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Biomedical subjects

R L Prager

Publications and source records attributed to R L Prager.

At least 37 records · Page 2Linked to original sources
PubMed1984

The questionable role of computed tomography in preoperative staging of esophageal cancer.

The findings of computed tomography (CT) in 18 patients with histologically proven esophageal carcinoma were compared with operative and pathological findings. Computed tomography delineated esophageal lesions in 14 of the 18 patients. In 11 patients, CT scanning was found to be inaccurate in assessing tumor involvement of esophageal lymphatic drainage. Nine patients had no abdominal nodal metastasis demonstrated by CT scan. Operative exploration revealed tumor involvement of celiac or left gastric lymph nodes in all of these patients. Two patients' CT scans demonstrated tumor involvement of celiac and left gastric lymph nodes; at operative exploration, these nodes were enlarged, but they were histologically negative for esophageal carcinoma. Operative exploration changed the preoperative TNM classification in 8 of the 11 patients. Review of these data indicates that surgical exploration continues to be the only reliable method of determining the actual extent and often the resectability of esophageal carcinoma.

Adenocarcinoma↗
PubMed1984

Suprarenal vena caval occlusion. Principles of operative management.

Retrohepatic occlusion of the inferior vena cava caused by tumor complicates complete resection and not infrequently is associated with life-threatening symptoms that accelerate the lethality of the underlying malignant process. This report summarizes our experience with caval thrombectomy and reconstruction that allowed complete removal of all gross tumor in seven patients with malignant occlusion of the retrohepatic inferior vena cava. Included in this group are five patients with renal cell carcinoma and extension of tumor into the retrohepatic vena cava. Three of these patients had extension of tumor thrombus into the right atrium. A sixth patient had recurrent right adrenal cortical carcinoma with tumor invasion of the vena cava and occlusion to the right atrium. Associated hepatic vein occlusion and secondary Budd-Chiari syndrome also was successfully managed in this patient. The final patient with occlusion of the entire suprarenal vena cava required caval reconstruction after resection of a primary leiomyosarcoma of the retrohepatic portion of the vena cava. Careful planning of the operative procedure, adequate exposure, complete mobilization of the retrohepatic vena cava, and control of the hepatic venous effluent will allow patients with retrohepatic vena caval occlusions to be managed with safety and success.

Adenocarcinoma↗
PubMed1984

Colonization of central venous catheters.

We studied etiologic factors important in colonization of 179 central venous catheters (CVCs) in patients randomized into group 1 (who received daily topical applications of povidone-iodine) or group 2 (who received only dry dressing changes). Colonization rates of CVC tips were similar between group 1 (18/84 or 21%) and group 2 (22/95 or 23%). Peripheral blood cultures grew Candida in eight hyperalimented patients (evenly divided between groups 1 and 2), S epidermidis in four other patients (also evenly divided), and gram-negative bacteria in three patients. Colonization rates for CVCs in place for 0 to seven days was 15.6% (17/109) and 76.7% (23/30) if used from eight to 30 days. Inflammatory signs at CVC sites were often absent when CVCs became colonized or produced bacteremia. Unimportant determinants of CVC colonization included skin securement of CVCs, antibiotic infusions through CVC lines, and masking and gowning of physicians before CVC placement. Daily applications of povidone-iodine did not reduce colonization of CVCs as compared to dry dressing changes.

Administration, Topical↗
PubMed1983

Arteriovenous fistula of the lung.

Pulmonary arteriovenous fistula is an unusual but not rare abnormality with more than 450 cases reported in the literature. Studies during the last 30 years have established the effective prevention of morbidity and relief of symptoms by operative excision. During the last 25 years, the Vanderbilt University Affiliated Hospitals have seen 7 patients with pulmonary arteriovenous fistula. This experience prompted a review of the literature. Particular emphasis is placed on current means of diagnosis and therapy.

Adult↗
PubMed1982

The subxiphoid approach to pericardial disease.

