnosis of HF. When compared with the adult sample, the pediatric sample showed a higher proportion with cardiac procedures (61.4% vs. 0.28%, p < 0.01), a higher prevalence of congenital heart disease (61% versus 0.3%, p < 0.01), a higher percentage of male patients (50% pediatric vs. 44% adult, p < 0.01), and a lower percentage of white patients (40.9% vs. 65.6%, p < 0.01). Children had a significantly different spectrum of co-morbidities compared with adults. There was no difference in mortality rate between children and adults (7.5% vs. 7.9%, p = NS). CONCLUSION: There are significant differences in the epidemiological profile of children and adults with heart failure. Children suffer from different types of co-morbidities and require different procedures in the hospital setting. As such, children with heart failure who are hospitalized may require significantly different facilities, management and therapeutic intervention than adults with similar symptoms.
Adolescent↗
Pediatric mechanical circulatory support: challenges and opportunities.
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Adolescent↗
Retrievable inferior vena cava filters: initial clinical results.
Anticoagulation is the accepted therapy for patients with thromboembolic disease. When contraindications to anticoagulant therapy are present, however, interruption of the inferior vena cava (IVC) may prevent pulmonary embolism (PE). The objective of this study was to report our early technical and clinical results with retrievable IVC filters (IVCFs) for the prevention of PE. One hundred and twenty-seven multitrauma patients between December 1, 2002, and December 31, 2004, underwent placement of Gunther-Tulip (n = 49), Recovery (n = 41), or OptEase (n = 37) retrievable IVCFs under real-time intravascular ultrasound (IVUS) guidance. All patients had abdominal X-rays to verify filter location. Prior to IVCF retrieval, all patients underwent femoral vein color flow ultrasonography to rule out deep vein thrombosis (DVT) and vena-cavography to assess the IVCF for trapped emboli, filter tilt, or retrained thrombus. Thirty-nine patients died of their injuries; no deaths were related to IVCF placement. One PE occurred during follow-up after filter retrieval, and two femoral vein insertion-site DVTs occurred. One hundred twenty (94.4%) of IVCFs were placed without complication at the L2-3 level, as verified by abdominal X-rays. Filter-related complications included three groin hematomas (2.9%) and three IVCFs misplaced in the right iliac vein early in our experience (2.3%); these filters were uneventfully retrieved and replaced in the IVC within 24 hr. Sixty-six patients underwent uneventful retrieval of IVCFs after DVT or PE anticoagulation prophylaxis was initiated. Forty-five IVCFs were not removed: 41 due to contraindications due to anticoagulation and four because of trapped thrombus within the filter. The role of retrievable IVCFs continues to evolve, but in this study of 127 patients, prophylactic temporary IVCF placement was simple and safe, prevented fatal PE, and served as an effective "bridge" to anticoagulation. Further investigation of this bedside IVUS technique and the role of temporary IVCFs in different patient populations is warranted.
Adolescent↗
Heterotopic heart transplant combined with postoperative Sildenafil use for the treatment of restrictive cardiomyopathy.
We report successful management of a 22-month-old child with restrictive cardiomyopathy and severe pulmonary hypertension using the heterotopic heart transplant technique. Additional lessons learned from postoperative management, including the novel use of Sildenafil (Viagra, Pfizer, NY) for controlling pulmonary arterial pressure are described.
Cardiomyopathy, Restrictive↗
In situ reconstruction with cryopreserved arterial allografts for management of mycotic aneurysms or aortic prosthetic graft infections: a multi-institutional experience.
