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Biomedical subjects

S R Klein

Publications and source records attributed to S R Klein.

At least 19 recordsLinked to original sources
PubMed1995

Laparoscopic inguinal herniorrhaphy in two stallions.

Two mature stallions that were used for breeding purposes were admitted for evaluation of inguinal hernias. In 1 horse, the hernia was reduced per rectum by gentle traction applied to the intestine. In the other horse, the hernia was reduced by placing the horse in dorsal recumbency and applying external pressure over the scrotum. Both horses were observed for recurrence of the hernia. Seven days later, an elective laparoscopic technique for inguinal herniorrhaphy was performed on each horse, using polypropylene mesh. Complications did not develop, and both horses have successfully completed 2 full breeding seasons. Laparoscopic inguinal herniorrhaphy allows preservation of the testis on the affected side and precludes many complications associated with open surgical techniques used on inguinal rings.

Animals↗
PubMed1995

Adverse consequences of increased intra-abdominal pressure on bowel tissue oxygen.

OBJECTIVE: Demonstrate the effect that increased intra-abdominal pressure (IAP) has on visceral oxygen delivery and bowel tissue oxygenation (TPO2). METHODS: Six Duroch swine underwent abdominal insufflation with helium to pressures of 15 and 25 mm Hg for 1 hour. Animals were instrumented with a pulmonary artery flotation catheter to measure cardiac output and calculate systemic oxygen delivery. Fluorescence quenching optodes were implanted in the terminal ileum and the subcutaneous tissue of an axillary fold to measure bowel and systemic (control) tissue oxygen levels, respectively. RESULTS: Bowel tissue oxygen fell from 43 +/- 12 mm Hg at baseline to 31 +/- 12 mm Hg, with 15 mm Hg of abdominal pressure at 60 minutes. With 25 mm Hg IAP, bowel TPO2 fell from 24 +/- 12 to 12 +/- 8 mm Hg (p < 0.02). No change in axillary TPO2 was observed during either period of increased IAP. Cardiac output (CO), systemic oxygen delivery, and mixed-venous oxygen saturation (Svo2) also declined, although blood pressure and oxygen consumption remained constant. CONCLUSIONS: Increased IAP produces significant decreases in bowel submucosal TPO2 without similar changes in extra-abdominal (subcutaneous) TPO2. This decline is dependent on the extent and duration of the elevation in IAP. Readily accessible parameters, such as CO and Svo2, also decline with increased IAP and may be useful variables to monitor as relative indicators of bowel hypoperfusion and TPO2.

Abdomen↗
PubMed1995

Scintimammography: the complementary role of Tc-99m sestamibi prone breast imaging for the diagnosis of breast carcinoma.

PURPOSE: To evaluate the complementary role of technetium-99m sestamibi scintimammography in improvement of the sensitivity and specificity of mammography in detection of carcinoma of the breast. MATERIALS AND METHODS: At 5 and 60 minutes after intravenous injection of Tc-99m sestamibi, scintimammograms were obtained in 147 women (age range, 18-73 years; mean age, 47.9 years +/- 10.2 [standard deviation]) with 153 lesions that warranted breast biopsy (102 lesions) or fine-needle aspiration cytologic analysis (51 lesions). There were 113 palpable and 40 nonpalpable lesions. Lesion size on mammograms was 0.8 x 0.6 cm to 15.0 x 11.0 cm (mean, 2.82 cm +/- 1.71 x 2.39 cm +/- 1.56). RESULTS: Scintimammographic findings were true-positive in 47 biopsy-confirmed carcinomas, true-negative in 91 benign lesions, false-positive in 11 lesions with benign histopathologic findings (fibrocystic disease [n = 8] or fibroadenoma [n = 3]), and false-negative in four lesions of infiltrating ductal carcinoma. The sensitivity of scintimammography was 92.2%; specificity, 89.2%; positive predictive value, 81.0%; and negative predictive value, 95.8%. CONCLUSION: The authors conclude that scintimammography is a sensitive test that can improve the detection of breast carcinoma.

Biopsy, Needle↗
PubMed1992

Laparoscopic occlusion of testicular veins for clinical varicocele.

Surgery via the laparoscope is now a reliable and cost-effective alternative to some open surgical procedures. Advances in videoendoscopy, incorporating optical magnification combined with the development of instruments with which to dissect, ligate, and transect blood vessels provide the urologist the opportunity to surgically correct a varicocele. In the outpatient setting, 4 patients (14-26 years of age) underwent laparoscopic ligation of the left internal spermatic veins for painful left varicocele. Carbon dioxide pneumoperitoneum was obtained using a Veress needle. A 10-mm laparoscope was placed intraperitoneally through a cannula inserted in the infraumbilical border. Utilizing two additional endosurgical ports (5 mm and 10 mm) through which 5-mm dissecting instruments and vaso-occlusive endoclips were placed, three veins were individually isolated and ligated in each of the 4 patients. In all 4 patients, the left testicular artery was visualized and preserved. There was no blood loss or other intraoperative complication. In each patient the varicocele was successfully corrected. Analgesic medication was not required postoperatively. We conclude that laparoscopic ligation of the internal spermatic veins is a safe and effective way of treating a varicocele without immediate postoperative sequelae. Long-term follow-up is necessary to determine the place of the endoscopic approach.