During the 36-month period from July, 1978, through July, 1981, 25 patients underwent a subxiphoid pericardial window procedure for diagnosis and therapy. Twelve patients were operated on for uremic pericarditis, 6 for malignancy, and 7 for etiological diagnosis of the pericarditis. All 12 patients with renal failure had enlarging effusions, despite aggressive dialysis. Eleven of the 12 are alive, free from recurrence, 3 to 36 months postoperatively. Six patients were operated on for suspected pericardial malignancy with hemodynamic compromise. Histological diagnosis was made from the pericardial tissue in all patients; only 1 patient lived more than 43 days following the procedure. In the group of 7 patients operated on for diagnosis, 4 were thought preoperatively to have tuberculous pericarditis. All 4 were treated with anti-tuberculosis chemotherapy and are asymptomatic, without evidence of calcification, 12 to 31 months postoperatively. This diverse group of patients demonstrates that the subxiphoid pericardial window is an effective approach for relief of uremic effusions and may adequately treat effusive tuberculous pericarditis when combined with multidrug chemotherapy. Patients with suspected malignant pericardial disease and hemodynamic compromise need to be carefully studied before an operative procedure is considered as a means of diagnosis and therapy.

Adult↗
PubMed1982

Alterations in pulmonary function following pneumonectomy for bronchogenic carcinoma.

Twenty-one patients who underwent pneumonectomy for bronchogenic carcinoma at the Nashville Veterans Administration Hospital from November, 1977, to March, 1980, were evaluated with standard pulmonary function tests preoperatively and postoperatively. Twelve patients had Stage I disease, 4 patients had Stage II, and 5 patients had Stage III disease. The interval between the operative procedure and postoperative testing ranged from 2 to 33 months (mean, 12.4 months). Mean functional loss of pulmonary capacity after pneumonectomy was based on analysis of preoperative and postoperative forced vital capacity (FVC) and initial-second forced expiratory volume (FEV1) indices. The mean functional loss as expressed by FVC was 41.5% after right pneumonectomy and 34.0% after left pneumonectomy. The mean functional loss as expressed by FEV1 was 40.2% after right pneumonectomy and 38.3% after left pneumonectomy. The postoperative functional status of each patient was classified according to the New York Heart Association criteria. Nineteen of the 21 patients were in Class I or II preoperatively. Postoperatively, 10 patients were in Class I or II and 11 in Class III or IV. The results indicate that a postoperative FVC less than 2.5 liters and FEV1 less than 1.5 liters are not compatible with active life.

Carcinoma, Bronchogenic↗
PubMed1981

Early operative intervention in aortic bacterial endocarditis.

Since 1974, 14 patients have required valve replacement for native aortic valve bacterial endocarditis at Vanderbilt University Medical Center. There were 7 male and 7 female patients ranging from 11 to 65 years old. Nine of the patients were less than 27 years old. All patients had congestive heart failure as a complication of the bacterial endocarditis and were in New York Heart Association (NYHA) Functional Class III or IV. Two patients were seen initially with arrhythmias, 3 had episodes of septic emboli, and 1 patient was operated on immediately after sustaining a cardiac arrest. Echocardiogram was utilized in 9 patients, and cardiac catheterization was performed in 6 patients who were suspected to have concomitant mitral valve or coronary artery disease. All patients were operated on within two weeks after the institution of antibiotic therapy, and there were no operative or early postoperatively deaths. Preoperative blood cultures were positive in 13 patients, with streptococcus cultured in 6 patients and staphylococcus in 4. Escherichia coli and enterococcus were the other pathogens cultured. All patients received antibiotics intravenously for a total of six weeks. There has been 1 late postoperative death, which occurred 2 months following operation in a patient with myocardial failure unresponsive to treatment. Two patients underwent reoperation, 1 because of a persistent aorto-right ventricular fistula and the second because of paraprosthetic aortic regurgitation. Nine patients are now in NYHA Functional Class I and 4 are in Class II.

