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Biomedical subjects

M S Nussbaum

Publications and source records attributed to M S Nussbaum.

At least 19 recordsLinked to original sources
PubMed1996

Laparoscopic splenectomy by the lateral approach: a safe and effective alternative to open splenectomy for hematologic diseases.

BACKGROUND: The purpose of this study was to compare the clinical outcomes and expense of laparoscopic splenectomy by the lateral approach with open splenectomy for the treatment of hematologic diseases. METHODS: Medical records of 20 matched patients undergoing open splenectomy and lateral approach laparoscopic splenectomy were retrospectively reviewed detailing perioperative course, clinical outcome, and hospital charges. RESULTS: Patients undergoing laparoscopic splenectomy (n = 10) experienced longer anesthesia (324 versus 176 minutes; p < 0.05) and operative times (261 versus 131 minutes; p < 0.05) than those undergoing open splenectomy (n = 10). No difference was noted in both intraoperative and postoperative packed red blood cells transfused. Laparoscopic splenectomy resulted in a shorter duration of nasogastric decompression (1.2 versus 2.6 days), more rapid resumption of normal oral intake (1.9 versus 4.4 days), and earlier hospital dismissal (3.0 versus 5.8 days). Although hospital charges were not significantly higher in the laparoscopic group ($17,071.00 versus $13,196.00; p > 0.05), operative charges were always significantly higher. CONCLUSIONS: When compared with open splenectomy, lateral approach laparoscopic splenectomy allows a more rapid return of normal gastrointestinal function and shorter hospital stay. The operative expense of laparoscopic splenectomy is significantly higher; however, the overall hospital expense is not. If costs can be decreased, the lateral approach laparoscopic splenectomy will be the preferred operative approach.

Adult↗
PubMed1995

Differential expression of intestinal and splenic cytokines after parenteral nutrition.

OBJECTIVE: To determine the effect of parenteral nutrition (PN) on the expression of message for inflammatory cytokines in the spleen and different segments of the intestine. DESIGN: Randomized controlled trial. PARTICIPANTS: Eleven adult male Sprague-Dawley rats weighing 250 to 300 g. INTERVENTIONS: All rats underwent central venous cannulation and were randomized to two groups. Group 1 (n = 6) received saline solution infusion and chow ad libitum; group 2 (n = 5) received lipid-free PN with no oral feeding. After 7 days, the animals were killed and the spleens and segments of small and large intestine were removed. MAIN OUTCOME MEASURES: The expression of message for tumor necrosis factor alpha (TNF-alpha), interleukin-6 (IL-6), and IL-1 in the spleen and intestine was determined using a semiquantitative reverse transcription polymerase reaction. Splenic macrophages were isolated and cultured for 24 hours with and without lipopolysaccharide. Production of TNF-alpha and IL-6 was determined by bioassay followed by enzyme-linked immunosorbent assay. RESULTS: After 7 days of infusion, messenger RNA (mRNA) expression for TNF-alpha, IL-1, and IL-6 was increased in the jejunum (P < .05), and TNF-alpha mRNA and IL-6 mRNA expression was decreased in the spleen (P < .01) of PN-fed animals when compared with saline/chow controls. In addition, TNF-alpha mRNA expression was increased in the cecum (P < .05), IL-1 mRNA expression was increased in the ileum (P < .05), and IL-6 mRNA expression was increased in the cecum (P < .05) and Peyer's patches (P < .007) in the PN-fed animals. Production of TNF-alpha and IL-6 by splenic macrophages was decreased following PN infusion in both lipopolysaccharide-treated and untreated cultures (P < .05). CONCLUSIONS: Infusion of lipid-free PN induces a differential mRNA expression for inflammatory cytokines in the spleen and intestine with an overall up-regulation of the expression of inflammatory cytokines in the intestine and a down-regulation in the spleen. These data provide evidence that the regulatory mechanisms for cytokine production are different in the intestine and the spleen. Further study is needed to elaborate the mechanism of this differential expression following lipid-free PN infusion.

Animals↗
PubMed1994

Candida in pancreatic infection: a clinical experience.

