Biomedical subjects
Publications and source records attributed to M D Kerstein.
Osteomyelitis in the digit of the diabetic patient is best managed by antibiotics and amputation. Antibiotics alone are not effective or cost-effective as demonstrated in a retrospective study of 22 such patients diagnosed clinically and confirmed roentgenographically. Definitive operation allows the patient to return to work within two weeks of amputation.
Spontaneous rupture of the common bile duct is rare, but may result from increased intraductal pressure with associated calculous erosion and necrosis of the bile duct wall secondary to thrombosis. Two cases are reported; one clearly related to calculous erosion and the other unexplained. Survival depends on early diagnosis. Aggressive supportive therapy, including Swan-Ganz catheter, intensive care unit monitoring, and appropriate antibiotics, are mandatory. Only with early operation to alleviate sepsis and decompression of the biliary system can better survival be expected.
A descending thoracic aortobifemoral artery bypass graft is proposed as an alternative procedure for revascularization of the lower extremities when an intra-abdominal approach is not feasible or is ill-advised. Three patients underwent a thoracobifemoral graft because of severe cardiopulmonary disease combined with multiple prior abdominal surgeries, complications of radiation, and sepsis. Patency of the aortobifemoral grafts was documented by palpable pulses and increased ankle: brachial ratios improving from 0.3 to 0.6, resulting in the relief of rest pain and obviating a limb-threatening situation.
Prostacyclin (PGI2), a major product of prostaglandin endoperoxide (PGH2) metabolism in blood vessels, has potent vasodilator and platelet activity. Therefore, modulation of PGI2 synthetase activity is of prime physiological importance in the regulation of blood vessel function. In this study, PGI2 synthetase activity of bovine coronary arterial microsomes could be altered over a 2-3 fold range by GSH or dithiothreitol in a concentration-dependent manner and over a microsomal protein range of 10-200 micrograms. Modulation of coronary artery PGI2 synthetase activity was also seen in vessels from sheep, dog and man. These data suggest that coronary artery PGI2 synthetase activity is unusually sensitive to the redox state or sulfhydryl oxidation of the enzyme. The present data also unmask an active PGE2 isomerase, previously reported to be absent in bovine coronary arterial microsomes.
Three patients awoke in the operating theater with a neurologic deficit after carotid endarterectomy with shunt under general anesthesia with either upper or lower extremity paralysis or both and evidence of a patent carotid artery confirmed by Doppler ultrasonography, B-mode real-time ultrasonography, or surgery. After confirmation of patency of the carotid artery, patients were anesthetized with thiopental (3 to 4 mg/kg) for 48 hours, with respiratory maintenance by ventilator. The therapeutic effect of barbiturates was monitored by prevention of spontaneous respiration without hypotension. All patients awoke approximately 36 to 48 hours after discontinuing the thiopental without the previously noted postoperative neurologic deficit or any adverse neurologic sequelae. At last follow-up more than 1 year postoperatively they were asymptomatic. Results of this study indicate that patients who undergo carotid endarterectomy and awake with a neurologic deficit and a patent operated vessel should be considered for barbiturate induced coma as a therapeutic modality.
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The purpose of this study was to ascertain if alterations were present in the prostacyclin synthetase (PGI2ase) activity in diabetic human venous tissue. Saphenous veins were obtained from a group of 12 patients with (HSV-D) or without (HSV-ND) diabetes who were undergoing coronary artery bypass surgery. 14C-Labeled prostaglandin endoperoxide (PGH2) was incubated for 2 minutes with venous microsomal protein. The products were separated by thin-layer chromatography and quantified by radiochromatographic scan. PGI2ase activity was determined by the formation of 6-keto-PGF1 alpha, the stable breakdown product of prostacyclin (PGI2). Results of this study indicate the following: both HSV-ND and HSV-D specimens have active PGI2ase and are capable of forming PGI2; there is no difference between PGI2ase activity in HSV-D and HSV-ND specimens; and in diabetes mellitus, any defects in PGI2 production similar to those associated with diabetes in other investigations must reside higher in the arachidonic acid cascade.