Adolescent↗
PubMed1992

Contemporary management of amebic liver abscess.

In a retrospective review covering 16 years divided into two time periods, 133 patients with amebic liver abscess were evaluated. Most of the patients were young, Hispanic men, and one-third had coexistent disease. A reliable diagnosis can be established in 24 hours using ultrasound or computed tomography scans. Over the entire time period, antiparasitic therapy was evolved to occupy a primary role and surgery was reserved for management of abscess complications.

Academic Medical Centers↗
PubMed1991

Are blood cultures effective in the evaluation of fever in perioperative patients?

Blood cultures are routinely performed as part of the evaluation of fever in the perioperative period. Results of 364 blood culture vials representing 108 consecutive febrile events (temperature greater than or equal to 101.5 degrees F) in 72 patients on adult surgical services without evidence of sepsis in a metropolitan hospital were prospectively studied. Eighty-nine percent of patients had undergone an operation prior to the febrile episode. Microorganisms were isolated in blood culture vials from 9 of 108 patient febrile events. Of these blood cultures, five were positive (contained pathogens), and four represented contaminants. Two of five positive blood cultures occurred in patients with an identifiable source of bacteremia. The cost of processing all blood culture vials was $13,992, which amounted to $2,798 spent to identify each of the five patients with positive blood cultures. Blood culture vials were more likely to be positive if blood was drawn during postoperative days 4 through 10, as opposed to days 1 through 3, or if it was drawn from patients with factors depressing immune function or who had indwelling devices. Neither the magnitude of the absolute leukocyte count nor the maximum temperature at the time of phlebotomy predicted a positive blood culture. The use of resin vials produced sterile cultures in the 10 vials submitted. In no case did a positive blood culture have a measurable effect on reducing patient morbidity or mortality.

Adolescent↗
PubMed1991

The socioeconomic impact of assault injuries on an urban trauma center.

In 1983, Los Angeles County designated 23 level I or II trauma centers. During the subsequent 7 years, ten centers closed because of adverse financial impact. To analyze the causes of this trend, hospital admissions for gunshot and stabbing injuries were reviewed for two separate 1-year periods at a level I urban trauma center. Of 1,160 patients arriving with injuries meeting county triage criteria from January 1, 1986 through December 31, 1986, 323 (27%) sustained penetrating assault, of which 96 were with firearms (30%). From January 1, 1988 through December 31, 1988, 1,213 met triage criteria; 301 (25%) were intentional, of which 179 (59%) were due to firearms. Epidemiologic and clinical data from the two periods is similar with 90 per cent of the patients being men ages 25 to 30 and of minority ethnic background. Seventy-five per cent of the patients required a truncal operative procedure and needed about 5.5 days of hospitalization. Overall, mortality averaged 4.7 per cent and morbidity 14.5 per cent. Complete financial data was available on 561 of the 624 intentionally injured patients for which costs totaled $2,481,346 (mean = $5,260 for gunshots; mean = $3,640 for stab wounds). The total collections were $545,896 (22% of total charges). Only 5 per cent of the charges were reimbursed from insurance; MediCal reimbursed 13 per cent and only 1 per cent was from Medicare. Eighty-one per cent of the patients had no financial resources, resulting in a hospital deficit of $1,861,009 (75% of the total charges).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1991

Time-course of cardiopulmonary effects tumor necrosis factor and endotoxin are similar.

Tumor necrosis factor (TNF) is a postulated proximal septic mediator. The authors compared the time course and extent of the cardiopulmonary effects of recombinant human TNF (rTNF) in swine vs those of Escherichia coli endotoxin (ETX). Intravenous boluses of either rTNF (n = 4), ETX (n = 2), or saline (n = 4) were given to swine. Mean pulmonary artery pressure and extravascular lung water (EVLW) were increased at 60 minutes for rTNF and ETX to 31 +/- 2 mmHg and 33 +/- 3 mmHg and 6.3 +/- 0.9 ml/kg and 7.1 +/- 1.6 ml/kg, while saline animals were unchanged. The authors conclude that rTNF mimics ETX both in time course and magnitude of effects. Right-sided cardiopulmonary effects predominate in both with minimal left-sided effects at these dosages. The time course of early increased EVLW suggests an initial hydrostatic influence on pulmonary edema formation in this septic model.