Pancreatic infection remains a significant clinical problem, with substantial morbidity and mortality. Published case reports of Candida species identified in these infections prompted a review of 17 consecutive patients recently treated for peripancreatic infection by scheduled relaparotomy. Six patients were transferred from other hospitals, all having undergone prior operative intervention (median stay elsewhere: 58 days). The 11 other patients underwent initial operation an average of 14 days after admission. Candida species were identified in the initial operative cultures of 5 patients (29%), three of whom had undergone previous drainage at other hospitals. Two patients (11.7%) had Candida identified at subsequent operation. Six patients were treated with Amphotericin B for a median of 12 days (range 6-32) and a median dosage of 420 mg (range 225-830 mg). All patients were cleared of their Candida infection, but three subsequently died, for an overall mortality of 17.6%. Candida infected patients suffered a 42 per cent mortality. Our series supports the suspicion that Candida is much more frequent (41% of patients) than previously recognized in peripancreatic sepsis, and is commonly acquired after the initial operation. Amphotericin B therapy is effective in clearing Candida infection, but affected patients have a high associated mortality.

Acute Disease↗
PubMed1993

Comparison of distal and proximal splenorenal shunts: a ten-year experience.

BACKGROUND: This study evaluated the effectiveness of distal (DSRS) versus the central or proximal (PSRS) splenorenal shunts in the elective treatment of bleeding varices. METHODS: A series of 48 patients with portal hypertension and established variceal bleeding were randomized to undergo PSRS or DSRS. Preoperative evaluation included endoscopic examination, angiography, serum amino acid profile, liver chemistry studies, and neurologic evaluation. Any patient with significant ascites and hepatofugal flow underwent PSRS shunt procedures; the remainder were randomized prospectively. RESULTS: Between 1979 and 1989, 29 patients underwent PSRS and 19 underwent DSRS. The mean length of follow-up was 48 months. The groups were equivalent with regard to age, gender, child's class, number of preoperative bleeds, and cause of disease. No difference was found in any of the factors measured. In particular there were no differences in the operative mortality rate (17% PSRS; 11% DSRS), 5-year survival rate (52% PSRS; 52% DSRS), rebleeding (34% PSRS; 32% DSRS), shunt occlusion (7% PSRS; 11% DSRS), development of individual episodes of postoperative encephalopathy (28% PSRS; 26% DSRS), chronic postoperative encephalopathy (17% PSRS; 11% DSRS), or mean branched-chain/aromatic amino acid ratios (PSRS = 0.88 +/- 0.05; DSRS = 0.66 +/- 0.05). CONCLUSIONS: The results do not support the contention that DSRS is associated with either greater survival or less encephalopathy than PSRS.

Ascites↗
PubMed1993

The pull-through procedure: technical factors in influencing outcome, with emphasis on pouchitis.

BACKGROUND: The purpose of the study was to review those features that we believed to be critical to the successful performance of the ileal pouch-anal anastomosis, or pull-through, procedure, and specifically the complication of pouchitis. METHODS: The charts of 205 patients who successfully underwent ileal pouch-anal anastomosis procedure were reviewed. No follow-up was available in five patients; therefore, the basis of this report and its analysis was based on 200 consecutive procedures in which at least two of the three surgeons participated. Particular emphasis was placed on continence, particularly nighttime continence. The incidence of pouchitis, either a single episode or intermittent episodes, was surveyed. Particular attention was paid to the level of rectal mucosectomy and anastomosis at the top of the columns of Morgagni, thus retaining the transitional zone. RESULTS: Only 5% of patients were incontinent in the absence of pouchitis. Twenty-five patients (13%) wore a pad at night, but only nine (5%) wore a pad during the day. Of those patients with pouchitis, 6% (12) have had a single episode and 12% (23) were intermittently on medication. Therapy of pouchitis was usually carried out with ciprofloxacin 500 mg by mouth everyday or twice a day. CONCLUSIONS: Ileal pouch-anal anastomosis is an excellent procedure, provided technical details are adhered to. Satisfactory outcome with respect to nighttime continence can be achieved with rectal mucosectomy with minimal manipulation and retaining the transitional epithelium, performing the pouch anastomosis at the top of the columns of Morgagni. The incidence of pouchitis is disappointing but need not be inhibiting of either patients or carrying out this life-saving procedure in patients with ulcerative colitis and familial polyposis.

