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Biomedical subjects

David Rosenthal

Publications and source records attributed to David Rosenthal.

At least 37 records · Page 2Linked to original sources
PubMed2004

Shadow Bowl 2003: a collaborative exercise in community readiness, agency cooperation, and medical response.

This paper describes a model for homeland security, community readiness, and medical response that was applied during an operational exercise around Super Bowl XXXVII. In addition, it describes the products provided by private companies involved in the exercise and how they would have contributed to a medical disaster had one occurred. The purpose of Shadow Bowl was to demonstrate community readiness and medical response to a mass casualty event. The goals of the project were to: (1) provide enhanced public safety using an advanced communication network and sensor grid; (2) develop mass casualty surge capabilities through medical reach-back; and (3) build a collaboration model between civilian, military, public, and private partners. The results of the Shadow Bowl Exercise accentuated the value of new telehealth and disaster medicine tools in treating large numbers of patients when infrastructure overload occurs.

Communication↗
PubMed2004

Retrohepatic vena cava and hepatic vein injuries: a simplified experimental methods of treatment by balloon shunt.

BACKGROUND: Fecal contamination from colon injury has been thought to be the most significant factor for the development of surgical site infection (SSI) after trauma. However, there are increasing data to suggest that other factors may play a role in the development of postinjury infection in patients after colon injury. The purpose of this study was to determine the impact of gastric wounding on the development of SSI and nonsurgical site infection (NSSI) in patients with colon injury. METHODS: Post hoc analysis was performed on data prospectively collected for 317 patients presenting with penetrating hollow viscus injury. One hundred sixty-two patients with colon injury were subdivided into one of three groups: patients with isolated colon wounds (C), patients with colon and stomach wounds with or without other organ injury (C+S), and patients with colon and other organ injury but no stomach injury (C-S) and assessed for the development of SSI and NSSI. Infection rates were also determined for patients who sustained isolated gastric injury (S) and gastric injury in combination with organ injuries other than colon (S-C). Penetrating Abdominal Trauma Index, operative times, and transfusion were assessed. Discrete variables were analyzed by Cochran-Mantel-Haenszel chi2 test and Fisher's exact test. Risk factor analysis was performed by multivariate logistic regression. RESULTS: C+S patients had a higher rate of SSI infection (31%) than C patients (3.6%) (p = 0.008) and C-S patients (13%) (p = 0.021). Similarly, the incidence of NSSI was also significantly greater in the C+S group (37%) compared with the C patients (7.5%) (p = 0.07) and the C-S patients (17%) (p = 0.019). There was no difference in the rate of SSI or NSSI between the C and C-S groups (p = 0.3 and p = 0.24, respectively). The rate of SSI was significantly greater in the C+S patients when compared with the S-C patients (31% vs. 10%, p = 0.008), but there was no statistical difference in the rate of NSSI in the C+S group and the S-C group (37% vs. 24%, p = 0.15). CONCLUSION: The addition of a gastric injury to a colon injury has a synergistic effect on the rate of postoperative infection.

Abdominal Injuries↗
PubMed2004

Real-time intravascular ultrasound-guided placement of a removable inferior vena cava filter.

BACKGROUND: Reports have demonstrated the benefit of prophylactic inferior vena cava filter (IVCF) placement to prevent pulmonary embolism. This series evaluates the potential for the bedside placement of a removable IVCF under "real-time" intravascular ultrasound (IVUS) guidance. METHODS: Twenty trauma patients underwent intensive care unit placement of a removable IVCF with IVUS guidance. All patients had ultrasonography of the femoral veins after placement to rule out postprocedure femoral vein thrombosis and radiographs to identify filter location. RESULTS: Nineteen of 20 IVCFs were placed at approximately the L2 level as verified by radiography. One patient had a large IVC (34 mm) and underwent bilateral common iliac IVCF placement under IVUS. Within 3 weeks of placement, 12 IVCFs were retrieved. Of the remaining eight patients, six had indications for permanent implantation, two had contralateral deep venous thrombosis, and one had ipsilateral deep venous thrombosis. CONCLUSION: Bedside insertion of a removable IVCF with IVUS guidance and its removal are simple, safe, and accurate.