Animals↗
PubMed1991

Differential diagnosis of facial nerve palsy.

The differential diagnosis of facial complex can be complex, but all efforts must be made to identify the cause so that appropriate treatment can be offered. This article presents a review of conditions associated with acute facial palsy and discusses the differential diagnosis of this condition. The focus is on the differentiation of other causes of acute facial palsy from the idiopathic, or Bell's type, which is a diagnosis of exclusion.

Acute Disease↗
PubMed1991

Septic embolism complicating infective endocarditis.

Embolic phenomena in patients with infective endocarditis may complicate the placement of a cardiac valvular prosthesis. To evaluate the vascular consequences of these emboli, a 15-year review of 102 patients undergoing valve replacement for proven infective endocarditis was undertaken. Thirty-one patients with 36 episodes of septic embolization were identified. Ten of these were separate extremity occlusive events. All patients with extremity emboli were admitted with pain; four had limb-threatening emboli. All patients grew gram-positive bacteria from their blood except a single Candida albicans isolate. Appropriate antimicrobial therapy was used in all patients. Angiography confirmed the diagnosis in 11 of 12 patients. Embolic targets included the lower extremities in all except a single instance. Four patients had multiple emboli. All but one of the vascular procedures were carried out subsequent to or simultaneously with cardiac valve replacement. Initial operative management included embolectomy (4) and primary amputation (2). Two delayed procedures were required. One patient died. Four patients had limited ischemia that resolved with antibiotics and anticoagulation. This report suggests that infective endocarditis requiring valvular replacement is associated with embolization in one third of patients. The presentation of peripheral vascular emboli is that of acute extremity ischemia. The diagnosis should be confirmed by angiography to rule out the possibility of multiple emboli. When possible, valve replacement should precede peripheral vascular management, which may include operative or medical components as dictated by the extent of limb ischemia.

Adult↗
PubMed1991

Peripheral arterial shotgun missile emboli: diagnostic and therapeutic management--case reports.

Arterial bullet embolism is an uncommon complication of vascular trauma. While many reports exist of peripheral embolism from aortic entry sites, few cases are described of distal embolization from peripheral arteries. Untreated emboli may cause ischemia and threaten the limb at a site far removed from the point of missile entry. Unless suspected, diagnosed, and extracted, these emboli may ultimately result in limb loss in spite of a successful proximal arterial repair. During the last 10 years we treated 4 such cases, all of whom had initial limb salvage. This report describes our diagnostic and operative management of these injuries and collectively summarizes our experience as well as all other cases in the literature.

Adolescent↗
PubMed1990

Inadequate bicarbonate resuscitation in trauma patients requiring crossclamping of the aorta.

The use of bicarbonate in the management of metabolic acidosis is controversial. We present three patients who required crossclamping of the aorta for control of shock and whose metabolic acidosis was inadequately treated with bicarbonate. Within minutes of aortic declamping, all became hypotensive and two went into refractory ventricular fibrillation and died. Arguments supporting the role of adequate bicarbonate resuscitation in this setting are discussed.

Acidosis↗
PubMed1990

A contemporary perspective on superior vena cava syndrome.

The superior vena cava (SVC) syndrome is usually associated with advanced malignancy and has a dismal prognosis. In order to analyze the impact of newer diagnostic and therapeutic modalities, we retrospectively examined the last 45 consecutive cases of SVC syndrome treated over a 12-year period. The underlying causes were advanced lung cancer (57%), mediastinal tumors (20%), and metastatic solid malignancy (5%). Forty-two patients (93%) were treated with external beam radiotherapy and/or chemotherapy with a mean patients survival of 3 months; 11 of 42 patients (26%) were treated without histologic diagnosis. Symptoms of SVC obstruction resolved in 80% of patients who underwent radiotherapy, with a mean interval of 4 weeks. The most common cause of death was respiratory arrest. Of the three patients with benign disease, two underwent caval reconstruction with greater than 3-year patency and relief of symptoms. We conclude that (1) SVC syndrome portends a grim prognosis when associated with malignancy but usually responds to radiation or chemotherapy; (2) CT scan is the best available method to document the extent and location of involvement; and (3) patients with benign disease should be evaluated for caval reconstruction, which may produce rewarding long-term results.

Adolescent↗
PubMed1990

Acute appendicitis in the pregnant patient.

