PubMed Health⌕ Search

Biomedical subjects

E F Hirsch

Publications and source records attributed to E F Hirsch.

At least 19 recordsLinked to original sources
PubMed1992

Nutritional outcome and pneumonia in critical care patients randomized to gastric versus jejunal tube feedings. The Critical Care Research Team.

OBJECTIVE: To compare nutritional status, gastric colonization, and rates of nosocomial pneumonia in ICU patients randomized to gastric tube feeding vs. patients fed by an endoscopically placed jejunal tube. DESIGN: Randomized, prospective study. SETTING: Medical and surgical ICUs at Boston City Hospital; surgical ICU at University Hospital. PATIENTS: Of the 38 study patients, 19 were randomized to gastric tube feeding and 19 were randomized to an endoscopically placed jejunal tube. The two groups were similar in age, sex, race, underlying disease, and type of surgery. RESULTS: The two patient groups were similar in number of days fed, duration of ICU stay, duration of mechanical ventilation, days of antibiotic therapy, and days with fever. Compared with the gastric group, the jejunal group had more patients with circulatory shock on admission (79% vs. 68.4%), higher admission Acute Physiology Score (24.0 vs. 21.7), and fewer patients with pneumonia at randomization (26.3% vs. 31.6%). The jejunal group received a significantly higher percentage of their daily goal caloric intake (p = .05), and had greater increases in serum prealbumin concentrations (p < .05) than the patients with gastric tube feeding. Although the jejunal tube group had more days of diarrhea (3.3 +/- 6.6 vs. 1.8 +/- 2.9), this difference was not statistically significant. Nosocomial pneumonia was diagnosed clinically in two (10.5%) patients in the gastric tube group and in no patients in the jejunal tube group. CONCLUSIONS: Patients fed by jejunal tube received a significantly higher proportion of their daily goal caloric intake, had a significantly greater increase in serum prealbumin concentrations, and had a lower rate of pneumonia than patients fed by continuous gastric tube feeding.

Adult↗
PubMed1992

Pathologic consequences of bilateral pulmonary lower lobectomies: case report.

Most injuries to the lung can be managed nonoperatively and rarely require resection. A case of bilateral hilar injuries requiring bilateral pulmonary lower lobectomies is presented. The resulting pulmonary hypertension, right ventricular failure, and cardiogenic shock explain the high mortality following extensive pulmonary resection in thoracic trauma and support the concept of a conservative approach.

Adult↗
PubMed1991

Liver viability after ischemia-reperfusion.

Lack of a reproducible model to quantitatively assess hepatocellular injury following ischemia has made it difficult to assess new strategies for minimizing hepatic injury. We studied the progression of hepatocellular injury after ischemia and ischemia with reperfusion in rats. Irreversible injury was quantitated using a triphenyltetrazolium chloride assay that was shown to correlate with ultrastructural changes. Adenosine triphosphate decreased to 36% of basal values after 30 minutes, but returned to normal with reperfusion with no decrease in viability. In contrast, viability fell by 30% after 60 minutes of ischemia, and by 64% when 60 minutes of ischemia was followed by reperfusion. We conclude that reperfusion of ischemic liver increases the degree of irreversible damage. The model employed here seems to be useful for studying ischemic and reperfusion injury in the liver.

Adenine Nucleotides↗
PubMed1991

Carinal injury: diagnosis and treatment--case report.

Injury to the thoracic trachea is a potentially lethal condition in a patient with multiple injuries. Several clinical signs are commonly associated with this process: subcutaneous emphysema, aphonia, stridor, pneumothorax refractory to thoracostomy tube drainage, pneumomediastinum, and hemoptysis. The clinical appearance of tracheobronchial rupture may be delayed for hours or even weeks following injury. Standard treatment for disruption of the thoracic trachea is primary repair via a right thoracotomy. We describe a patient with a complex carinal injury following blunt thoracoabdominal trauma who was successfully managed with prompt surgical intervention.

Accidents, Traffic↗
PubMed1989

Glucan enhances survival in an intraabdominal infection model.

The immunomodulator glucan exists in two forms, particulate (glucan-P) and soluble (glucan-F). Both preparations of glucan, either alone or in combination with antibiotic therapy, were evaluated for their ability to augment survival in rats following cecal ligation and puncture (CL/P). Adult male rats were infused once daily for 5 consecutive days with either glucan-P (10 mg/kg), glucan-F (10 mg/kg), or 5% (w/v) dextrose in water. Three days later all rats underwent CL/P. Postoperatively, the rats received (a) no therapy, (b) saline (1 ml subcutaneously every 12 hr) or (c) ampicillin (33 mg/kg subcutaneously every 12 hr) for 7 days. Without any associated pre-or postoperative treatment, CL/P was associated with an 85% 7-day mortality. Neither glucan preparation alone significantly altered this mortality. Administering ampicillin postoperatively decreased the mortality to 53% (P less than 0.001 vs untreated controls). When postoperative ampicillin therapy was combined with preoperative glucan treatment, the mortality was reduced even further (26% for glucan-P, 21% for glucan-F; P less than 0.02 vs ampicillin-treated controls). We conclude from these results that (i) neither glucan preparation alone effectively enhances survival following CL/P when using the doses and administration schedule employed herein, (ii) both glucan-P and glucan-F do act synergistically with antibiotics to enhance survival in this rat model of polymicrobial sepsis, and (iii) in this particular model, nontoxic glucan-F is as efficacious as glucan-P.