We designed this study to evaluate a multi-institutional experience regarding the efficacy of cryopreserved aortic allografts in the treatment of infected aortic prosthetic grafts or mycotic aneurysms. We reviewed clinical data of all patients from 4 institutions who underwent in situ aortic reconstruction with cryopreserved allografts for either infected aortic prosthetic graft or mycotic aneurysms from during a 6-year period. Relevant clinical variables and treatment outcomes were analyzed. A total of 42 patients (37 men; overall mean age 63 +/- 13 years, range 41-74 years) were identified during this study period. Treatment indications included 34 primary aortic graft infections (81%), 6 mycotic aneurysms (22%), and 2 aortoenteric erosions (5%). Transabdominal and thoracoabdominal approaches were used in 38 (90%) and 4 patients (10%), respectively. Staphylococcus aureus was the most commonly identified organism (n=27, 64%). Although there was no intraoperative death, the 30-day operative mortality was 17% (n=7). There were 21 (50%) nonfatal complications, including local wound infection (n=8), lower-extremity deep venous thrombosis (n=5), amputation (n=6), and renal failure requiring hemodialysis (n=2). The average length of hospital stay was 16.4 +/- 7 days. During a mean follow-up period of 12.5 months, reoperation for allograft revision was necessary in 1 patient due to graft thrombosis (6%). The overall treatment mortality rate was 21% (n=9). In situ aortic reconstruction with cryopreserved allografts is an acceptable treatment method in patients with infected aortic prosthetic graft or mycotic aneurysms. Our study showed that mid-term graft-related complications such as reinfection or aneurysmal degeneration were uncommon.
Adult↗
Determining optimal clinical target volume margins in head-and-neck cancer based on microscopic extracapsular extension of metastatic neck nodes.
PURPOSE: To determine the optimal clinical target volume margins around the gross nodal tumor volume in head-and-neck cancer by assessing microscopic tumor extension beyond cervical lymph node capsules. METHODS AND MATERIALS: Histologic sections of 96 dissected cervical lymph nodes with extracapsular extension (ECE) from 48 patients with head-and-neck squamous cell carcinoma were examined. The maximum linear distance from the external capsule border to the farthest extent of the tumor or tumoral reaction was measured. The trends of ECE as a function of the distance from the capsule and lymph node size were analyzed. RESULTS: The median diameter of all lymph nodes was 11.0 mm (range: 3.0-30.0 mm). The mean and median ECE extent was 2.2 mm and 1.6 mm, respectively (range: 0.4-9.0 mm). The ECE was <5 mm from the capsule in 96% of the nodes. As the distance from the capsule increased, the probability of tumor extension declined. No significant difference between the extent of ECE and lymph node size was observed. CONCLUSION: For N1 nodes that are at high risk for ECE but not grossly infiltrating musculature, 1 cm clinical target volume margins around the nodal gross tumor volume are recommended to cover microscopic nodal extension in head-and-neck cancer.
Adult↗
The concentration of substance use, criminal justice involvement, and HIV/AIDS in the families of drug offenders.
Substance use (SU), criminal justice involvement (CJI), and HIV/AIDS co-occur in many urban families, but little is known about their intergenerational prevalence and the impact of their conjunction on these families. We determined lifetime prevalence of SU, CJI, and HIV/AIDS in 62 families with a member (the index case) on parole or probation for a drug offense and enrolled in the direct service arm of Family Justice, La Bodega de La Familia--a community support program in New York City's Lower East Side. Among these families, index cases are 94% male, and 97% Latino, with a median age of 37. Records of 80% of open cases, in months March through May, in 2003 (N = 62) were reviewed, and the family maps or "genograms," were analyzed and coded (by age, sex, and relationship to the index) to identify all significant members with histories of SU, CJI, and HIV/AIDS. Of the 62 families (with a total of 592 individuals) 82% had at least one other member besides the index case with a history of SU, 62% had two or more, and 40% had three or more; 72% had one other member with a history of CJI, 45% had two or more, and 24% had three or more. At least one member had HIV/AIDS in 49% of the families, 16% had two or more, and 10% had three or more. Of the 105 family members who reported a history of CJI, 88% had a history of substance use. These data demonstrate the extent to which many families in communities such as this are struggling with the burdens associated with having multiple relatives involved in the criminal justice system, largely related to drug use and frequently with HIV and AIDS. These data point to an important role for family-focused interventions to ameliorate the consequences of high rates of familial drug use, incarceration and other forms of CJI, and HIV/AIDS.
Adolescent↗
Intensity-modulated radiotherapy: is xerostomia still prevalent?