Acute appendicitis is the most common surgical problem in pregnancy requiring emergent intervention. To establish a contemporary patient profile and formulate an effective management strategy, a retrospective review was conducted of 84 pregnant patients who underwent laparotomy with a preoperative diagnosis of acute appendicitis. Gestational stage at presentation included the first trimester in 27 patients (32%), the second trimester in 37 patients (44%), the third trimester in 13 patients (16%), and the puerperium in 7 patients (8%). Fifty-four patients (64%) had pathologically proven acute appendicitis; the incidence did not vary by trimester. Other intra-abdominal conditions were detected in 15 patients (18%). There were no significant differences between patients with positive and negative laparotomies (or among trimesters) regarding frequency of presenting symptoms and signs or laboratory results. Operation occurred within 24 hours of symptom onset in 19 of 54 (35%) instances of proven acute appendicitis. Perforation occurred in 23 of 54 patients (43%), all of whom had symptoms exceeding 24 hours (p less than 0.0005). Five instances of perinatal death and one case of extreme perinatal morbidity were associated with negative laparotomies; only one of these was attributed to operation itself. No adverse long-term maternal morbidity or mortality occurred. Wound infection developed in seven cases of acute appendicitis (six perforated) and two negative explorations. We conclude that (1) gestational physiologic changes obscure the accurate diagnosis of acute appendicitis; (2) the natural history of acute appendicitis is not affected by trimester of presentation; and (3) adverse sequelae of acute appendicitis are obviated by prompt operative exploration and prevention of appendiceal perforation.

Acute Disease↗
PubMed1990

Endovascular occlusive intervention in the management of trauma.

This report summarizes a 10-year experience (1978-1987) in a metropolitan hospital with 102 patients sustaining a variety of complex or inaccessible vascular injuries. Management included the application of occlusive interventional arteriographic techniques. Regional injuries included head and neck (56%), trunk (13%), and extremity (32%). Techniques of vascular occlusion were often performed in conjunction with the initial arteriographic evaluation and were comprised of particulate embolization (42%), placement of mechanical devices (36%), or tissue adhesives (1%), or a combination (21%). There were no deaths in this series and the only complications included four cases of dislodgement of the occlusive agent. We demonstrate that endovascular occlusion is a useful, safe and efficacious procedure in selected patients with complex, inaccessible or life-threatening vascular trauma.

Adolescent↗
PubMed1989

Management strategy of complex extremity injuries.

In this retrospective review of 37 patients with combined orthopedic and vascular injuries, our management strategy emphasized the prompt recognition of limb threat. Twenty-two patients had lower-extremity and 15 had upper-extremity injuries. No deaths occurred. Five delayed amputations were performed for limbs left denervated by associated soft tissue or neural injuries. No late vascular insufficiency was recorded in patients who underwent reconstruction with autogenous tissue. Whenever possible, the precise site of vascular injury was identified angiographically to help plan an approach that would provide adequate exposure for vessel repair as well as orthopedic stabilization. Vascular reconstruction typically preceded osseous stabilization. We conclude that improved outcome requires a coordinated multidisciplinary approach, expeditious limb revascularization, fasciotomy as indicated, rapid fixation of osseous injuries, and adequate soft tissue coverage of the underlying repair.

Adolescent↗
PubMed1989

The problem of vascular shotgun injuries: diagnostic and management strategy.

This report details our diagnostic and management protocol derived from experience with 11 consecutive shotgun injuries. The injured vessels in nine men and one woman were: brachial artery (6), femoral artery (2), iliac artery (1), tibioperoneal trunk (1), and axillary vein (1). All those with arterial injuries had evidence of distal ischemia; 60% had absent distal pulses. Preoperative arteriography was obtained in seven who were stable and proved useful in outlining the local extent of their vascular injury as well as delineating available distal run-off vessels. Routine chest x-ray revealed evidence of pulmonary or cardiac missile emboli in three. Patients underwent primary repair (4), saphenous vein graft (4), and prosthetic graft (1). Associated venous disruption was noted in all patients with primary arterial injuries; this was either repaired (5/10) or ligated (4/10). Five patients had completion arteriograms, two of which revealed unsuspected distal arterial-arterial emboli. Associated soft tissue destruction included seven nerve injuries and three instances of extensive compartment injury which required fasciotomy. Average follow-up time was nine months, with the majority of complications due to associated nerve damage or soft tissue loss. We have evolved the following strategy: 1) After hemodynamic resuscitation, stable patients undergo arteriography to define the anatomic origin of complex injuries; 2) Surgery commences with rapid proximal and distal control of disrupted segments; 3) Following vessel debridement, continuity is restored either by primary repair or by an autogenous graft which is placed to allow coverage by viable muscle or by soft tissue; 4) On-table completion arteriograms evaluate patency and provide evidence of distal arterial emboli; 5) Fractures are stabilized and disrupted nerves isolated for subsequent repair; and 6) Fasciotomy is performed in the presence of distal swelling or prolonged ischemia.

Adult↗