Abdomen↗
PubMed1988

Intraabdominal sepsis after hepatic trauma.

In a review of 58 patients who survived liver trauma seen at Boston City Hospital, 10 patients had 13 intraabdominal abscesses and 1 died from overwhelming sepsis. Multivariate analysis of risk factors revealed that the number of units of perioperative, postoperative, and total blood transfused were each highly significant (p less than 0.0001). Mode of injury, hepatic resection, gastrointestinal tract perforation, and the number of associated injuries were not significant risk factors when transfusion requirements were accounted for. Fever and leukocytosis were unreliable predictors of abscess formation. The available literature suggests a strong relationship between intraperitoneal bleeding and septic complications.

Abdomen↗
PubMed1986

A comparative evaluation of particulate and soluble glucan in an endotoxin model.

Particulate glucan (P) but not soluble glucan (F) has been shown to sensitize rats to endotoxins. This phenomenon is believed to be mediated by the reticuloendothelial system (RES). The effect of glucan-P and -F on the RES, and the response of glucan-treated rats to nonlethal doses of endotoxin were investigated. Rats were injected for 5 days with 10 mg/kg of glucan-P, -F or saline. Three days later rats were either (1) injected with colloidal carbon for clearance studies, (2) sacrificed for organ histology and determination of serum glucose, plasma thromboxane (Tx) B2, and plasma 6-keto-prostaglandin (PG) F1 alpha concentrations, or (3) challenged with a nonlethal dose of endotoxin. The latter were further subdivided into groups for either 30-day survival or for sacrifice at 30 min or 4 h post-endotoxin infusion to obtain blood samples for glucose, TxB2, and 6-keto-PGE1 alpha determinations. Glucan-P induced hepatosplenomegaly and granulomatous changes within the liver and spleen. The carbon clearance halftime was markedly decreased in these animals. In glucan-P-treated rats challenged with endotoxin, elevated concentrations of both plasma prostanoids were observed as well as alterations in serum glucose levels. These changes were less pronounced in glucan-F- or saline- treated rats. Following endotoxin challenge, only 40% of glucan-P-treated rats survived 30 days whereas 100% of both the glucan-F and saline-treated rats survived. We conclude that glucan-P, in contrast to glucan-F, significantly heightens RES function and that this effect likely accounts for the endotoxin sensitivity.

Animals↗
PubMed1986

Residents' experience in the surgery of trauma.

Performance of surgery for trauma is an important part of residency training, yet what constitutes an adequate exposure to trauma surgery is ill defined. A retrospective review of records at a metropolitan receiving hospital was carried out for the academic year 1981-1982. Of the 50,902 patients treated in the Emergency Room more than one third were seen by a surgical resident. During this period 1,651 patients were admitted to General Surgery with traumatic injuries; 193 (12%) required intensive care. Two hundred twenty-seven major operations were performed by the General Surgical Service. For each patient operated on, 56 were seen in the Emergency Room and six required admission for nonoperative care of their injuries. Furthermore, less than 50% of patients admitted to the I.C.U. required surgery. An adequate education in trauma must be based on a large experience in the nonoperative resuscitation, diagnosis, and treatment of trauma victims. Nevertheless, the number of cases performed as operating surgeon provides a useful means of evaluation experience in trauma. Thirty cases are suggested as an appropriate level of exposure to the surgery of trauma, yet only one third of applicants to the American Board of Surgery attained this level.

Boston↗
PubMed1985

Prostanoid production by lipopolysaccharide-stimulated Kupffer cells.

Although some data suggest that macrophages in the reticuloendothelial system (RES) are important sources of thromboxane A2 (TxA2) and prostacyclin (PGI2) during endotoxic shock, we are unaware of data documenting the ability of hepatic macrophages (Kupffer cells) to release either TxA2 or PGI2 when exposed to lipopolysaccharide (endotoxin, LPS). In this study, Kupffer cells were examined for their ability to release prostaglandin E2 (PGE2), TxA2, and PGI2 following stimulation with 0, 1.0, 50.0, and 100.0 micrograms/ml of Escherichia coli LPS. Kupffer cells were obtained from rat livers by enzymatic digestion with 0.05% collagenase followed by enrichment of the macrophage population on the basis of differences in density and adherence among the various cell populations isolated. Based on several criteria (phagocytosis of opsonized sheep erythrocytes, positive staining for esterase and peroxidase, failure to replicate), 95% of adherent cells were Kupffer cells. After 4 days of incubation, cells were stimulated with various doses of LPS for 4 and 8 hr. Prostanoid concentrations in culture supernatants were determined by radioimmunoassay. Increasing doses of LPS significantly (P less than 0.001) increased the concentration of immunoreactive PGE2 (iPGE2) and iTxB2 (the stable metabolite of TxA2). The concentration of i6-keto-PFG1 alpha (stable metabolite of PGI2) increased following stimulation with 1.0 microgram/ml of LPS, but declined as the dose of LPS was increased. The results provide evidence that endotoxin-activated Kupffer cells, like other macrophage populations, release several metabolites of arachidonic acid. Kupffer cell-derived prostanoids, particularly TxA2, may be important mediators of some of the pathophysiologic manifestations of acute endotoxemia.