Conformal radiation with intensity-modulated radiotherapy (IMRT) is a technique that potentially can minimize the dose to salivary glands and thereby decrease the incidence of xerostomia. Precise target determination and delineation is most important when using salivary gland-sparing techniques of IMRT. Reduction of xerostomia can be achieved by sparing the salivary glands on the uninvolved oral cavity and keeping the mean parotid gland dose of less than 26 to 30 Gy as a planning criterion if the treatment of disease is not compromised and parotid function preservation is desired.
Carcinoma, Squamous Cell↗
Transthoracic cuffed hemodialysis catheters: a method for difficult hemodialysis access.
BACKGROUND: Recurrent vascular access failure is a major cause of morbidity in patients receiving long-term hemodialysis. Central venous catheters are often necessary for dialysis, and easily accessed vessels (ie, the internal jugular vein and subclavian vein) frequently occlude because of repeated cannulation. When standard access sites occlude, unconventional access methods become necessary. We report a technique of placing hemodialysis catheters directly into the superior vena cava (SVC). METHODS: Between January 2002 and December 2004, 22 patients with documented bilateral jugular and subclavian vein occlusion underwent transthoracic SVC permanent catheter placement. Femoral vein access was obtained, and a sheath was placed. Under fluoroscopic guidance, a diagnostic catheter was then inserted into the SVC, and a venogram was obtained. By using the fluoroscopic image as a reference guide, supraclavicular access directly into the SVC was performed with lateral and anteroposterior views to better localize the SVC. Once venous blood was obtained, a hydrophilic wire was passed into the inferior vena cava. A 5F sheath was then placed, and, with the use of an exchange catheter, the wire was switched for a stiffer wire. The hemodialysis catheter was then placed in the standard fashion over this wire. RESULTS: In a 24-month period, 22 patients underwent transthoracic permanent catheter placement. All patients had the permanent catheters successfully inserted. Two major complications occurred. One patient experienced a pneumothorax, and another patient experienced a hemothorax. Both patients were successfully treated with chest tube decompression. All permanent catheters functioned immediately with a range of 1 to 7 months. CONCLUSIONS: Transthoracic permanent catheter placement is an appropriate alternative for patients in whom traditional venous access sites are no longer available.
Arteriovenous Shunt, Surgical↗
Preserving today's scientific record for tomorrow.
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Internet↗
International Society for Heart and Lung Transplantation: Practice guidelines for management of heart failure in children.
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Acute Disease↗
Cellular remodeling of depopulated bovine ureter used as an arteriovenous graft in the canine model.
BACKGROUND: One of the greatest challenges in hemodialysis access surgery is improving the durability of prosthetic grafts caused by structural deterioration. The depopulated bovine ureter SynerGraft (SG) (CryoLife, Inc) is a tissue-engineered vascular graft processed to remove the xenograft cells while maintaining an unfixed connective tissue matrix capable of autologous cell repopulation by the recipient. STUDY DESIGN: Nineteen 6-mm diameter bovine ureter SG conduits were implanted in 12 dogs as arteriovenous grafts between the carotid artery and jugular vein (n = 11) or between the femoral artery and vein (n = 8). Performance of these biologic conduits was compared with that of 15 IMPRA (Bard) ePTFE grafts implanted in 9 dogs, including 9 arteriovenous grafts between the carotid artery and jugular vein and 6 femoral artery to femoral vein grafts. After 14 days, the grafts were accessed once weekly. Histologic and immunohistochemical analyses were performed on grafts explanted between 10 to 60 weeks. RESULTS: The 6- and 12-month primary patency rates of the bovine SG were 72.6% and 58.6%, respectively, compared with 6- and 12-month primary patency for ePTFE conduits of 57.4% and 57.4%, respectively. None of the bovine SG grafts became infected, but synthetic conduits became infected within 54 days of implantation. At 10 weeks, bovine ureter SG conduit showed fibroblast cell migration and proliferation with incorporation into the surrounding subcutaneous tissue, and elongated cells expressing the contractile protein smooth muscle actin were also observed. After 24 weeks, procollagen synthesis was demonstrated in the fully colonized graft matrix. The ePTFE grafts had no evidence of cellular ingrowth and an absence of endothelium. CONCLUSIONS: The bovine SG was appropriately remodeled to its host environment through an organized process of recellularization and neovascularization. The absence of infection, similar patency rates, and cell repopulation of the matrix warrant further investigation.
