Effects of morbid obesity and diabetes mellitus on risk of coronary artery bypass grafting.
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Coronary Artery Bypass↗
Biomedical subjects
R L Nelson
Publications and source records attributed to R L Nelson.
The effect of vagotomy and pyloroplasty on colorectal tumor induction in the rat.
Epidemiologic studies have suggested that vagotomy increases subsequent colorectal cancer risk. This hypothesis was investigated in the rat 1,2 dimethylhydrazine (DMH) colorectal carcinogenesis model. Eighty-five rats were divided into four groups having either truncal vagotomy and Heineke-Mickulicz pyloroplasty, pyloroplasty alone, laparotomy alone, and anesthesia alone. After recovery from the procedures, colon tumors were induced with five injections of DMH. Results of carcinogenesis show a trend towards increased incidence and yield of colorectal and duodenal tumors after vagotomy, though this was not statistically significant, perhaps because the high postoperative mortality from vagotomy diminished the power of the study.
1,2-Dimethylhydrazine↗
Acute ischemic proctitis. Report of six cases.
Acute ischemic proctitis is a rare clinical entity caused by vascular insufficiency of the major or collateral circulation to the rectum. It usually occurs following aortic or aortoiliac operations. Six patients with acute ischemic proctitis are presented; four cases occurred after direct arterial interruption, one after accidental embolization of the blood supply to the rectum, and one from tumor edema. Bloody diarrhea was the most common symptom. Loss of anal sphincter tone was also an early sign in three patients. The diagnosis of ischemia was made by mucosal appearance on proctosigmoidoscopy and is differentiated from infectious proctitis by stool culture. Superficial mucosal ischemia was treated without surgery, but deeper levels of necrosis required laparotomy and Hartmann's resection. Rectal excision was not necessary. Four patients survived the ischemic event.
Acute Disease↗
Multifactorial index of preoperative risk factors in colon resections.
Our aim was to analyze the predictive value of a variety of preoperative risk factors on operative outcomes. We reviewed all colorectal resections performed in a single hospital between January 1985 and May 1990. Nine hundred seventy-two resections were performed on 825 patients. We studied 17 preoperative risk factors generated from various medical risk categories. Using the multivariate discriminant function analysis, we calculated that 11 of the 17 risks were of significance in predicting outcomes (all with P less than or equal to 0.031). These factors included emergent operation, age greater than or equal to 75 years, congestive heart failure (CHF), prior abdominal or pelvic radiation therapy, corticosteroid use, albumin less than 2.7 g/dl, chronic obstructive pulmonary disease (COPD), previous myocardial infarction (MI), diabetes, cirrhosis, and renal insufficiency. The classification function generated by the discriminant analysis was used to categorize patients into one of four risk groups depending on their "risk score." The index used to develop each patient's "risk score" ranged from six points for an emergency operation to one point for diabetes. The mortality rates for the various risk groups were as follows: Group 1, zero to four points, 1 percent; Group 2, five to eight points, 10 percent; Group 3, 9 to 13 points, 19 percent; Group 4, greater than 13 points, 33 percent. In contrast to previous reports, we showed that age greater than or equal to 75 years alone is not a major preoperative risk factor but, rather, acts as a modifier for the other predictors of postoperative complications. We then assessed clinical questions concerning specific preoperative risks, such as steroid use, obesity, inflammatory bowel disease, COPD, and prior laparotomy, and their associated specific postoperative complications and have developed prevention strategies based on these findings. Through the use of the risk index, we also were able to assess an individual patient's operative risk more accurately.
Adolescent↗
Dietary iron and colorectal cancer risk.
Intestinal exposure to ingested iron may be a principal determinant of human colorectal cancer risk. Evidence exists associating iron with both the initiating and promoting phases of carcinogenesis as well as somatic defenses against early cancers through hypoferremia (progression or proliferation). Iron intake and the ingestion of associated foods that greatly affect iron bioavailability and absorption (phytate, tannin, ascorbate, and alcohol) vary widely between high-risk and low-risk countries as well as within the United States. These variances in intake may explain not only the gradients in risk between populations, but the crossover in risk between sexes related to age within the United States. Human and rodent studies support the above hypothesis and are reviewed herein, however they are few in number and in many cases lack key data.