Adolescent↗
PubMed1980

Pulmonary, mediastinal, and cardiac presentations of histoplasmosis.

Sixty-one patients with histoplasmosis were identified. They ranged from 14 months to 67 years old. There were 56 male and 5 female patients. Disease presentations were categorized into pulmonary (47), mediastinal (11), pericardial (2), and cardiac (1). Twenty of the patients with pulmonary involvement had histoplasmomas treated by wedge resection (18) or lobectomy (2). Twenty-two of the 27 cavitary lesions were treated by lobectomy and 4 by segmental resection, and 1 required pneumonectomy. The patients with mediastinal granulomas or fibrosis underwent exploration for diagnosis and curative or palliative procedures. Two patients with pericardial histoplasmosis required pericardial windows to relieve acute tamponade. One patient with disseminated histoplasmosis required aortic valve replacement for histoplasmosis valvulitis with severe regurgitation. The 1 operative death was a patient requiring pneumonectomy for mediastinal histoplasmosis. Indications for operative intervention in pulmonary histoplasmosis included resection of a new or enlarging pulmonary nodule to provide a definite pathological diagnosis and resection of persistent thick-walled pulmonary cavities. Mediastinal granuloma with or without fibrosis required exploration for diagnosis, palliation, or cure. Fungal endocarditis necessitated treatment with amphotericin B and valve replacement to stabilize the patient's hemodynamic status and prevent embolization of large fungal vegetations. Pericardial effusion, a rare manifestation of histoplasmosis, was seen as acute tamponade requiring emergency intervention.

Adolescent↗
PubMed1980

Oculoplethysmography in diagnosing obstruction of the superior vena cava.

Preoperative evaluation of a patient with symptomatic obstruction of the superior vena cava secondary to sclerosing mediastinitis demonstrated abnormal plethysmographic findings in the central venous and carotid systems. Arteriography confirmed diminished blood flow to the arms and cerebral vessels. Following in continuity saphenous vein conduits to the jugular system, he improved symptomatically and postoperative oculoplethysmography showed a return to normal of his pulse wave form and absent pulse delay in the venous and arterial systems.

Adult↗
PubMed1980

Histoplasma capsulatum endocarditis requiring aortic valve replacement for aortic insufficiency.

A patient with valvular heart disease was found to have disseminated histoplasmosis and Histoplasma endocarditis. Refractory congestive heart failure secondary to severe progressive aortic insufficiency and the presence of a large valvular vegetation necessitated aortic valve replacement, which was timed to coincide with the midpoint of a course of therapy with 4 gm of amphotericin B. The patient has done well since the completion of treatment.

Aortic Valve↗
PubMed1979

Endotoxin-induced intravascular coagulation (DIC) and its therapy.

Anticoagulants in the form of heparin, dipyridimole, steroids, prostaglandin E1, Macrodex, and antithrombin III were administered in separate experiments prior to endotoxin infusion in the dog. The pattern of disseminated intravascular coagulation (DIC) developed consistently when endotoxin alone was administered. Heparin dosages from 1 to 10 mg/kg did not influence the appearance of thrombocytopenia but effectively eliminated the decrease in fibrinogen levels ordinarily found. Antithrombin III (AT III), obtained from the National Red Cross, administered in a dose designed to provide a doubling of the circulating AT III, reduced the fibrinogen utilization to a similar degree as heparin without affecting the platelet loss. Dipyridimole, as administered, was ineffective in this model, and did not alter the development of thrombocytopenia or the hypofibrinogenemia. Steroids, Macrodex, and prostaglandin E1 had minimal effect on the coagulopathy. Our finding would suggest that the endotoxin effect on dog platelets id direct, and not mediated by thrombin, and that the role of heparin in the clinical management of DIC should be considered only in instances in which renal complications exist.

Animals↗