6-Ketoprostaglandin F1 alpha↗
PubMed1985

The clinical consequences of an industrial aerosol plant explosion.

The factors relating to the clinical outcome of an industrial aerosol plant explosion are reviewed. Eighteen of 24 workers inside the plant required hospitalization and five died. Proximity to the blast was associated with extensive injuries unless workers were shielded by physical barriers or partitions. Burn severity and mortality were increased in those wearing synthetic garments compared to their counterparts wearing fiber clothing. Facial burns occurred in all unprotected workers. Forearm and hand burns in 11 patients required decompressive escharotomies. Topical treatment with silver sulfadiazine was associated with more significant leukopenia and neutropenia than treatment with silver nitrate. We conclude that industrial design should include safeguards which isolate workers from flammable materials, including isolation of explosive materials from working areas, alarm systems to detect leakage of flammable agents, protective barriers and shields, and the regulation and institution of flame and flash-resistant clothing.

Accidents, Occupational↗
PubMed1985

Pericardial complications in hepatic trauma.

During a 5-year period, 35 of 70 patients with liver trauma required entry of the thoracic cavity, with nine deaths. Pericardial complications developed in four of the nine survivors who had both thoracic and abdominal incisions. Two patients resolved their problems (postpericardiotomy syndrome, late pericarditis) with medical therapy. One patient required emergency thoracotomy for pericardial tamponade, and one patient developed constrictive pericarditis that required pericardiectomy. Available data support closure of the pericardium after pericardiotomy. Thoracic extension of abdominal incisions is often necessary. Pericardial complications may occur with hepatic trauma in the early or late postoperative periods and are potentially fatal.

Adolescent↗
PubMed1985

Prognosis and survival as determined by visceral amino acid clearance in severe trauma.

Sepsis, the commonest cause of late death following severe trauma, is related in part to inadequate uptake of amino acids (AA) and synthesis by the liver and other central tissues of proteins essential to immunological defense. Since 'central plasma clearance rate' of amino acids (CPCR-AA) has been found to reflect these functions, serial measurements of CPCR-AA were made in 32 seriously injured patients of whom ten died (31%), nine of sepsis. The mean Index Severity Score on admission for survivors was 31 +/- 1.8 and in deaths 34 +/- 3.9 (N.S.). The blood plasma AA concentrations were not significantly different. However, early in the course before the onset of infection, CPCR-AA in surviving patients was 227 +/- 30 and in those who ultimately died 83 +/- 24 ml/M2/min (p less than 0.001). Later during sepsis the values of CPCR-AA were 176 +/- 28 and 85 +/- 14 ml/M2/min, respectively (p less than 0.01). Thus CPCR-AA appears to be of value as an indicator of amino acid utilization by central tissues and as a predictor of survival or death following severe trauma.

Adult↗
PubMed1983

Rectal trauma. A retrospective analysis and guidelines for therapy.

Twenty patients seen at Boston City Hospital required general or spinal anesthesia for rectal injuries, and 17 required laparotomy. Findings on sigmoidoscopy were falsely negative in 4 of 13 patients examined. Diagnosis was delayed in two patients. Associated injuries occurred in 55 percent, with the lower genitourinary tract being the area most frequently injured. Complications occurred in eight patients (40 percent). Abscess formation and bacteremia were the most common, but iatrogenic complications occurred in four patients. Pulmonary embolism occurred in two patients and was suspected in a third patient. Routine treatment included diverting colostomy with distal irrigation and adequate drainage. Repair of the injury was performed when possible. Two of the 20 patients (10 percent) died, one after a prolonged septic course and one from recurrent pulmonary embolism. Rectal trauma continues to be a challenging injury.

Abscess↗
PubMed1982

Management of vascular injuries to the leg.

Our experience with 69 vascular injuries in 56 patients led us to modify the management of vascular injuries to the leg. We believe that prompt and complete angiography whenever the general condition of the patient allows it, early fasciotomy when indicated before vascular repair, thrombectomy of the injured artery and vein and local instillation of heparinized saline solution, vascular repair before orthopedic stabilization of fractures in selected cases, external fixation of the fracture when there is significant soft tissue injury, and early skin grafting resulted in an improved level of care with a low morbidity and no mortality in our series.

Adolescent↗