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Biomedical subjects

J C Milliken

Publications and source records attributed to J C Milliken.

At least 19 recordsLinked to original sources
PubMed2001

Photodynamic therapy for patients with advanced non-small-cell carcinoma of the lung.

Patients with advanced non-small-cell lung carcinoma (NSCLC) have poor prognoses and experience negative sequelae of disease. Patients often suffer from dyspnea and/or hemoptysis, with overall pulmonary compromise. Patients with advanced, inoperable disease have limited options for treatment. This study summarizes our early experience and findings using photodynamic therapy (PDT) as an effective modality in the palliation of hemoptysis, dyspnea, and physical airway obstruction in cases of inoperable lung cancer. A retrospective review was conducted for the first 10 patients diagnosed with stage III/IV obstructive NSCLC who underwent PDT at our institution. Endobronchial lesions were identified by bronchoscopy. Treatments were initiated 48 hours after intravenous injection of 2 mg/kg of the photosensitizing agent porfimer sodium (Photofrin, QLT PhotoTherapeutics, Vancouver, BC). The porfimer sodium was then activated by illumination with a 630 nm wavelength light using a Coherent argon ion laser through a flexible bronchoscope. Repeated bronchoscopies were performed 1-3 days following initial PDT for evaluation and airway debridement. In 8 cases, a second treatment of PDT was administered within 72 hours of the first injection. One patient received a third treatment several months later. Three patients also received endobronchial stents after PDT. Overall, all 10 patients responded to PDT. Physical airway obstruction was reduced in all patients, with a noted improvement in bronchoscopic luminal diameter. Acute hemoptysis resolved in all 7 symptomatic patients. Median survival was 5.5 months post-PDT, while median survival postdiagnosis was 10.5 months. Three patients are alive at the time of this review at 5-21 months following therapy. Patients with unresectable late-stage NSCLC have few options for treatment. Our early experience with PDT indicates effective relief of hemoptysis, dyspnea, and airway obstruction and improves their quality of life.

Journal Article↗
PubMed2000

Annular abscesses in surgical endocarditis: anatomic, clinical, and operative features.

BACKGROUND: The aim of this study was to determine patterns of anatomic, clinical, and operative features in surgical endocarditis (SE) with annular abscess (AA). METHODS: The study consisted of a retrospective analysis of SE cases with AA between 1981 and 1997. RESULTS: A total of 41 cases with AA were found in 106 consecutive SE cases. There was a higher incidence of AA in aortic (37 of 71 [52%]) (p<0.01) compared to mitral (6 of 42 [14.3%]) or tricuspid (0 of 12) infections. However, the mitral abscesses had a greater tendency toward fistula or pseudoaneurysm formation (4 of 6 [67%]) than other valve abscess cavities (7 of 46 [15%]) (p<0.01). Severe heart failure (p<0.01), heart block (p<0.05), and fistula/pseudoaneurysm (p<0.001), were more often found in SE with AA than without. There were 46 separate aortic AA in 37 instances of aortic valve SE. Of these, 31 of 46 (67%) were less than 1 cm (group 1), 10 of 46 (22%) were large but confined to a given cusp annulus (group 2), 4 of 46 (8.6%) were large between multiple cusps (group 3), and 1 of 46 (2.2%) was circumferential (group 4). There were four instances of aortoventricular discontinuity. Group 1 abscesses were repaired by local closure without a patch significantly more often than the other groups. The mortality of SE with AA was significantly greater for larger AA (groups 3 and 4, 3 of 5 [60%]) than for smaller AA (groups 1 and 2, 0 of 36) (p<0.001). There were six separate mitral AA in six instances of mitral SE, five requiring patch repair. The 30-day operative mortality for AA cases was 3 of 41 (7.3%) compared to 2 of 65 (3.1%) without AA. All AA mortalities involved large AA in the aortic valve position. Of 35 mechanical valves placed for AA, only one required subsequent removal for prosthetic endocarditis. CONCLUSIONS: Annular abscesses are most frequent in aortic AA, but fistulas/pseudoaneurysms are more frequent in mitral AA. Small to moderate aortic AA can be managed by local closure without an increased mortality compared to SE without AA. Patients with large aortic AA have a higher operative mortality. Mechanical prostheses are safe and effective for the majority of patients with AA.

