Biomedical subjects
L Gottesman
Publications and source records attributed to L Gottesman.
Sustiva may cause false positive on marijuana test.
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Anorectal pathology in AIDS.
Anorectal complaints are common in persons with AIDS and are being seen increasingly because advances in therapy for HIV, such as the new antiretroviral protease inhibitors, have resulted in longer life expectancy for those with HIV infection. In the past, many patients with HIV infection were seen at referral centers; now, however, primary care physicians as well as gastroenterologists and surgeons in the community are managing and caring for these patients. For this reason, it is important for clinicians to recognize the spectrum of anorectal disease in patients with AIDS, as well as its appropriate evaluation and management.
Surgical debridement and intralesional steroid injection in the treatment of idiopathic AIDS-related anal ulcerations.
BACKGROUND: The treatment of idiopathic anal ulcerations in AIDS patients is still evolving. These patients suffer with severe incapacitating anal pain. PATIENTS AND METHODS: Relief of pain was achieved with the use of intralesional steroid injections. Twenty-one patients from 1990 to 1993 presented with severe anal pain of 4.5 months average durations (range 3 weeks to 2 years). The average CD4 count was 52.1 (range 0 to 150). Fourteen (67%) patients had a solitary ulcer, while 7 (33%) had complex ulcerations. RESULTS: All patients were treated by debridement of the ulcer, biopsy, and intralesional injection of steroids. Microscopic evaluation revealed nonspecific inflammatory changes, without histopathologic evidence of viral infection or malignancy. Viral tissue cultures were negative. Fifty-seven percent of patients required only one injection to achieve dramatic relief of pain. Forty-three percent necessitated additional injections at 2-week intervals. The average patient was injected 1.9 times (range 1 to 7), with 20 of 21 patients (95%) reporting good to excellent pain relief. CONCLUSION: AIDS anal ulcerations should be treated aggressively with surgical debridement, biopsy and intralesional steroids. The efficacy of this therapy suggests that symptoms are partially due to inflammatory mediators.
Anorectal diseases.
A proper understanding of the disease of the anorectum in the HIV-positive population mandates a familiarity with the ongoing advances in antiviral chemotherapy, mechanisms of oncogenesis, and effect of HIV infection on wound dynamics. As the prognosis for HIV-infected patients improves, therapies must reflect the expected increased survival of these patients.
Progressive mandibular retrusion--idiopathic condylar resorption. Part I.
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Progressive mandibular retrusion-idiopathic condylar resorption. Part II.
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Sexually transmitted diseases and anal manifestations of AIDS.
During the past 20 years, there has been an increased use of the anorectum for erotic pleasure. Consequently, this has led to an overwhelming rise in sexually transmitted diseases (STDs) of the anus and rectum. It is important that surgeons involved with the care of colon and rectal disorders be familiar with each of these diseases. The recent AIDS epidemic has been a challenge to the medical community. Equally as challenging is the management of common anorectal disorders in the AIDS patient. AIDS not only influences the manner in which STDs present but is associated with its own spectrum of anorectal disorders. Discussion and management of STDs and anorectal disorders of AIDS patients are presented.
Ulcerative disease of the anorectum in the HIV+ patient.
Ulcerative processes are the most disabling of anal diseases in HIV+ patients. The spectrum ranges from "benign" fissures to invasive ulcerative processes. It is important to recognize their salient features in order to effectuate proper management. Since 1989, 74 HIV+ patients with ulcerative anal disease were evaluated. Of 33 patients with benign fissures, 13 had sphincterotomy, with symptomatic relief in 12 and healing in 11. Ten had improvement with standard conservative treatment, and 10 did not return for re-evaluation. Of 41 patients with "idiopathic" anal ulcers, 34 underwent operative evaluation, biopsy, viral culture, and debridement. Thirty had significant pain relief, and 17 showed variable evidence of healing. Four patients with intractable pain had injection of Depo-Medrol (The Upjohn Co., Kalamazoo, MI) into the bed of the ulcer with significant pain relief. One patient was diverted. We propose that anal ulcerative disease be classified as benign lesions and therefore treated as if the patient were HIV negative. In those patients with HIV-associated anal ulcers, evaluation under anesthesia, biopsy, culture, and debridement should be performed and therapy directed against any neoplastic or viral agents found. Those patients with no identifiable agents may be helped with aggressive debridement or intralesional steroid therapy. This approach allows safe and effective treatment in most patients.
Anorectal manometry--a call for reason.
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Anorectal surgery in the HIV+ patient: update.
Anorectal surgery in HIV+ patients historically has been viewed with a great deal of nihilism. Advances in medical therapy and better understanding of unique pathophysiologic processes have afforded the colorectal surgeon the ability to treat better and sometimes cure the anorectal complications of AIDS. We present a series of 75 consecutive surgical procedures (1-year accrual) on HIV+ (40) and CDC AIDS (22) patients. Surgical procedures, perioperative T cell counts, and outcome will be presented; 53 percent of procedures resulted in complete healing of anal wounds; 30 percent resulted in partial healing with symptomatic relief; 17 percent resulted in symptomatic relief or tissue diagnosis without appreciable wound healing. The healing rate was significantly higher in the HIV+ group (69 percent) compared to the AIDS group (26 percent). Perioperative T cell counts did not have predictive value on outcome. No patients suffered significant unexpected morbidity, mortality, or incontinence. Pathophysiologic mechanisms of several disease processes unique to HIV+ patients and data from our ongoing investigation using RNA hybridization are presented.
