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Biomedical subjects

E Nash

Publications and source records attributed to E Nash.

At least 19 recordsLinked to original sources
PubMed2000

Comparative effects of potassium chloride and bicarbonate on thiazide-induced reduction in urinary calcium excretion.

BACKGROUND: The chronic low-grade metabolic acidosis that occurs in various renal disorders and in normal people, and that is related both to dietary net acid load and age-related renal functional decline, may contribute to osteoporosis by increasing urine calcium excretion. Administration of potassium (K) alkali salts neutralizes acid and lowers urine calcium excretion. Urine calcium excretion also can be reduced by the administration of thiazide diuretics, which are often given with supplemental K to avoid hypokalemia. We determined whether the K alkali salt potassium bicarbonate (KHCO3) and the thiazide diuretic hydrochlorothiazide (HCTZ) combined is more effective in reducing urinary calcium than KHCO3 alone or HCTZ combined with the conventionally coadministered nonalkalinizing K salt potassium chloride (KCl). METHODS: Thirty-one healthy men and women aged 50 or greater were recruited for a four-week, double-blind, randomized study. After a baseline period of 10 days with three 24-hour urine and arterialized blood collections, subjects were randomized to receive either HCTZ (50 mg) plus potassium (60 mmol daily) as either the chloride or bicarbonate salt. Another 19 women received potassium bicarbonate (60 mmol) alone. After two weeks, triplicate collections of 24-hour urines and arterialized bloods were repeated. RESULTS: Urinary calcium excretion decreased significantly in all groups. KHCO3 alone and HCTZ + KCl induced similar decreases (-0.70 +/- 0.60 vs. -0.80 +/- 1. 0 mmol/day, respectively). Compared with those treatments, the combination of HCTZ + KHCO3 induced more than a twofold greater decrease in urinary calcium excretion (-1.8 +/- 1.2 mmol/day, P < 0. 05). Both HCTZ + KHCO3 and KHCO3 alone reduced net acid excretion significantly (P < 0.05) to values of less than zero. CONCLUSIONS: KHCO3 was superior to KCl as an adjunct to HCTZ, inducing a twofold greater reduction in urine calcium excretion, and completely neutralizing endogenous acid production so as to correct the pre-existing mild metabolic acidosis that an acid-producing diet usually induces in older people. Accordingly, for reducing urine calcium excretion in stone disease and osteoporosis, the combination of HCTZ + KHCO3 may be preferable to that of HCTZ + KCl.

Acid-Base Equilibrium↗
PubMed2000

Antiretroviral prophylaxis of health care workers at two urban medical centers.

We examined the influence of job category, source patient HIV status, and exposure type as predictors of whether health care workers initiated antiretroviral prophylaxis after potential blood-borne pathogen exposures. Of 639 exposures over an 18-month period, 82 individuals (13%) elected to receive prophylaxis, of whom 66% took medications for fewer than 96 hours and 12% completed a 4-week course. Reasons for early drug discontinuation included confirmation of source patient HIV-negative serological status (65%), gastrointestinal side effects (13%), headache (4%), and personal decision after counseling/other input (18%). Individuals exposed to HIV-positive source patients were more likely to initiate prophylaxis (odds ratio [OR], 5.1; 95% confidence interval [CI] 2.6 to 9.9). Licensed nurses were less likely than others to accept prophylaxis (OR, 0.5; 95% CI, 0.3 to 0.8), whereas physicians and medical students were more likely to accept prophylaxis (OR, 1.9; 95% CI, 1.1 to 3.3).

Adult↗
PubMed1998

Laparoscopic cholecystectomy for acute cholecystitis and the consequences of gallbladder perforation, bile spillage, and "loss" of stones.