Abscess↗
PubMed1999

Central venous injuries of the subclavian-jugular and innominate-caval confluences.

Injuries to the central venous system can result from penetrating trauma or iatrogenic causes. Injuries to major venous confluences can be particularly problematic, because the clavicle and sternum seriously limit exposure of the injury site. We report our institution's experience with central venous injuries of the subclavian-jugular and innominate-caval venous confluences. Significant injuries of the subclavian-jugular venous confluence frequently result from penetrating trauma, while injuries to the innominate-caval confluence are usually catheter-related. Median sternotomy provides adequate exposure of the innominate-caval confluence, while exposure of the subclavian-jugular venous confluence requires extension of the median sternotomy incision into the neck and resection of the clavicle. The literature is reviewed.

Adolescent↗
PubMed1998

Characteristics of patients less than 45 years of age compared with older patients undergoing coronary artery bypass grafting.

BACKGROUND: Coronary artery disease (CAD) was not recognized as common among young patients until the study by Yater in 1948. Subsequent studies further elucidated the nature of the disease, which had become more apparent in the younger groups. HYPOTHESIS: The study was undertaken to determine the prevalence of risk factors and severity of coronary disease among young patients aged < or = 45 years undergoing coronary artery bypass grafting (CABG) compared with older patients. METHODS: In all, 112 young patients aged < or = 45 years (Group 1) and 798 older patients aged > 45 years (Group 2) were analyzed for trends to hypertension, smoking, diabetes, family history of heart disease, hypercholesterolemia, obesity, and history of previous myocardial infarction (MI). The severity of disease was examined in terms of number of diseased vessels, vessel size, number of grafts performed, performance of endarterectomies, and left ventricular function. RESULTS: Group 1 had a higher incidence of positive family history (68.5 vs. 51.2%, p < 0.05), and lower incidences of hypertension (62.7 vs. 81.5%, p < 0.05), obesity (42.9 vs. 83.9%, p < 0.05), and history of previous MI (54.5 vs. 94.6%, p < 0.05). Group 2 had a higher incidence of left main disease (22.6 vs. 11.4%, p < 0.05). The distribution of the affected vessels of the young patients was most commonly the left anterior descending (90.4%) followed by the right coronary (79.8%) and circumflex arteries (69.2%). Group 2 had more grafts per patient (3.82 vs. 3.37, p < 0.05). The size of the diseased vessels measured intraoperatively was similar (1.56 vs. 1.58 mm, p = NS) in both groups. Endarterectomy was performed almost three times more often in Group 1 patients (8.2 vs. 3.0%, p < 0.05). Operative mortality was less in Group 1 mean (1.8 vs. 6.3%, p < 0.05). Group 2 had a greater mean left ventricular ejection fraction (53.8 vs. 49.7%, p < 0.05). CONCLUSION: Compared with the older population, patients < or = 45 years of age who underwent CABG had (1) a higher incidence of positive family history of CAD, (2) a higher likelihood of requiring an endarterectomy, and (3) lower operative mortality rate despite a slightly poorer ventricular function.

Adult↗
PubMed1998

Closure of short, wide patent ductus arteriosus with cardiopulmonary bypass and balloon occlusion.

The wide, short patent ductus arteriosus in adults and older adolescents poses an extreme hazard with standard closed ligation techniques. The method of transpulmonary balloon catheter occlusion and repair of pediatric ductus arteriosus is herein reported in older patients using a Foley catheter and normothermic bypass. Transesophageal echocardiography is crucial in assessing the size of the ductus and confirming adequacy of repair. The technique is simple and safe even in the presence of a wide, short ductus.

Adolescent↗
PubMed1998

Changes in pulmonary physiology after lung volume reduction surgery in a rabbit model of emphysema.