Animals↗
Remote superficial femoral artery endarterectomy and distal aSpire stenting: multicenter medium-term results.
OBJECTIVE: The purpose of this study was to examine the results of remote superficial femoral artery endarterectomy (RSFAE) in conjunction with distal aSpire stenting. METHODS: RSFAE is a minimally invasive procedure performed through a limited groin incision. Forty patients were included in the study. The indications for the procedure were claudication in 36 patients and limb salvage in 4 patients. RSFAE was performed with the MollRing Cutter device through a femoral arteriotomy. The distal atheromatous plaque was "tacked" with the aSpire stent, which is an expandable polytetrafluoroethylene-covered nitinol stent with high radial strength, yet is flexible and able to withstand compressive forces proximal to the knee joint. Before stent deployment, if the stent position is not optimal it can be wrapped down, repositioned, and re-expanded. Therefore, not only is the plaque end point tacked, but the collateral vessels may be preserved. All patients underwent follow-up examination with serial color-flow ultrasound scanning. RESULTS: The mean length of endarterectomized superficial femoral artery was 26.2 cm +/- 6.2 cm (range, 13-41 cm). The primary cumulative patency rate by means of life table analysis was 68.6% +/- 13.5% (SE) at 18 months (mean, 13.2 months; range, 1-31 months). During follow-up percutaneous transluminal balloon or stent angioplasty was necessary in 6 patients, for a primary assisted patency rate of 88.5% +/- 8.5% at 18 months. The locations of recurrent stenoses after RSFAE were evenly distributed along the endarterectomized artery. There were no deaths and one wound complication, and mean hospital length of stay was only 2.1 +/- 0.5 days. CONCLUSIONS: RSFAE with distal aSpire stenting is a safe and moderately durable procedure. If long-term patency rates are similar to those of above-knee femoropopliteal bypass graft, this procedure may prove to be a minimally invasive adjunct for the treatment of superficial femoral artery occlusive disease.
Adult↗
Role of prophylactic temporary inferior vena cava filters placed at the ICU bedside under intravascular ultrasound guidance in patients with multiple trauma.
OBJECTIVE: Patients with multiple trauma often have injuries that preclude the use of anticoagulation therapy or sequential compression device prophylaxis. Temporary inferior vena cava (IVC) filters (IVCFs) offer protection against pulmonary embolism during the early immediate injury and perioperative period, when risk is highest, while averting potential long-term sequelae of permanent IVCFs. The objective of this study was to evaluate the efficacy of prophylactic, temporary IVCF placement at the intensive care unit bedside under real-time intravascular ultrasound (IVUS) guidance in patients with multiple trauma. INTERVENTIONS: Ninety-four patients with multiple trauma seen between July 1, 2002, and November 1, 2003, underwent placement of OptEase (Cordis Endovascular) retrievable IVCFs under real-time IVUS guidance. Mean (+/-SD) Injury Severity Score was 25.1 +/- 2.2). Abdominal x-ray films were obtained in all patients to verify filter location. Before IVCF retrieval all patients underwent femoral vein color-flow ultrasound scanning to rule out deep vein thrombosis (DVT), and pre-procedure and post-procedure vena cavography to identify possible IVCF thrombus entrapment and post-retrieval inferior vena cava injury. RESULTS: Nineteen patients died of their injuries; no deaths were related to IVCF placement. One pulmonary embolism occurred during follow-up after filter retrieval, and 1 insertion site femoral vein DVT occurred. As verified on abdominal x-ray films, 96.8% (91 of 94) of IVCFs were placed without complications at the L2-3 level. Filter-related complications included 2 groin hematomas (2.1%) and 3 IVCFs misplaced in the right iliac vein (3.2%), early in our experience; the filters were uneventfully retrieved and replaced in the inferior vena cava within 24 hours. Thirty-one patients underwent uneventful retrieval of IVCFs after DVT or pulmonary embolism anticoagulation prophylaxis was initiated. Forty-four filters were not removed, 41 because severity of injury prevented DVT or pulmonary embolism prophylaxis and 3 because of thrombus trapped within the filter. CONCLUSIONS: Prophylactic, temporary IVCF placement at the intensive care unit bedside under IVUS guidance in patients