Adolescent↗
PubMed1992

Neuropeptide Y secretion from a malignant extraadrenal retroperitoneal paraganglioma.

A patient with a malignant extraadrenal retroperitoneal paraganglioma had elevated levels of immunoreactive neuropeptide Y (NPY) in the peripheral blood (5988 pg/ml; normal, 123 +/- 30 pg/ml [mean +/- standard error of the mean]). A 6-month course of chemotherapy allowed surgical removal of the previously unresectable primary tumor. Postoperatively, the plasma NPY level initially fell to 1089 pg/ml; continued chemotherapy caused an additional decrease to 440 pg/ml. Four months after surgery, the plasma NPY level increased to 940 mg/ml, coincident with hepatic metastases. This case is the first report of a NPY-secreting clinically nonfunctional malignant extraadrenal paraganglioma. Determination of circulating NPY levels may be useful in the diagnosis and follow-up of patients with neuroendocrine tumors.

Female↗
PubMed1992

Management of myasthenia gravis by extended thymectomy with anterior mediastinal dissection.

BACKGROUND: Thymectomy has continued to gain acceptance as definitive treatment for myasthenia gravis. Because of the nature of thymic embryology with scattered rests throughout the anterior mediastinum, we advocate a transsternal thymectomy with extended anterior mediastinal dissection. METHODS: A series of 48 patients with myasthenia gravis treated by thymectomy between 1979 and 1991 were reviewed. RESULTS: The mean length of duration of disease from onset to operation was 48.7 +/- 11.3 months, and the mean length of follow-up was 51.6 +/- 6.5 months. The operation was associated with a 21% morbidity rate (4% major morbidity) with no deaths. Forty-five patients (94%) have improved, requiring decreased medication. The overall drug-free remission rate was 42%. Of the 20 patients in remission, three had thymomas and four had hyperplastic glands. All of the patients who achieved drug-free remission were classified as Osserman's I or II. CONCLUSIONS: An aggressive surgical approach to myasthenia gravis can result in a high percentage of overall improvements and drug-free remissions. The best results are achieved in patients with lower-stage disease. Therefore transsternal extended thymectomy for myasthenia gravis appears to be the procedure of choice and should be advocated as soon as the diagnosis is made and the patient stabilized.

Adult↗
PubMed1991

Lipid-free total parenteral nutrition and macrophage function in rats.

Certain lipids are immunosuppressive when used for nutritional support, while other lipids and nutritional additives may enhance immunologic function. We hypothesized that total parenteral nutrition (TPN) may be immunosuppressive irrespective of lipids. Twenty-four rats underwent central vein catheterization and received either intravenous saline solution and oral chow or TPN alone. At 7 or 14 days, the animals were killed. Splenic and bone marrow macrophages were isolated and cultured in either M199 medium alone or were stimulated with Escherichia coli lipopolysaccharide. The supernatants were tested for prostaglandin E2 and C3. The splenic prostaglandin E2 levels were significantly higher in the TPN group following lipopolysaccharide stimulation at 7 days but not at 14 days. Administration of TPN to rats, even without lipids, may be immunosuppressive through the release of prostaglandin E2 from splenic macrophages following a septic challenge. This effect appears to be abolished after 14 days of TPN infusion.

Animals↗
PubMed1991

Penetrating injury of a duplicated ureter: case report.

Duplications of the genitourinary tract are uncommon and may be a source of confusion in the early diagnosis of ureteral trauma when their presence is not suspected. We present a case of delayed diagnosis of a penetrating injury to a duplicated ureter and its management.

Adult↗
PubMed1991

Pathogenesis of hepatic steatosis during total parenteral nutrition.