Critical Care↗
PubMed2004

A novel alpha-galactosidase a mutant (M42L) identified in a renal variant of Fabry disease.

A 65-year-old man presented to our institution for workup of proteinuria. His serum creatinine level was 1.7 mg/dL (130 micromol/L), and he had proteinuria with protein of almost 5 g/24 h. Fabry disease was diagnosed by means of kidney biopsy and low serum and leukocyte levels of alpha-galactosidase A. Review of his history, family history, physical examinations, and diagnostic studies did not show other findings typical of this disease. His renal function continued to decline, and he eventually underwent a living unrelated renal transplantation 5 years later. Three years after transplantation, his creatinine level is 1.7 mg/dL (130 micromol/L), and corrected iothalamate clearance is 53 mL/min/1.73 m2 . Genetic studies showed that he has a novel missense mutation (M42L) in exon 1. Methionine at codon 42 is highly conserved in eukaryotic alpha-galactosidase A orthologues. This genotype predicts a minor misfolding of alpha-galactosidase A because of a small difference in hydrophobicity between methionine and leucine. His mutation resulted in a very low, but detectable, serum level of alpha-galactosidase A (0.002 U/L; normal range, 0.016 to 0.2 U/L). Cases of Fabry disease that present with predominantly renal manifestations are rare and require a high index of suspicion for diagnosis. Because treatment for Fabry disease recently has become available, it is important for clinicians to be aware of this disease and pursue the diagnosis in cases of otherwise unexplained renal dysfunction.

Aged↗
PubMed2003

Bedside intravascular ultrasound-guided vena cava filter placement.

OBJECTIVE: Several reports have demonstrated the efficacy of inferior vena cava filter (IVCF) placement with intravascular ultrasound guidance (IVUS). The majority of these procedures,however, have been done in concert with contrast venography and/or fluoroscopic guidance. The purpose of this report was to evaluate the potential for bedside IVCF placement with "real-time" IVUS guidance only. DESIGN OF STUDY: In a phase I trial, 10 patients underwent IVUS interrogation of the IVC for diameter measurements and localization of the renal veins. Contrast venography verified the IVUS findings prior to filter deployment. In a phase II trial, another 35 patients underwent intensive care unit bedside placement of an IVC filter with only "real time" IVUS guidance using a double puncture technique in the same femoral vein. All patients underwent color-flow ultrasonography of the femoral veins after filter placement to rule out post procedure femoral vein thrombosis and plain radiographs of the abdomen to identify filter location. RESULTS: In the phase I trial, all filters were placed within 15 mm of the most inferior renal vein identified by IVUS. There were no complications, and successful filter placement was verified by contrast venography. In phase II, 33 IVCFs were placed without complications at approximately the L2 level by plain radiograph. One patient had an IVCF deployed in the common iliac vein, which necessitated placement of an uneventful second IVCF at the infrarenal location by IVUS. This same patient had a femoral deep venous thrombosis identified by postoperative duplex ultrasonography. A second patient had IVC thrombus identified by IVUS, and placement was performed with contrast venography in the fluoroscopy suite. IVC measurements ranged from 18-28 mm in diameter. CONCLUSIONS: IVUS accurately measures the IVC diameter and localizes the renal veins, allowing for exact placement of IVCFs. IVUS further avoids the need for contrast agents and for transport of critically ill patients. Bedside insertion of an IVcF with IVUS guidance is simple, safe, and accurate. Further assessment of this technique is warranted.

Female↗
PubMed2003

The prevention and treatment of radiotherapy - induced xerostomia.

Efforts to reduce the severity of postradiotherapy xerostomia include the use of salivary substitutes to gain symptomatic relief, salivary gland stimulants, agents delivered to protect the glands during radiotherapy (RT), and physical means to partially spare the major salivary glands from RT while adequately irradiating tumor targets. These means include advanced RT treatment planning and salivary tissue transfer to nonirradiated areas. The relative potential gain from each of these strategies is discussed in this article. The combination of partial salivary gland sparing and radiation protectors/stimulants may provide additive or synergistic gains in reducing the severity of xerostomia.