OBJECTIVE: To study the factors associated with accidental perforation of the gallbladder and spillage of bile and stones and to assess the consequences of these mishaps. DESIGN: Prospective study with retrospective bacteriological evaluation. SETTING: Teaching hospital, Israel. SUBJECTS: 189 Patients who were treated for clinical acute cholecystitis between January 1994 and August 1996. INTERVENTIONS: Emergency laparoscopic cholecystectomy. MAIN OUTCOME MEASURES: Incidence of accidental perforation of gallbladder and spillage of bile and stones and of conversion and complications in relation to preoperative and operative findings. RESULTS: Bile was spilt in 65 (34%) and gall-stones were "lost" in 27 (14%), 44 (23%) required conversion to an open approach and 36 (19%) developed complications. Preoperative duration of symptoms >96 hours and a palpable gallbladder were associated with accidental perforation of the gallbladder and spillage of bile. A palpable gallbladder, gangrenous cholecystitis, and WBC > 15 x 10(9)/L were associated with stones "lost" in the peritoneum. A history of biliary disease was inversely related to "lost" stones. Conversion of laparoscopic to open cholecystectomy was associated with male sex, age >60 years, a non-palpable gallbladder, WBC > 15 x 10(9)/L, and a gangrenous gallbladder. Complications of surgery were more common among men and associated with fever of >38 degrees C. Neither the conversion nor the complications were associated with perforation of the gallbladder or "lost" stones. CONCLUSION: Perforation of the gallbladder and intraperitoneal spillage of bile or stones during laparoscopic cholecystectomy for acute cholecystitis are not associated with undesirable events, are not indications for conversion, and are not associated with further complications. When patients are given appropriate antibiotics perioperatively and the spilt bile is properly aspirated and the peritoneum irrigated, the operative and postoperative courses are similar to those of patients with unperforated gallbladder.

Acute Disease↗
PubMed1998

Laparoscopic cholecystectomy for the various types of gallbladder inflammation: a prospective trial.

Laparoscopic cholecystectomy (LC), the procedure of choice for elective cholelithiasis, is now also used in the management of acute cholecystitis. In the various types of gallbladder disease, favorable and unfavorable conditions may influence the conversion and complication rates. Information about these conditions may help elucidate the optimal circumstances for LC or indicate when the procedure is best avoided. We attempted to perform emergency LC on 215 patients with acute cholecystitis. The procedure was successful in 171 patients (79.5%), and conversion to open cholecystectomy (OC) was needed in 44 (20.5%). Complications occurred in 37 patients (17%). Uncomplicated acute cholecystitis was associated with age <50 years, duration of complaint <48 h, temperature <38.5 degrees C, a nonpalpable gallbladder, and an alkaline phosphatase >100 U/L. Acute gangrenous cholecystitis was associated with a negative gallbladder history, other associated diseases, temperature >38.5 degrees C, a palpable gallbladder, and serum bilirubin levels <1 mg/dl. Hydrops was associated with a temperature <38 degrees C and a leukocyte count of >12,000/cc3, and empyema of the gallbladder was associated with duration of complaint >48 h and a palpable gallbladder. The conversion rate of acute gangrenous cholecystitis (40%) was significantly higher than that of uncomplicated acute cholecystitis (8%) (p < 0.00001, odds ratio=7.7), as well as that of empyema of the gallbladder (12.5%) (p=0.005, odds ratio=4.7). The conversion from LC to OC in uncomplicated acute cholecystitis was associated with male sex and with duration of complaint >24 h, and in gangrenous cholecystitis with age >60 years, a nonpalpable gallbladder, and a leukocyte count of >15,000/cc3. The complication rates of acute cholecystitis, hydrops, empyema of the gallbladder, and gangrenous cholecystitis were 16%, 7%, 22%, and 21%, respectively (p = NS). The total complication rate in acute cholecystitis tended to be associated with a duration of complaint >48 h and in gangrenous cholecystitis with male sex, age >60 years, other associated disease, larger bile stones, and elevated serum bilirubin levels. Generally, LC is safe in all forms of cholecystitis, with acceptably low conversion and complication rates, excluding gangrenous cholecystitis. In gangrenous cholecystitis, a conversion rate of approximately 40% is expected. Predictors of conversion and complications may be particularly helpful in planning the laparoscopic approach to acute gangrenous cholecystitis. Patients >60 years of age, with a nonpalpable gallbladder and with a leukocyte count >15,000/cc3, frequently need conversion. In men >60 years old, with other associated disease, with larger bile stones, and with elevated serum bilirubin levels, complications are frequently expected. Under these conditions, laparoscopic approach should be undertaken by especially experienced teams, or OC should be considered.

Acute Disease↗
PubMed1997

Laparoscopic cholecystectomy for acute cholecystitis: prospective trial.