The hepatic toxicity of TPN that is seen clinically appears to be multifactorial in origin. Most patients develop a combination of hepatic steatosis with evidence of cholestasis and abnormalities in liver function. The model that we have studied is one of pure hepatic steatosis since, on repeated study, these rats do not develop any liver function abnormalities. It is unclear whether this is related to the fact that these are short-term experiments, that rat livers respond differently from humans, or that rats do not have gallbladders. It has not been possible to carry these experiments out beyond 3 weeks since the rats develop bacterial colonization of the central lines as well as evidence of line sepsis. thus confounding the issue of hepatic toxicity being due to the TPN or to sepsis. One hypothesis is that hepatic steatosis is an early marker of liver toxicity and that prevention or reversal of hepatic steatosis may protect the liver from further abnormality. Insulin and glucagon seem to play a critical role in the development of TPN-associated hepatic steatosis. Specifically, an elevated portal venous insulin-glucagon molar ratio appears to be the primary stimulus and any treatment that lowers this ratio should diminish hepatic steatosis. The use of glucagon as a treatment modality is new. We have found no evident side effects of low dose glucagon in rats when it is added to the TPN solution. Glutamine has received much attention recently as a nutritional pharmacological agent in ameliorating some of the intestinal complications of parenteral nutrition and is well tolerated when administered appropriately. Intravenous lipid administration is an important nonprotein calorie source, especially when a high dextrose base cannot be used, and plays a role as well in preventing the development of hepatic steatosis. Thus, it is suggested that the clinical treatment of hepatic steatosis during TPN can be safely performed using any one, or a combination, of these modalities and without having to discontinue the TPN infusions. Since we observed no deterioration of liver function in rats receiving TPN for up to 2 weeks, we cannot completely relate these findings and recommendations to the hepatic dysfunction seen clinically with the use of TPN. Additional study will be required before this can be conclusively determined.

Animals↗
PubMed1990

Addition of L-glutamine to total parenteral nutrition and its effects on portal insulin and glucagon and the development of hepatic steatosis in rats.

Infusion of total parenteral nutrition (TPN) with excess carbohydrate calories leads to hepatic steatosis in rats and is associated with an elevated portal insulin/glucagon molar ratio. Previously we have shown that adding glucagon to TPN prevents and reverses hepatic steatosis in rats, possibly by increasing hepatic lipid export. It has been reported that steatosis is eliminated in rats by the addition of L-glutamine to TPN. In this study, we examined the effect of glutamine on portal insulin and glucagon levels and the development of hepatic steatosis. Adult rats (n = 19) received internal jugular catheters: Group 1 (n = 6), saline (3 cc/hr) and chow ad libitum; Group 2 (n = 7), 25% dextrose base TPN; Group 3 (n = 6), 25% dextrose base TPN with 2% glutamine. The infusion rate of TPN was 1.2 cc/100 g body wt/hr. Daily nitrogen balance was determined and at 7 days, portal venous blood was drawn for insulin and glucagon radioimmunoassay, livers were removed for histology and lipid content determination, and the small intestines were removed for mucosal protein and DNA content determination. Panlobular vacuolization of the hepatocytes was noted on histology in Group 2 (TPN) while Group 1 (chow) and Group 3 (TPN + glutamine) showed normal liver morphology. Hepatic lipid content was significantly elevated in Group 2 (P less than 0.05). The portal insulin/glucagon molar ratio was increased because of excessive portal venous insulin in Group 2 (TPN). In contrast, portal glucagon was significantly elevated while the insulin/glucagon ratio and hepatic lipid content did not increase above control levels in the glutamine-supplemented Group 3 rats.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1990

Endogenous peptide YY is dependent on jejunal exposure to gastrointestinal contents.

Peptide YY (PYY), a homolog of pancreatic polypeptide, has been shown to be released after stimulation of colonic mucosa with bile and fatty acids. In this study proximal jejunal and biliary involvement in the regulation of circulating PYY and the distribution of PYY-containing cells in rat intestine was evaluated. Six rats underwent proximal jejunal bypass, six rats had Roux-en-Y cholangiojejunostomies, and six sham-operated rats were used as controls. Three months after surgery feeding studies using either a mixed meal or a pure fat meal were performed in unanesthetized animals and venous blood was collected for plasma PYY radioimmunoassays. After the feeding studies, fresh specimens were taken from multiple areas of the intestine for immunohistochemical analysis. The surgical procedures did not significantly affect basal PYY plasma levels. Both mixed and fat meals significantly increased circulating PYY in control animals. Exclusion of the proximal jejunum resulted in inhibition of postprandial PYY release. The PYY response in rats with Roux-en-Y cholangiojejunostomies was blunted after a mixed meal and delayed after a fat meal. The incidence of PYY-containing cells increased along the functional gut in all rats. The bypassed jejunum in both experimental groups of animals contained fewer PYY-staining cells than sham-operated rats. Our results suggest that the exclusion of a segment of proximal jejunum from gastrointestinal continuity in rats leads to an inhibition of postprandial PYY release. PYY release may be controlled in part by stimulatory neural and/or endocrine signals originating from the proximal jejunum.