OBJECTIVE: The purpose of this study is to investigate the effects of lung volume reduction surgery on pulmonary compliance, airway flow, and helium lung volumes in an elastase-induced emphysema animal model. METHODS: A 15,000-unit bolus of elastase was aerosolized through an endotracheal tube in 14 New Zealand White rabbits to induce emphysema. Stapled lung volume reduction of bilateral upper and middle lobes was performed through a midline sternotomy at 4 weeks after induction of emphysema. Lung functions were measured at baseline before induction of emphysema, preoperatively at 4 weeks, and 1 week postoperatively. RESULTS: Compliance increased after induction of emphysema and decreased in response to lung volume reduction surgery. Functional residual capacity decreased after lung volume reduction surgery in proportion to the amount of excised lung tissue. Expired flows suggested improvement in response to lung volume reduction surgery. Histologic examination confirmed presence of diffuse heterogeneous emphysema in each animal at necropsy. CONCLUSIONS: The decreased compliance and increased airway flow after volume reduction surgery in this model parallels findings in human studies and suggests that similar mechanisms of increased elastic recoil and airway support contribute to improvement.

Animals↗
PubMed1998

Accelerated recovery after coronary artery bypass surgery in patients with poor left ventricular function: preliminary report.

The success of "fast-track" accelerated recovery pathways in improving patient outcomes after coronary artery bypass graft surgery (CABG) has prompted expanded application. Although initially used only in routine cases, higher-risk cohorts may also benefit from this collection of management techniques. Twenty-seven consecutive patients with ejection fractions (EFs) less than or equal to 30 per cent (group I) undergoing CABG requiring cardiopulmonary bypass were started on our routine care path. The results of this effort were retrospectively compared with 27 concurrent patients with an EF greater than or equal to 50 per cent (group II) undergoing CABG at our institution. Outcome criteria included postoperative extubation (by 6 hours), transfer from intensive care unit (in < or = 24 hours), and hospital discharge on or before postoperative day 5. As anticipated, group I patients deviated from pathway criteria more frequently than did group II. However, despite severely compromised preoperative cardiac function, 52 per cent of group I patients were extubated within the first 6 hours postoperatively, 51 per cent were discharged from the intensive care unit on the 1st postoperative day, and 52 per cent were discharged from the hospital within the first 5 postoperative days. Group II patients' values for these parameters were 96, 96, and 70 per cent, respectively. No adverse effects could be attributed to pathway expectations. The results of this preliminary study suggest that accelerated care pathways may be safely applied to patients with severely low EFs and deserve further study.

Adult↗
PubMed1998

Reversible snaring for proper prosthetic seating during valve replacement.

A method of reversible suture snaring is described for evaluating the final valve seating and positioning before knot tying of valve sutures. This allows for alteration of the operative plan before investing substantial ischemic time in a nonfunctional result. The procedure has been used in 577 consecutive prosthetic valve replacements in the past 5 years. The technique maintains proper seating while the valve is permanently anchored in place.

Heart Valve Diseases↗
PubMed1997

Underuse of coronary revascularization procedures: application of a clinical method.

OBJECTIVES: Our main objective was to apply a new method to determine whether coronary revascularization procedures are underused, especially among African-Americans and uninsured patients. BACKGROUND: Although overuse of revascularization procedures has been studied, underuse as defined clinically has not been examined before. METHODS: The study was conducted at four public and two academically affiliated private hospitals in Los Angeles; 671 patients who underwent coronary angiography between June 1, 1990 and September 30, 1991 and met explicit clinical criteria for coronary revascularization were included. The main outcome measure was the proportion of patients undergoing an indicated procedure within 12 months (ascertained by medical record review and confirmed with a telephone survey). Adjusted relative odds of undergoing an indicated procedure for African-Americans and patients in public hospitals compared with whites and patients in private hospitals were calculated. RESULTS: Overall, 75% of patients underwent a revascularization procedure. Of 424 patients requiring bypass surgery, 107 angioplasty and 140 either bypass surgery or angioplasty, 59%, 66% and 75% underwent the procedure, respectively. African-Americans were less likely than whites to undergo operation (adjusted odds ratio [OR] 0.49, p < 0.05) and angioplasty (adjusted OR 0.20, p < 0.05). Patients in public hospitals were less likely than those in private hospitals to undergo angioplasty (adjusted OR 0.10, p < 0.005). CONCLUSIONS: Underuse of coronary revascularization procedures is measurable and occurs to a significant degree even among insured patients attending private hospitals. Underuse is especially pronounced among African-Americans and patients attending public hospitals. Future cost-containment efforts must incorporate safeguards against underuse of necessary care.