Head and Neck Neoplasms↗
PubMed2003

How should we measure and report radiotherapy-induced xerostomia?

Xerostomia is commonly measured and graded using objective measures of major salivary gland output and observer-rated toxicity grading. The separation between the different grades is somewhat ambiguous in the current toxicity grading systems. We propose a new grading system based primarily on the functional deficits associated with xerostomia. Salivary flow rates have been added as a criterion to the grading system, notwithstanding the weak correlation reported in most studies between the symptoms and objective functional measures. In addition to the observer-rated toxicity grading, recording of patient-reported quality of life, using validated instruments, is encouraged.

Head and Neck Neoplasms↗
PubMed2003

Dicarboxylic amino acids and glycine-betaine regulate chaperone-mediated protein-disaggregation under stress.

Active protein-disaggregation by a chaperone network composed of ClpB and DnaK + DnaJ + GrpE is essential for the recovery of stress-induced protein aggregates in vitro and in Escherichia coli cells. K-glutamate and glycine-betaine (betaine) naturally accumulate in salt-stressed cells. In addition to providing thermo-protection to native proteins, we found that these osmolytes can strongly and specifically activate ClpB, resulting in an increased efficiency of chaperone-mediated protein disaggregation. Moreover, factors that inhibited the chaperone network by impairing the stability of the ClpB oligomer, such as natural polyamines, dilution, or high salt, were efficiently counteracted by K-glutamate or betaine. The combined protective, counter-negative and net activatory effects of K-glutamate and betaine, allowed protein disaggregation and refolding under heat-shock temperatures that otherwise cause protein aggregation in vitro and in the cell. Mesophilic organisms may thus benefit from a thermotolerant osmolyte-activated chaperone mechanism that can actively rescue protein aggregates, correctly refold and maintain them in a native state under heat-shock conditions.

Adenosine Triphosphate↗
PubMed2003

Remote superficial femoral artery endarterectomy and distal vein bypass for limb salvage: initial experience.

PURPOSE: To examine the results of remote superficial femoral artery endarterectomy (RSFAE) performed through a small groin incision in conjunction with distal saphenous vein (SV) bypass for limb salvage. METHODS: A retrospective study was conducted of 21 patients (14 men; mean age 68.5 years, range 47-78) who underwent RSFAE and distal SV bypass between May 1998 and September 2001 for limb salvage. Thirteen had gangrene and 8 had rest pain. RSFAE was performed with the MollRing Cutter device through a femoral arteriotomy; the distal atheromatous plaque was "tacked up" with a stent. Distal SV bypass from the proximal popliteal artery was performed in situ in 7, from a transposed harvested vein in 8, or from a reversed graft in 6. All patients underwent follow-up examination with serial color-flow ultrasound scans. RESULTS: The mean length of the endarterectomized SFA was 26.5 cm (range 12-40). There were no deaths, only 2 wound complications, and the mean hospital length of stay was 3.1+/-0.6 days. The primary cumulative patency rate by life-table analysis was 71.4% with follow-up extending to an average of 12.4 months (range 1-18). There were 2 amputations for gangrene and 6 percutaneous procedures in 4 (19.1%) patients to maintain bypass patency, producing an assisted primary patency rate of 81.5%. The locations of the restenoses were evenly distributed along the endarterectomized SFA and SV graft. CONCLUSIONS: When adequate SV is not available, RSFAE with residual SV bypass is a safe and moderately durable procedure that may prove to be a useful adjunct for limb salvage, especially in the presence of foot infection, where an autogenous tissue bypass is preferred.

Aged↗
PubMed2002

Hemodialysis graft infections treated with cryopreserved femoral vein.