Animals↗
PubMed1990

The postprandial circulatory and ileal intraluminal release of neuropeptide Y in conscious dogs.

Neuropeptide Y (NPY), a 36-amino-acid peptide, was measured in the peripheral circulation and ileal lumen of conscious dogs using a sensitive radioimmunoassay. Fasting NPY concentrations averaged 448 +/- 15 pg/ml in the peripheral blood and 364 +/- 23 pg/ml in the ileal effluent. Following a mixed meal, circulating NPY levels rose to 499 +/- 37 pg/ml (P less than 0.05), whereas recoverable quantities of ileal intraluminal NPY fell to 257 +/- 19 pg/ml (P less than 0.05). Neither fat nor glucose meals significantly changed circulating or ileal intraluminal NPY recovery. These results demonstrate release of NPY into the blood and ileal lumen for the first time and support NPY as a candidate gut hormone.

Animals↗
PubMed1990

Proximal jejunal and biliary effects on the enteroinsular axis.

The objective of this study was to investigate the roles of the proximal jejunum and endogenous bile within the proximal jejunum on the enteroinsular axis. Twelve Sprague-Dawley rats underwent proximal jejunal bypass, 11 rats underwent Roux-en-Y cholangiojejunostomies, and 12 rats underwent sham operations. After 3 months, oral glucose tolerance tests were performed in unanesthetized animals and venous blood was collected for plasma glucose and insulin measurements. The surgical procedures did not significantly affect the basal glucose and insulin levels compared with sham-operated animals. The insulin response in rats with excluded proximal jejunal segments was inhibited. The decreased insulinogenic index seen in these animals indicates a possible diabetogenic effect of this procedure. An oral glucose challenge resulted in significant hyperinsulinemia, with an increased insulinogenic index in animals that had undergone Roux-en-Y cholangiojejunostomies. These findings suggest that bile is a potential mediator in the proximal jejunal involvement in the enteroinsular axis.

Anastomosis, Roux-en-Y↗
PubMed1989

Synthesis and biological properties of 4-norleucine-neuropeptide Y; secondary structure of neuropeptide Y.

Neuropeptide Y (NPY) is a 36 amino acid peptide amide isolated from porcine brain. The NPY analog, 4-norleucine-NPY was synthesized by a solid-phase method and purified to homogeneity in 20% yield by reverse-phase chromatography. Investigation of the biological properties indicated that the analog is an agonist of NPY. Secondary structural analyses revealed that NPY and the analog exhibited predominantly alpha-helical and beta-sheet structures, respectively; however, experiments in trifluoroethanol indicated that the analog has the potential of assuming an alpha-helical structure. Based on circular dichroism (CD), Raman spectroscopy and Chou-Fasman analyses, a model has been proposed for the secondary structure of NPY.

Amino Acid Sequence↗
PubMed1989

Transduodenal sphincteroplasty and transampullary septotomy for primary sphincter of Oddi dysfunction.

We examined 29 patients without stone disease or pancreatic ductal ectasia who underwent transduodenal sphincteroplasty and transampullary septotomy for symptoms of biliary colic or pancreatitis. The combination of biliary symptoms and a fibrotic ampulla of Vater portends a favorable surgical outcome in virtually all such patients. Patients with pancreatitis did worse overall, perhaps due to the existence of unappreciated subclinical parenchymal disease not related to sphincter dysfunction. Although endoscopic retrograde cholangiography was sensitive in demonstrating abnormalities of the pancreaticobiliary system, its specificity as a predictor of good results was poor. It seems prudent to temper one's enthusiasm for sphincteroplasty in the patient with pancreatitis, whereas patients with biliary symptoms, the postcholecystectomy syndrome, or both will usually benefit significantly from this procedure.

Adult↗