The value of contrast dye to the planning and evaluation of cardiovascular disease cannot be overestimated. However, adverse renal sequellae may cause the surgeon to hesitate in obtaining an arteriogram, especially in patients with compromised renal function. The purpose of this study was to evaluate the incidence of renal dysfunction in patients requiring angiography. Standard contrast angiography for cerebral or peripheral vascular disease was administered to 150 consecutive patients (89 men and 61 women), with an average age of 63.3 years (range 49 to 89 years). All patients received 100 to 150 ml of dye, with a concentration of approximately 50% iodine. Patients were hydrated with 0.5 N saline/5% dextrose, intravenously, for 8 hours before the procedure (1 to 3 ml/kg/hr). In 31 patients (11 women and 20 men) the serum BUN and/or creatinine levels were elevated (mean BUN value of 48 +/- 9 mg/dl; mean creatinine level of 2.8 +/- 0.6 mg/dl). The patients with abnormal renal function received an additional 300 to 500 ml of intravenous fluid, plus 20 to 40 mg intravenous furosemide, 1 hour before roentgenography to establish a diuresis. All patients were hydrated for 6 hours after angiography with the same solution at the same rate (1 to 3 ml/kg/hr). There were no episodes of compromised renal or cardiopulmonary dysfunction because of contrast angiography. In no patient did the BUN or creatinine level rise, nor was there evidence of acute tubular necrosis, as documented by oliguria and abnormal cells in the urine. Angiography is a safe procedure, even with patients who may have compromised renal function, if appropriate prehydration/posthydration and diuretic measures are undertaken.
Injection of saline as well as trypsin into the pancreatic duct of the rat may cause changes in the histology and surface tension of the lung, as well as histological and biochemical evidence of pancreatitis. Nontoxic chemicals also may be the source of pancreatitis and subsequent pulmonary dysfunction. In the research setting, pressure injection into the pancreatic duct may produce systemic effects.
Thrombolytic therapy for thrombosed arterial bypass grafts has received little attention in the medical literature. We carried out successful thrombolysis in occluded polytef arterial bypass grafts. A femoral-femoral artery crossover graft had been occluded 13 days, and a femoral-popliteal artery bypass graft had been occluded three months. No surgical intervention was required. Follow-up showed continued patency nine months following thrombolytic therapy. Long-term oral anticoagulation seems indicated. Also, data suggest thrombus in polytef grafts may be particularly susceptible to lyses. Thrombolytic therapy should play an increasing role in vascular surgery.
The described methodology allows for analysis of metabolism of the prostaglandin PGH2 in subcellular fractions (microsomes) obtained from human saphenous veins. Prostacyclin (PGI2) synthetase as identified by its stable breakdown product 6-keto-PGF1a is present in human saphenous vein. Thromboxane A2 is absent. The enzymatic formation of PGE2 was demonstrated by the addition of glutathione (GSH) indicating the presence of an active PGE2 isomerase. The data suggest that the enzymatic endoperoxide-metabolizing pathways in human saphenous vein microsomes are prostacyclin synthetase and prostaglandin E isomerase. It is suggested that the ability of the vein graft to produce prostacyclin and PGE2 may contribute to short- and long-term graft patency.
A hyperemic stress test was used to determine vasculogenic impotence in 100 men (50 potent, 50 impotent). Normal potent males had a resting penile:brachial index ratio of 0.75 and uniformly demonstrated a hyperemic response to the cuff occlusion stress test with a mean of 20 per cent increase in penile pressure. Penile blood pressure did not increase in impotent men, and often it decreased in response to the stress test.
A patient with antithrombin III (ATT) deficiency after arterial embolism manifested an increasing requirement for heparin to adjust a partial thromboplastin time. This was corrected by dramatically increasing doses of heparin and by conversion to warfarin sodium. "Heparin-resistance" should direct the physician to examine antithrombin III levels, and ATT levels should be determined as a baseline before anticoagulation therapy.
Primary aortoduodenal fistula presenting as a diverticulum of the distal duodenum with GI bleeding may be a difficult diagnostic entity with nondiagnostic endoscopy and angiography. We have described a patient in whom diagnosis was established at laparotomy, with treatment including debridement, repair, and extra-anatomic bypass.
In a ten-year retrospective study of 233 patients who sustained a vascular injury to an extremity, eight (3.4%) extremities were amputated. Factors that affect the incidence of amputation after peripheral vascular trauma include early operation, fasciotomy, preoperative antibiotics, appropriate vascular reconstruction with adequate tissue coverage, use of arteriography during and after reconstruction, and early reoperation for postoperative complications. Some patients benefit psychologically and physically from early definitive amputation.
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The influence of hemorrhagic pancreatitis on pulmonary ultrastructure was investigated in 21 mongrel dogs. The animals were intubated but not ventilated. Pancreatitis was induced with an autologous bile-trypsin mixture. The degree of pancreatitis was confirmed clinically, chemically, and histologically. The animals were sacrificed at four time frames: zero time, one, three, and five hours after the onset of pancreatitis. There was progression, with time, of distorted pulmonary microarchitecture. Interstitial edema, including dispersion of endoplasmic reticulum, disruption of lamellar bodies, and blunting of the pseudopods in the type II pneumocyte, were noted. There was a decrease in osmiophilic content as well as loss of organization of the lamellar bodies. Since surfactant is produced and stored by the lamellar bodies in the type II pneumocyte, these data add support to the concept of pulmonary congestive atelectasis secondary to pancreatitis--related to absence of or diminished surfactant.