This prospective study determines the indications for and the optimal timing of laparoscopic cholecystectomy (LC) following the onset of acute cholecystitis. It also evaluates preoperative and operative factors associated with conversion from laparoscopic cholecystectomy to open cholecystectomy in the presence of acute cholecystitis. Having been established as the procedure of choice for elective cholelithiasis, LC is now also used for management of acute cholecystitis. Under these circumstances the procedure may be difficult and challenging. Certain favorable and unfavorable conditions may be present that influence the conversion and complication rates. Information about these conditions may be helpful for elucidating the optimal circumstances for LC or when the procedure is best avoided. We performed LC on an emergency basis as soon as the diagnosis was made on all patients presenting with acute cholecystitis from January 1994 to December 1995. All preoperative, operative, and postoperative data were collected on standardized forms. Of the 137 patients registered, 130 were eligible for the audit. Seven patients found by laparoscopic intraoperative cholangiography to have choledocholithiasis were converted for common bile duct exploration and were excluded from the study. Altogether 83 patients (72%) underwent successful LC and 37 (28%) needed conversion to open cholecystectomy. The conversion rate of acute gangrenous cholecystitis (49%) was significantly higher than that for uncomplicated acute cholecystitis (4.5%) (p < 0.00001) and for hydrops (28.5%) and empyema of the gallbladder (28.5%) (p = 0.004). The difference in conversion between the group with acute necrotizing (gangrenous) cholecystitis and the two groups with hydrops and empyema of the gallbladder was not statistically significant (p = 0.07). The complication rates of acute cholecystitis, hydrops, empyema of the gallbladder, and gangrenous cholecystitis were 9.0%, 9.5%, 14.0%, and 20.0%, respectively (p = NS). Patients with an operative delay of 96 hours or less from the onset of acute cholecystitis had a conversion rate of 23%, whereas a delay of more than 96 hours was associated with a conversion rate of 47% (p = 0.022). The complication rate was 8.5% in the laparoscopic group and 27% in the converted group (p = 0.013). Patients over 65 years of age, with a history of biliary disease, a nonpalpable gallbladder, WBC count over 13,000/cc, and acute gangrenous cholecystitis were independently associated with a high LC conversion rate; male patients, finding large bile stones, serum bilirubin over 0.8 mg/dl, and WBC count over 13,000/cc were independently associated with a high complication rate following laparoscopic surgery with or without conversion. Generally, LC can be performed safely for acute cholecystitis, with acceptably low conversion and complication rates. Different forms of cholecystitis carry various conversion and complication rates in selected cases. LC for acute cholecystitis should be performed within 96 hours of the onset of disease. Predictors of conversion and complications may be helpful when planning the laparoscopic approach to acute cholecystitis.

Acute Disease↗
PubMed1997

Possible association of the allele status of the CS.7/HhaI polymorphism 5' of the CFTR gene with postnatal female survival.

Cystic fibrosis (CF) patients show a high degree of linkage disequilibrium between the CF transmembrane conductance regulator (CFTR) gene and polymorphisms 5' of that gene. To determine whether the region 5' of CFTR contains biologically important sequences, the allele frequencies of six CFTR-linked polymorphisms (metH/MspI, XV-2c/TaqI, CS.7/HhaI, KM19/PstI, MP6d9/MspI, J44/XbaI) were determined in 417 randomly selected elderly individuals (over 75 years of age) from the Czech population. The elderly individuals were considered "escapees" of strong selective pressures that had operated during their lifetime, prior to the introduction of modern health care since 1950. The pooled allele frequencies of the analyzed marker polymorphisms in the elderly did not significantly differ from published data. However, when analyzed by ex, the allele frequencies of markers CS.7/HhaI and KM19/PstI differed significantly (P < 0.05) between elderly females and males. The allele frequencies of the six polymorphisms were then determined in 646 newborns and 345 young adults of reproductive age; these individuals were selected in a similar manner and drawn from the same population. In these control groups, the studied marker polymorphisms exhibited no statistically significant differences between sexes and/or between individuals of the same sex, only between different age groups. A gradual relative increase in the frequency of allele "2" of marker CS.7/HhaI was observed from newborn females to elderly women, the overall difference in allele frequencies of this marker polymorphism between newborn females and elderly women reaching statistical significance (P < 0.05). Interestingly, allele "2" is the major constituent of the extended "B-haplotype", which is in strong linkage disequilibrium with common CF alleles. Taken together, our data suggest that the region spanning markers CS.7 and KM19 is associated with a genetic factor that influences postnatal female survival, providing a possible mechanism for increasing the frequency of particular mutations in the adjacent CFTR gene.