Animals↗
Bilateral gluteus maximus transposition for anal incontinence.
Seven patients (five men and two women) ranging in age from 26 to 65 years (means = 44) underwent bilateral gluteus maximus transposition for complete anal incontinence. The indications for operation were sphincter destruction secondary to multiple fistulotomies (n = 4), bilateral pudendal nerve damage (n = 2), and high imperforate anus (n = 1). The procedure is performed without the use of a diverting colostomy. The inferior portion of the origin of each gluteus maximus is detached from the sacrum and coccyx, bifurcated, and tunneled subcutaneously to encircle the anus. The ends are then sutured together to form two opposing slings of voluntary muscle. Postoperatively, six patients regained continence to solid stool, two to liquid stool as well, and only one patient in this group was able to control flatus. Although resting pressures remained unchanged, voluntary squeeze pressures were restored by this operation. In addition, rectal sensation was markedly improved, which helps make this a worthwhile procedure for properly selected patients.
Adult↗
Rodless end-loop stomas. Seven-year experience.
The rodless, end-loop stoma was developed as an alternative to the more traditional loop stoma to minimize patient management problems. A retrospective review of our seven-year experience in 229 patients with end-loop colostomies (135), ileocolostomies (70), and ileostomies (24) is presented. A total of 30 stoma-related complications were observed in 27 stomas, for an overall complication rate of 13.1 percent. The most common complications were skin excoriation secondary to leakage (3.5 percent), retraction (3.5 percent), partial necrosis (2.6 percent), and peristomal sepsis (1.8 percent). Mucocutaneous separation, prolapse, and stenosis were each seen in less than one percent of patients. No cases of stomal herniation, obstruction, or hemorrhage were encountered. Twelve deaths occurred, but none was attributed to stoma-related complications. The rodless, end-loop stoma is a simple and safe procedure with many advantages and a low incidence of complications.
Adolescent↗
Inverted U-pouch construction for restoration of function in patients with failed straight ileoanal pull-throughs.
Patients who have undergone straight ileoanal pull-through operations without a reservoir in adult life frequently have unsatisfactory results. Operative correction of this problem has been difficult. We propose a new operation that preserves the ileoanal anastomosis, constructs a reservoir, and has resulted in good restoration of bowel function in three patients. The operative procedure consists of division of the ileum 30 cm above the dentate line. The distal ileum is then folded over itself so that the point of division reaches into the pelvis, between the rectal muscular cuff and pulled-through ileum, to a point just proximal to the dentate line. The two limbs of ileum are connected using a stapler, completing the reservoir construction. The proximal divided ileum is anastomosed, end-to-side, to the pouch. A protective ileostomy that can be closed in three months is constructed.
Adult↗
Epicardial lead failure due to dense scarring: a solution.
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Adult↗
Thumb duplication and contralateral thumb hypoplasia in infant of mother with diabetes.
Uncontrolled maternal diabetes frequently results in congenital anomalies. This report describes an infant of a mother with diabetes born with thumb hypoplasia and contralateral thumb duplication without other associated anomalies. Maternal diabetes should be part of the etiologic differential diagnosis of thumb anomalies. The concomitant occurrence of thumb duplication and hypoplasia, apparently as a result of the same systemic insult, suggests a close relationship between hypoplasia and duplication.
Adult↗
Diagnosis of fetal anterior abdominal wall defects by use of ultrasonography.
Omphalocele and gastroschisis involve protrusion of intestine through a defect in the abdominal wall. It is important to differentiate between the two because of a difference in the incidence of associated anomalies and of chromosomal abnormalities. The distinguishing characteristics are the location of umbilical cord insertion, the echogenicity of the contents of the protruding mass and, usually, the presence or absence of a sac surrounding the mass. Early detection is critical so that decisions can be made about the possibility of surgical correction and the outcome of the pregnancy. We describe an omphalocele detected by ultrasonography in the 20th week of gestation during a routine prenatal check-up.