with multiple trauma is simple and safe, and serves as an effective "bridge" to anticoagulation therapy until venous thromboembolism prophylaxis can be initiated. Further investigation of this bedside technique and the role of temporary IVCFs in patients with multiple trauma is warranted. CLINICAL RELEVANCE: Patients with multiple trauma often have injuries that preclude the use of anticoagulation therapy or sequential compression device prophylaxis. Temporary inferior vena cava filters (IVCFs) offer protection against pulmonary embolism during the perioperative and immediate injury period, when risk is highest. Ninety-four patients with multiple trauma underwent prophylactic, temporary IVCF placement at the intensive care unit bedside under real-time intravascular ultrasound. One pulmonary embolism occurred during follow-up after filter retrieval, and 1 insertion site femoral vein deep venous thrombosis occurred. Ninety-one of 94 IVCFs (96.8%) were placed without complication. Thirty-one patients underwent uneventful retrieval of IVCFs after anticoagulation prophylaxis was initiated. Forty-four filters were not removed, because of severity of injury (n = 41) or because of trapped thrombus within the filter (n = 3). Prophylactic, temporary IVCFs placed under intravascular ultrasound guidance at the bedside in patients with multiple trauma is simple, safe, and an effective bridge to anticoagulation therapy.
Critical Care↗
Stent-graft repair of traumatic thoracic aortic disruptions.
OBJECTIVE: Blunt traumatic thoracic aortic disruption results in pre-hospital death in 80% to 90% of patients. Because of the significant surgical morbidity and mortality associated with open operative repair, endovascular stent-graft repair has been investigated. The objective of this study was to evaluate the efficacy of thoracic aortic disruptions treated with commercially available proximal aortic extension cuffs. METHODS: Nine patients with multiple system trauma (age range, 16-42 years) were seen after motor vehicle accidents between January 1, 2003, and April 1, 2004. Chest x-ray findings warranted thoracic computed tomography scans, which revealed disruptions of the thoracic aorta. Aortograms delineated the extent of the aortic injuries and identified a "landing zone" (neck length range, 1.5-2.0 cm) distal to the subclavian artery but proximal to the tear. The repairs were performed with AneuRx (n= 8) and Excluder (n = 1) proximal aortic extension cuffs. A left femoral artery approach was used in 6 patients, a suprainguinal retroperitoneal approach with an iliac conduit in 2 patients, and direct tunnel in 1 patient. An Amplatz super-stiff wire was placed in the right axillary artery to enable easy tracking of the endografts, and left brachial artery access was used for arch arteriography. RESULTS: In each patient the stent-graft cuff was deployed adjacent to the left subclavian artery, with successful exclusion of traumatic disruptions verified at intraoperative arteriography and on computed tomographic scans obtained within 48 hours of initial repair. One patient required a second cuff for exclusion of a type I endoleak at the distal attachment site 1 month after the initial endograft repair. There were no procedure-related deaths; 1 patient, however, died of other injuries. CONCLUSIONS: Stent-graft repair of traumatic thoracic aortic disruptions is technically feasible. Placement of a stiff wire in the right axillary artery and percutaneous left brachial artery access for arteriography are useful adjuncts during endograft deployment. Endovascular stent grafts may enable definitive repair or serve as a bridge until the patient is stable enough to undergo an operation, if necessary. This technique warrants further investigation.
Accidents, Traffic↗
Renal cell carcinoma invading the inferior vena cava: use of a "temporary" vena cava filter to prevent tumor emboli during nephrectomy.
Renal cell carcinoma with tumor thrombus extension into the inferior vena cava (IVC) remains a difficult operative challenge. Placement of a suprarenal "temporary" IVC filter, with its ease of insertion and removal, makes it the ideal treatment to prevent pulmonary embolism in these difficult cases. We report the first 2 cases of temporary suprarenal IVC filters placed at the time of radical nephrectomy to eliminate the possibility of perioperative pulmonary embolus and avoid the potential long-term sequelae of a permanent suprarenal IVC filter.
Abdominal Pain↗