Adult↗
PubMed1997

Delay of surgery in acute appendicitis.

BACKGROUND AND OBJECTIVES: It is generally assumed that delayed diagnosis of acute appendicitis results in higher morbidity but this assumption is not strongly supported in the literature. We attempt to define the effect of patient and physician delay on the outcome of patients with acute appendicitis. PATIENTS AND METHODS: We studied 486 patients admitted between 1980 and 1992. Patient delay in presenting to a physician and surgeon delay from hospital admission to operation were studied in relation to stage of disease at operation as well as to postoperative complications. RESULTS: Postoperative complications occurred in 10% of cases with simple acute appendicitis versus about 20% of cases with gangrenous or perforated appendicitis (P <0.001). The mean patient delay from onset of symptoms to presentation to a physician was 1.7 days in simple acute appendicitis versus 2.3 days in gangrenous or perforated appendicitis (P <0.001). Mean surgeon delay was 13.6 hours in simple acute appendicitis versus 14.5 hours in advanced appendicitis (P = NS). CONCLUSION: Delay in patient presentation adversely affects the stage of disease in acute appendicitis and leads to increased incidence of infectious complications and to prolonged hospital stay. Conversely, physician delay does not affect the stage of disease. A surgeon's decision to observe patients in hospital in order to clarify the diagnosis is justified, as it does not adversely affect outcome.

Acute Disease↗
PubMed1997

Crohn's disease associated with pellagra and increased excretion of 5-hydroxyindolacetic acid.

A 47-year-old woman with seronegative polyarthritis, diarrhea, and photosensitivity dermatitis was found to have Crohn's disease and pellagra. The presence of high values of 5-hydroxyindolacetic acid in the urine began the exhaustive investigations and finally enterotomy. No mass lesion was found. Argyrophilic cells were not increased in areas of inflamed intestinal mucosa or the normal mucosa. The disagreement between biochemical and histologic findings was attributed to sampling error. Antiinflammatory treatment for Crohn's disease was given and the gastrointestinal and articular symptoms improved, excretion of 5-hydroxyindolacetic acid returned to normal and there was no relapse of pellagra. Pellagra as a complication of Crohn's disease has been described in 4 cases; malnutrition and intestinal malabsorption were the proposed mechanisms for the niacin deficiency and pellagra of those patients. In the current case, the pathogenesis of pellagra may be accounted to wastage of tryptophan by an increased pool of intestinal argyrophilic cells, suggested by increased urinary excretion of 5-hydroxyindolacetic acid.

Anti-Inflammatory Agents↗
PubMed1997

Laparoscopic versus open cholecystectomy in acute cholecystitis.

Elective laparoscopic cholecystectomy is established as the treatment of choice for symptomatic cholecystolithiasis and is now proposed for the treatment of acute cholecystitis. We initiated the present study in order to clarify the question of safety of the procedure in the presence of an inflamed gallbladder, and to compare the results with those of a traditionally treated group with acute cholecystitis. We compared the preoperative, operative, and postoperative courses of 146 patients with acute cholecystitis, managed laparoscopically between 1994 and 1996, with those of 97 patients, treated traditionally by open cholecystectomy for the same diagnosis between 1992 and 1993. In the acute cholecystitis cases, when laparoscopic cholecystectomy was successfully performed, the operative and postoperative courses were superior to those of open cholecystectomy. The use of drains and NG tubes, the need for antibiotics and analgesia, the associated morbidity, and the hospital stay were significantly reduced. Following conversion, the postoperative course was similar to that of open cholecystectomy. Of the group of acute cholecystitis cases laparoscopically approached 39 (27%) needed conversion. Twenty-five complications occurred in 24 (16.5%) patients of the laparoscopic group, whereas 30 complications occurred in 25 (26%) patients of the traditionally operated group. Male sex, older patients, and larger bile stones were found to be associated with a higher conversion rate as well as a higher complication rate. A nonpalpable gallbladder and gangrenous cholecystitis were associated with conversion while fever was associated with complications. Laparoscopic cholecystectomy can be performed safely in selected cases of acute cholecystitis, with acceptable conversion and low complication rates. When laparoscopic cholecystectomy is successfully performed, the operative and postoperative courses are superior to those of open cholecystectomy. Following conversion, the postoperative course is similar to that of open cholecystectomy. According to this study, male sex, older age, large bile stones, a nonpalpable gallbladder, and gangrenous cholecystitis may be regarded as predictors of conversion, while male sex, older age, large bile stones, and fever may be regarded as predictors of complications. The timing of laparoscopic cholecystectomy should be within 96 h from onset of the inflammation.