Abdominal Muscles↗
Preparation for human study of pesticide applicators: sister chromatid exchanges and chromosome aberrations in cultured human lymphocytes exposed to selected fumigants.
In preparation for a human study of worker exposure to grain fumigants and pesticides, we decided to screen commonly used fumigants for genotoxic effects in vitro. This research strategy was employed to test the possibility that structurally simple chemicals might have similar genotoxic properties in vivo and in vitro. As a first step, we designed our in vitro protocol to mimic to the extent possible, a single in vivo exposure of lymphocytes to fumigants. Go lymphocytes were treated with different doses of carbon tetrachloride, carbon disulfide, methyl bromide, chloropicrin, and melathion with and without addition of rat liver homogenate for 1/2 hour, washed free of toxicant, and stimulated with PHA. After culture, the prepared slides were studied for chromosome aberrations and SCEs. Malathion, methyl bromide, and chloropicrin significantly induced SCEs without S-9. Carbon disulfide alone required S-9 for significant SCE induction. Chromosome aberrations were significantly increased by malathion and methyl bromide. Carbon tetrachloride failed to induce SCEs or chromosome aberrations with or without S-9. We concluded from these preliminary studies and other comparable work that the fumigants studied here may be less likely to express genotoxicity in terms of SCEs or chromosome aberrations than ethylene oxide or phosphine given a single short-term in vivo exposure. The final design of our human study was altered to focus on seasonal worker exposure rather than on a single exposure event.
Adult↗
Phase I trial of intravenous vinzolidine (LY 104208) given on a biweekly dosing schedule.
Vinzolidine (VZL) is a semisynthetic vinca alkaloid with broad antitumor activity in animal models of malignancy but had unpredictable toxic effects when given orally to humans. To minimize the toxic effects due to potential erratic gastrointestinal absorption, this drug was restudied in man as an intravenous preparation given as a rapid injection every two weeks. The maximum tolerated dose (MTD) on this schedule was 9.0 mg/m2 with unpredictable leukopenia (usually occurring 5-14 days post treatment but appearing erratically), constipation, paralytic ileus, and inappropriate ADH syndrome as major toxicities. Nonhematologic toxicities were dose-limiting. Repetitive dosing at two week intervals was associated with leukopenia at D 14-15 in some but not all patients treated above 5.0 mg/m2 precluding further treatment on schedule. In contrast, the oral MTD of this agent in our prior studies was 45 mg/m2 with no evidence of delayed leukopenia. Intrapatient variability of toxicity was small; interpatient variability of toxicity was substantial and did not correlate with prior therapy. Because of the presence of delayed hematologic toxicity on repetitive dosing schedules, intravenous VZL should be given on a dosing schedule longer than 14 days. No antitumor activity was seen in this study.
Adult↗
Indium 111-labeled granulocyte scan in the diagnosis and management of acute inflammatory bowel disease.
The indium 111 granulocyte scan was used to evaluate 39 individuals known to have or suspected of having inflammatory bowel disease. Twenty-three of these individuals had positive scans and 16 had negative scans. Eighty-seven confirmatory studies, which consisted of barium radiography, endoscopy, operative findings, and histopathology, were performed in 37 of these individuals. The remaining two negative scans corroborated only by clinical course, CBC, and erythrocyte sedimentation rate. In addition, 10 follow-up scans were performed in six of the 39 patients to monitor therapy or investigate a change in symptoms. As an anatomic indicator of acute granulocytic infiltration of the intestinal lamina propria and crypts, the authors found that this scan had a 97 percent rate of sensitivity and 100 percent specificity. Specific indications for the use of the indium 111-labeled granulocyte scan are described. For the authors, in general, this test has become a vital adjunct to endoscopy and radiography in the diagnosis and management of patients with symptoms of inflammatory bowel disease.
Acute Disease↗
Island flap anoplasty for the treatment of anal stricture and mucosal ectropion.
Twenty patients with benign anal strictures and five patients with mucosal ectropion were treated with island flap anoplasty. U-shaped or diamond-shaped islands of perianal skin were created, without undermining, and advanced into the anal canal to remedy the stricture or site of ectropion. Over a postoperative follow-up period that averaged 19 months, 16 patients judged their clinical results as excellent and 7 as good. There were two failures. In all patients the skin flaps survived, even in the elderly patients. Island flap anoplasty is a simple, effective alternative to other forms of anoplasty such as Y-V advancement or S-plasty.