Black or African American↗
PubMed1997

Management of tracheobronchial injuries following blunt and penetrating trauma.

Disruptions of the trachea and bronchi are an infrequent but a life-threatening injury following trauma. We reviewed our experience with tracheobronchial injury from 1988 to 1996. Out of 12,789 trauma patients treated at a university Level I trauma center, 16 patients (0.13%) with tracheobronchial injuries were seen. Mechanism of injuries involved gunshot wound in eight (50%), stab wound in two (13%), blunt trauma in three (19%), hanging injury from suicide attempt in one (6%), and intubation injury in two (13%). Preoperative diagnostic bronchoscopy was performed in 11 patients. Emergent operative exploration was needed in most penetrating tracheal injuries. All patients with blunt trauma had multisystem involvement with numerous associated injuries. Management of these injuries included early primary repair of the disrupted airway in 12 (75%), stenting of the injured airway in two (13%), and negative pressure mechanical ventilation with the iron lung in one (6%). Nonoperative management was successful in three (19%). Early mortality was 13 per cent. A high index of suspicion is essential for rapid diagnosis and successful surgical intervention in patients with tracheobronchial injuries.

Adolescent↗
PubMed1996

Tricuspid valve surgery: 15-year experience.

Tricuspid valve surgery has been associated with a high operative mortality. This study reviewed 51 patients who underwent 53 tricuspid valve procedures between 1975 and 1989. Most patients (82%) had evidence of rheumatic heart disease. Twenty-six patients (51%) had 42 previous cardiac operations, most involving the mitral valve. Eighty-two percent of patients were New York Heart Association (NYHA) class III or IV preoperatively, and almost all patients had associated disease of other valves. The indication for operation was tricuspid regurgitation in 45 patients, infectious endocarditis in 4, and tricuspid stenosis in 2. The tricuspid abnormality was functional in 67% and organic in 33%. There were 32 tricuspid valve replacements, 20 annuloplasties, and 1 tricuspid valve excision. The hospital mortality rate was 11.8% (six patients). On statistical analysis, none of the perioperative variables were a significant risk factor for hospital mortality. Twenty-nine patients (51%) had postoperative complications. Postoperative functional status improved markedly with 80% in NYHA class I and 13% in class II. Long-term follow-up was attempted but was unsatisfactory in this transient, indigent population.

Adolescent↗
PubMed1994

Application of ultrafast computed tomography for diagnosis of perivalvular abscesses. Surgical implications.

The presence of a perivalvular abscess is associated with an increased risk of morbidity and mortality with valve replacement and can require extensive debridement and reconstructive procedures. An accurate noninvasive method for preoperative diagnosis may hasten operation and aid in preoperative and surgical management. Two cases are presented in which ultrafast computed tomography accurately identified perivalvular abscesses not detected on two-dimensional transthoracic echocardiography and guided operative intervention.

Abscess↗
PubMed1993

Inhibition of intra-abdominal adhesions: fibrin glue in a long term model.

Fibrin glue is being used more frequently to assist in the control of surgical bleeding in the abdominal and thoracic cavities. Prior investigation at this institution has indicated that fibrin glue actually inhibits adhesion formation in the peritoneal cavity of rats up to the first week postoperatively. To ascertain whether this protective effect is borne out in the long term, a randomized study was performed in 42 rats. As in the initial study, bilateral circular peritoneal-muscular defects were created to induce adhesion formation. The right-sided defects were closed linearly with interrupted sutures, thus closing the peritoneum, and the left-sided defects were closed with a continuous suture placed circumferentially, leaving the peritoneal defect open. The rats were randomized to two groups. In 21 animals, the abdomen was closed with no further treatment. In the other 21 animals the defects were covered with fibrin glue made from 0.2 mL of human fibrinogen (31.5 g/L) from cryoprecipitate and 0.2 mL of bovine thrombin and calcium. All rats were killed at 30 days, and adhesions were graded on a scale of 0 to 4 by a blinded observer. In the control group, 15 of 21 rats had high grade adhesions to the closed defect compared with 3 of 21 in the experimental (fibrin glue) group (P = 0.0003). For the left-sided lesions, 16 of 21 animals in the control group had high grade adhesions compared with 2 of 21 animals in the experimental group (P = 0.0004).(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