Acute Disease↗
PubMed1997

Does the index operation influence the course and outcome of adhesive intestinal obstruction?

OBJECTIVE: To ascertain the incidence of obstruction after various operations and find out if the index operation influenced the course and outcome of adhesive small bowel obstruction. DESIGN: Retrospective study. SETTING: Teaching hospital, Israel. SUBJECTS: 190 of 248 patients who presented with small bowel obstruction between January 1980 and December 1994. INTERVENTIONS: All patients were treated conservatively and operated on only if they did not improve or deteriorated. MAIN OUTCOME MEASURES: Incidence of obstruction depending on site of index operation, and response to treatment. RESULTS: 46 Patients (24%) had undergone upper abdominal operations, 26 (14%) small bowel resection, 47 (25%) appendicectomy, 27 (14%) gynaecological operations, and 44 (23%) colonic resections. The annual incidence of obstructive complications among the 190 patients in the groups studied was highest after appendicectomy (3.1/year) and colonic resections (2.9/year) and lowest after operations on the gallbladder and pancreas (1.1/year). Postoperative adhesive obstruction presented earlier after operations on the small bowel (median 1 year, range 5.4-20) and colon (median 1 year, range 2.2-40) than after the other operations. 60 (32%) of patients with acute small bowel obstruction had a history of abdominal malignancy, and obstruction was more likely to be complete after small bowel resection (20/26, 77%) compared with 39/74 (53%) after appendicectomy or gynaecological surgery, 17/46 (37%) after upper abdominal surgery, and 15/44 (34%) after colonic resection. Patients who developed obstruction after colonic resection had the longest period of conservative treatment (median 60 hours, range 24-216) and had the highest morbidity (8/44, 18%) although only 2 required bowel resection. Two patients died, both after obstruction following upper abdominal operations. CONCLUSIONS: Patients who present with obstruction after small bowel resection are extremely likely to be completely obstructed. Perhaps the morbidity associated with obstruction after colonic resection could be reduced if patients were operated on earlier.

Adolescent↗
PubMed1997

Intussusception in adults.

Adult intussusception is a rare condition, chronic and recurring in nature, and presenting as intermittent intestinal obstruction. Surgeons generally have limited experience with it. We present 13 cases that have been treated in our department over a period of 19 years. In most of the cases there is an identifiable cause and it is often a malignancy. Awareness, plain abdominal films, barium enema and CT are valuable tools for diagnosis. Resection without reduction is the treatment of choice in most cases. In instances where resection would necessitate a permanent stoma, attempts at manual reduction are justified. Timely treatment, properly carried out, should result in a good prognosis.

Adult↗
PubMed1996

Safety of laparoscopic cholecystectomy on a teaching service: a prospective trial.

In a prospective audit of our first 213 laparoscopic cholecystectomies (LC), we compared the results obtained by qualified surgeons to those obtained by residents. The first group started performing LC after undergoing formal laboratory laparoscopic courses. The second group was introduced to LC by standard attending-resident teaching in the operating room. In all, 137 LC wer performed by qualified surgeons and 76 by residents. Patients' clinical and laboratory characteristics were not significantly different in the two groups. The conversion rate to laparotomy (11.5% and 12.5%), mean duration of surgery (88 and 83 min), iatrogenic perforation of the gallbladder (16% and 18.5%), "lost stones" (7% and 4%), use of drains (12% and 13%), and extension of the umbilical port incision (about 30% in both groups) were similar in the two groups. The incidence of biliary (3% and 4%) and infectious (3.5% and 4%) complications was equivalent in both groups. We conclude that with the traditional attending-resident approach to surgical education, residents safely and quickly acquire the necessary skills to perform LC without jeopardizing the safety of patients.

Adult↗