Adult↗
A comparison of simultaneous longitudinal and radial recordings of anal canal pressures.
A new anal manometry perfusion catheter is described that offers the capability of simultaneous linear longitudinal pressure measurements. The authors studied 20 control subjects with this catheter and with a four-quadrant perfusion catheter. An asymmetry of basal, squeeze, and relaxation pressures was found. The highest basal pressures were in the middle of the anal canal, regardless of quadrant orientation. Using the radial perfusion catheter, the squeeze pressure profile was consistent with a double-loop external sphincter mechanism. Using the linear perfusion catheter, the internal sphincter relaxation pressures show a greater negative deflection at the proximal portions of the sphincter, which was not achieved at points distally in the same quadrant. This implies that during reflex relaxation, pressure is maintained in the distal anal canal so that patients remain continent during sensory sampling of rectal contents. The authors believe this is the first time this same-quadrant longitudinal asymmetry of relaxation has been shown with a single rectal balloon stimulus.
Adult↗
Clinical pharmacokinetics of intravenously injected tritiated vinzolidine.
Vinzolidine (VZL), a novel, semi-synthetic vinca alkaloid showing evidence of oncolytic activity in phase I/II clinical trials, was studied in six patients for its pharmacokinetic and metabolic behavior. Following i.v. administration of [3H]-VZL at doses of 5, 6.7, and 9 mg/m2, blood and urine samples were collected and analyzed by sample oxidation and HPLC. Following a single i.v. dose, decay of total tritium in plasma was tetraphasic, with a rapid initial t1/2 alpha of 0.044 +/- 0.013 h, followed by a t1/2 beta of 0.54 +/- 0.22 h and a t1/2 gamma of 9.48 +/- 4.89 h; the terminal t1/2 gamma was 219 +/- 57 h. The mean plasma clearance of total tritium was 0.054 +/- 0.044 l.kg/h, and the mean volume of distribution was 14.3 +/- 5.4 l/kg; mean urinary excretion was 13.6% +/- 4.3% of the delivered radioactivity. Qualitative analysis of plasma and urine revealed the predominance of unchanged VZL plus two unidentified metabolites with different elution times. In comparison with oral VZL, as previously reported, i.v. injected VZL showed comparable values with respect to the volume of the central compartment (VC), plasma clearance (Clp), and terminal t1/2 for total tritium. Qualitatively, the metabolites observed in plasma and urine were comparable in number and quantity with values obtained in analyses after oral administration.
Antineoplastic Agents, Phytogenic↗
Altering residency curriculum in response to a changing practice environment: use of the Mayo internal medicine residency alumni survey.
To elicit the opinions of practicing internists who had graduated from a single internal medicine residency program about the adequacy of their training and its relevance to their medical practice, we mailed a survey to 1,342 physicians who had spent at least 1 year in the Mayo internal medicine residency training program. Of this group, 703 alumni (52%) responded to the survey, 532 of whom were currently practicing internal medicine. Our detailed analysis was based on responses from these 532 and, for some aspects of evaluation, on the 121 general internists who had completed residency training after 1970. Of the respondents, 42% spent more than 80% of their time in general medicine, and 53% had at least some subspecialty practice; 55% were involved in teaching, 20% in some research, and 37% in various administrative duties. In 27%, all patient-care activities involved primary care, an increase from 18% in a 1979 survey and 9% in 1972. Of those who were subspecialists, 67% spent more than half their time in subspecialty practice. Of those who were trained after 1970, 90% were board certified. Most respondents thought that their training in the internal medicine subspecialties was adequate, that additional procedure training was needed in joint aspiration, line placement, and flexible sigmoidoscopy, and that many allied medical areas were important to their practice and necessitated additional training. Although virtually all respondents assessed their inpatient training as adequate, only 42% were fully satisfied with their outpatient training. Alumni surveys can be useful in restructuring a residency program to meet the needs of the trainees.
Curriculum↗