Surgical implications of sclerosing mediastinitis. A report of six cases and review of the literature.
Sclerosing mediastinitis is an uncommon disease associated with a multiplicity of clinical syndromes. The cause of this disorder is probably an abnormal fibroproliferative response to an inflammatory stimulus, most commonly a granulomatous infection secondary to Histoplasma capsulatum. The pathophysiology of this disease is predicated on the encasement of mediastinal vital organ structures within a dense fibrotic mass. This mass appears to emanate from an invasive chronic inflammatory process causing erosion as well as external compression of these structures. The following case reports illustrate the diversity of this disease entity, representing a patient population from the Ohio River Valley, endemic for histoplasmosis. The purpose of this report is to elucidate the various clinical manifestations of sclerosing mediastinitis and to correlate the pathologic process with a rational approach to treatment.
The use of anxiolytic and parasympathomimetic agents in the treatment of postoperative urinary retention following anorectal surgery. A prospective, randomized, double-blind study.
Approximately 30 percent of patients undergoing anorectal surgery will develop acute urinary retention. The cause of this complication is poorly understood. Anxiety, anal distention, bladder distention as a result of vigorous hydration during surgery, and reflex inhibition of the urinary bladder detrusor muscle secondary to pain have been postulated as contributing factors. A four-armed prospective, double-blind, randomized trial was carried out to determine whether an anxiolytic agent (midazolam, 5 mg intramuscularly) and/or a parasympathomimetic agent (bethanechol, 10 mg subcutaneously) reduce the incidence of postoperative urinary retention following anorectal surgery. One hundred thirty-two patients (ages, 18 to 50 years), in acute urinary retention 6 to 12 hours following anorectal surgery, were enrolled. Sixty-nine percent of patients responded to bethanechol. Side effects were minimal. Midazolam alone had no effect on retention. Bethanechol and midazolam in combination resulted in less retention than midazolam and a placebo (P less than 0.05). Bethanechol alone was better than a placebo (P less than 0.002). Mean intraoperative intravenous fluid volume for the entire study group was 900 cc. Initial postoperative urinary volumes of patients who failed the treatment protocol were significantly higher than in those responding to bethanechol (mean of 527 cc vs. 241 cc, P less than 0.001). The use of an anxiolytic agent was not effective in the treatment of postoperative urinary retention. Bladder distention may increase the incidence of urinary retention. Bethanechol, in a dose of 10 mg subcutaneously, significantly lowered the incidence of postoperative urinary catheterization and should be considered as initial treatment of postoperative urinary retention following anorectal surgery.
Surgical implications of hepatic venocclusive disease following bone marrow transplantation.
Hepatic venocclusive disease occurs with a spectrum of severity in an estimated 21% of bone marrow transplant patients. Clinical features include severe right upper quadrant pain, ascites, weight gain and initially minimal derangement of liver function. In contrast to hepatic graft versus host disease, venocclusive disease usually occurs within the first three weeks of engraftment and in autologous grafts. Urgent surgical consultation is requested when these features are prominent enough to mimic common acute processes requiring laparotomy. This condition must be included in the differential diagnosis in order to avoid an unnecessary laparotomy in this select group of patients who are usually severely thrombocytopenic and leukopenic. Clinical diagnosis alone is very reliable.
A suction retriever to expedite recovery of colonic polyps.
An inexpensive, simple device which may be used to expedite colonoscopic retrieval of small polyps is described.
A modified technique for use of the intraluminal valve cutter in in situ saphenous vein grafts.
A modified technique for the use of the disposable intraluminal valve cutter in the performance of in situ saphenous vein arterial bypass grafts is presented. The technique results in a more physiologic dilatation of the vein and can be expeditiously performed with minimal intimal trauma to the vein graft. Long incisions necessary to expose the entire vein with the use of other techniques can be avoided, thereby decreasing the potential for wound healing problems commonly associated with vascular reconstruction in ischemic limbs.
Adrenocortical carcinoma.
From 1962 to 1985, 47 patients with carcinoma of the adrenal cortex were treated at Memorial Sloan-Kettering Cancer Institute. There were 21 men and 26 women. Seventy-two percent of the tumors were functional and 28% were nonfunctional. Despite the advent of ultrasonography and computerized tomography, these tumors were infrequently diagnosed until they infiltrated adjacent organs or metastasized to distant sites. Only 30% of patients had tumors confined to the adrenal gland; their mean duration of survival was 5.0 years. Seventy percent of the patients had invasion of the kidney, lymph nodes, liver, diaphragm, and/or pancreas at the initial operation; their mean duration of survival was 2.3 years. Eight patients had reoperation for abdominal recurrences; three of the patients with abdominal recurrence and one additional patient underwent thoracotomy to resect localized lung metastases. The mean duration of survival of these nine patients was 3.5 years, not significantly different from the mean overall survival of 3.1 years. The duration of survival of all patients was not significantly correlated with age, sex, adjuvant therapy, or production of hormones by the tumor. Only two patients were deemed unresectable. Wide en-bloc dissection of the primary tumor, resection of contiguous organs for local invasion, and excision of resectable metastases in the liver and lungs remain the basis of therapy.
Concomitant cardiac and vascular disease: "through the looking glass".
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