Introduction. Treatment of infected hemodialysis grafts is associated with prolonged hospitalization and wound care. The use of cryopreserved femoral vein (CFV) for angioaccess in infected hemodialysis grafts was prospectively evaluated.Methods. Forty-three CFV arteriovenous grafts (AVGs) were placed in 43 patients with prosthetic AVG infections. Thirty-two of the CFV AVGs were constructed adjacent to the infected AVG using a parallel tunnel tract, while 11 were placed into the infected field. All patients were prospectively followed at three-month intervals for graft complications and recurrent infections.Results. With a mean follow-up of 418 days, there was one recurrent infection (2.3%). The one-year primary and secondary graft patency rates were 42% and 68%, respectively. The two-year primary and secondary patency rates were 31% and 63%, respectively.Conclusions. Cryopreserved femoral vein proved useful in the treatment of infected hemodialysis grafts. The absence of infection after implantation around an infected area shows promise for salvaging an angioaccess site that would otherwise have been abandoned.

Adult↗
PubMed2002

Screening for colorectal cancer: the business case.

Colorectal cancer screening is advocated by expert groups based on strong evidence of effectiveness, yet only approximately 1 in 3 Americans are screened. For a screening program to be effective, it is necessary for providers to offer and patients to accept screening, insurers to pay for screening, and provider groups to have monitoring and reminder systems and the expertise and facilities to perform the tests well. Whether and when such screening programs become successful depends on the priorities of healthcare decision makers as much as on the efforts of individual physicians and patients. There are strong arguments for decision makers giving colorectal cancer screening programs high priority: it saves as many lives as other services now in common use; it is a good use of scarce resources, costing less than $20,000 per year of life saved; and members of insurance programs increasingly expect screening benefits and programs, and failure to offer them might lead to member dissatisfaction and malpractice claims. Screening is costly, however, taking into account the cost of screening, follow-up tests, and treatments, and the costs occur many years before the benefits. Programs that are promoted to members but not fully implemented could create disappointment and backlash. Also, this screening can cause medical complications. Nevertheless, successful programs have been developed, proving that they are feasible in today's cost-conscious environment. We believe that colorectal cancer screening programs are integral to any organization purporting to provide high-quality care. Organizations without such programs should give them high priority for implementation.

Aged↗
PubMedDate not supplied

Prevention of intimal hyperplasia; Initial results with low-dose beta-radiation applied by an external vascular polymer wrap.

OBJECTIVE: Endovascular brachytherapy, delivered by a variety of catheter-based devices, has proven clinically effective for the inhibition of neointimal hyperplasia (NIH) after coronary and peripheral balloon/stent angioplasty. No platform, however, has been developed to deliver low-dose radiation in concert with vascular surgical operations. The purpose of this study was to evaluate the vascular response following balloon injury to the rabbit carotid artery, with and without topical low-dose 45Ca, applied by an external vascular "wrap". METHODS: Twelve rabbit carotid arteries were subjected to balloon injury by embolectomy catheter. The common carotid artery was then "wrapped" circumferentially with a biostable polyurethane membrane (Nanoskin Secant Medical, Perkasie, PA), without radiation (n = 6), or with radiation (n = 6) (45Ca approximately 50 microCi). The animals were sacrificed at 4 weeks for histologic assessment of the treated vessels. RESULTS: The 45Ca wrap inhibited NIH evidenced by trends towards reduction of intimal area (0.46 +/- 0.19 control carotid vs. 0.35 +/- 0.15 (45)Ca-treated carotid arteries; P = .11), maximal intimal thickness (0.21 +/- 0.08 vs. 0.16 +/- 0.05; P = .12), average intimal thickness (0.12 +/- 0.06 vs. 0.08 +/- 0.03; P = .08), marginally significant reduction in percent area stenosis (33 +/- 15% vs. 21 +/- 9%; P = .06) and marked neointima suppression in areas immediately adjacent to 45Ca wrap remnants. Medial necrosis (P = .003), however, was observed slightly more for 45Ca-treated carotid arteries versus control arteries. CONCLUSION: Low-dose 45Ca beta-radiation labeled onto a polyurethane membrane appears to inhibit NIH in an animal model.

Angioplasty, Balloon↗
PubMedDate not supplied

Topical application of beta-radiation to reduce intimal hyperplasia after carotid artery balloon injury in rabbit. A possible application for brachytherapy in vascular surgery.

PURPOSE: Endovascular brachytherapy for the prevention of intimal hyperplasia (IH) and restenosis after balloon/stent angioplasty has proven effective both in animal preparations and clinical trials. A variety of beta-emitting isotopes and catheter-based devices have been developed for the delivery of low-dose radiation in clinical coronary and peripheral trials. No platform, however, has yet been developed for brachytherapy in concert with vascular surgical operations. The purpose of this study was to evaluate the vascular histopathologic response following balloon injury to rabbit carotid arteries with and without topically applied low-dose beta-radiation. METHODS: The beta-emitting isotope strontium-90 (Sr-90) was conjugated onto the matrix of polypropylene (PLYP) mesh. Rabbit carotid arteries were balloon-injured with a #2 embolectomy catheter. Six carotid arteries were wrapped with nonradioactive PLYP mesh (controls) and Sr-90 ( approximately 90 microCi) PLYP mesh in order to deliver low-dose radiation to the vessel wall from the external (adventitial) surface. Tissue was harvested at 6 weeks and processed for histologic examination. RESULTS: There was consistent blockade of fibrocellular neointima formation with virtually no neointima present in all treated segments, compared to moderate neointima formation in controls. Medial thinning and smooth muscle cell (SMC) necrosis were also associated with topical brachytherapy. CONCLUSION: beta-Radiation applied by an externally wrapped PLYP mesh labeled with Sr-90 markedly suppressed neointima formation in an animal vascular surgical injury model. Further studies, however, are necessary to determine a suitable isotope and dosage for clinical application.

Administration, Topical↗
PubMedDate not supplied

OptEase retrievable inferior vena cava filter: initial multicenter experience.

The purpose of this article is to describe our experience with the retrievable OptEase inferior vena cava filter (IVCF) (Cordis Corporation, Miami Lakes, FL) in the prevention of pulmonary embolus (PE). Forty patients (24 men, age range 15-85 years, mean age 38 years) who were at temporary risk of PE underwent insertion and retrieval of the OptEase IVCF at two institutions. Eleven patients were treated with filter implantation and subsequent repositioning in the inferior vena cava (IVC) to extend implantation time. All patients were followed up for 24 hours after retrieval, with additional follow-up at the physician's discretion. Forty patients had successful filter insertion. Two patients who underwent intravascular ultrasound guidance for filter deployment required filter repositioning within 24 hours owing to inadvertent placement in the right common iliac vein. All 40 patients underwent successful filter retrieval with no adverse events. In those patients who did not undergo IVCF repositioning, the time to retrieval ranged from 3 to 48 days (mean +/- SD 16.38 +/- 7.20 days). One patient had a successful retrieval at 48 days, but all other retrieval experiences were performed within 23 days. The second strategy involved implantation, with repositioning at least once before final retrieval. This latter strategy occurred in 11 patients, and the time to first capture ranged from 4 to 30 days (mean +/- SD 13.82 +/- 6.13 days). No symptomatic PE, IVC injury or stenosis, significant bleeding, filter fracture, or filter migration was observed. In this feasibility study, the OptEase IVCF prevented symptomatic PE, was safely retrieved or repositioned up to 48 days after implantation, and served as an effective bridge to anticoagulation. In patients who require extended IVCF placement, the OptEase IVCF can be successfully repositioned within the IVC, thereby extending the overall implantation time of this retrievable IVCF.

Adolescent↗
PubMedDate not supplied

Traumatic superior mesenteric arteriovenous fistula and aortic pseudoaneurysm 20 years after repair.

A case of traumatic superior mesenteric arteriovenous fistula (SMAVF) and aortic pseudoaneurysm successfully treated by a unique combination of operative and endovascular techniques with a 20-year follow-up is reviewed. After 20 years, the patient presented with an aortoenteric fistula, which was managed with a cryopreserved aortic interposition graft. In this report, we review the evolution of the treatment for traumatic SMAVF and aortic pseudoaneurysm and the current management of aortoenteric fistula.

Adolescent↗