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Biomedical subjects

W E Strodel

Publications and source records attributed to W E Strodel.

At least 55 records · Page 3Linked to original sources
PubMed1993

Lymphangioleiomyomatosis.

Lymphangiomyomatosis (LAM) is a progressive disease afflicting women of childbearing age. LAM remains a rare disease, unfamiliar to many clinicians. It usually poses a diagnostic dilemma for the primary physician, possibly resulting in a delayed or missed diagnosis, unnecessary operative intervention, and inappropriate therapy. LAM is characterized microscopically by abnormal smooth muscle proliferation causing gradual obstruction of small airways, lymphatics, and vasculature. The proliferation eventually results in a characteristic clinical syndrome of progressive dyspnea, recurrent pneumothorax, chylous effusion, and hemoptysis. Despite a variety of treatment regimens developed since the first description of LAM, patient survival has not improved appreciably. Most patients die within 10 years of the time of diagnosis. This report presents a patient with LAM and a review of the literature.

Adult↗
PubMed1993

Use of an Objective Structured Clinical Examination (OSCE) to measure improvement in clinical competence during the surgical internship.

BACKGROUND: Traditional ward ratings and multiple-choice tests do not reliably assess clinical competence. This study determined the reliability of the Objective Structured Clinical Examination (OSCE) and its sensitivity in detecting the performance gains and deficits in surgical interns. METHODS: A comprehensive 35-station OSCE was administered to 23 incoming interns and seven outgoing interns. The OSCE comprised 17 two-part clinical problems, relying primarily on actual or simulated patients. The reliability of the examination was assessed by coefficient alpha. Significant differences in performance between the two intern groups, between parts A and B, and among the 17 problems were determined by a three-way ANOVA: OSCE performance was also correlated with National Board of Medical Examiners Part II scores. RESULTS: The reliabilities of part A, part B, and parts A and B combined were 0.72, 0.70, and 0.82, respectively. Overall, the outgoing interns performed significantly better than the incoming interns: 58% +/- 1% mean OSCE score versus 47% +/- 1% (p = 0.0001). The 17 clinical problems differed significantly in difficulty; major performance deficits were seen in both groups of trainees. The correlation of OSCE scores with National Board of Medical Examiners Part II scores was not significant (r = 0.11, p = 0.633). CONCLUSIONS: We conclude that the OSCE is an innovative, reliable tool for evaluating resident competence. Although outgoing interns performed better than did incoming interns, the OSCE scores clearly indicated major performance deficits in all interns.

Clinical Competence↗
PubMed1993

Perforated gastric and duodenal ulcer: an analysis of prognostic factors.

A review of patients treated operatively for perforated ulcer was undertaken to determine factors that independently predict mortality and morbidity. From 1980 to 1989 84 patients were treated with operative mortality and morbidity rates of 18 and 37 per cent, respectively. Patients with gastric ulcer were significantly older and were more likely to have concomitant medical problems, to use steroids, and be hospitalized at time of their perforation. They also had a higher perioperative mortality rate when compared to patients with gastroduodenal ulcers (P < 0.05 for each). Patients treated with definitive operation (n = 51) had a significantly lower recurrent ulcer rate when compared to an equivalent group treated with simple closure (n = 33) (mean follow-up, 47 months). Multivariate analysis confirmed a patient's likelihood of complication or death could be predicted using three variables (P < 0.03); age greater than 42 years, hospitalization at time of perforation, concomitant medical illness. While the relative distribution of these three factors in patients with gastric versus peptic ulcers appears to account for the difference in outcome between these two groups, the distribution of these factors between patients treated with patch closure and definitive operation was not significantly different. Patient outcome from operation for perforated ulcer is dependent on preoperative conditions and appears to be independent of surgical procedure performed. There was no benefit to simple closure of a perforated ulcer. Definitive procedures of perforated ulcers are associated with lower ulcer recurrence and therefore are advocated to treat perforation.

Adolescent↗
PubMed1991

Hemodynamic monitoring and pulse oximetry during percutaneous gastrostomy and jejunostomy: necessity or nuisance?

Hemoglobin desaturation and arrhythmias have been reported during diagnostic gastroscopy and colonoscopy. During endoscopic placement of percutaneous gastrostomy tubes (PEG), the gastroscope is inserted twice and the stomach is markedly distended, thus increasing the potential risk of complications. Also, the procedure is frequently performed in patients exhibiting underlying systemic disease or little respiratory reserve. Patients undergoing PEG or percutaneous endoscopic jejunostomy (PEJ) were studied prospectively. Blood pressure, pulse, pulse oximetry, and lead II ECG tracings were obtained. Measurements were made before sedation, after sedation, at gastroscope insertion, at gastrostomy placement, at gastroscope reinsertion, and at 5 min after the procedure. In all, 50 patients (mean age, 56.8 years; 16 women, 26 men) underwent PEG only (39 cases) or PEG/PEJ (11 cases). The endoscopy suite was the site for the procedure in 38 cases and the intensive care unit was used in 12 cases. The mean time required for PEG and PEG/PEJ was 14.7 +/- 1.1 and 18.9 +/- 2 min, respectively. Blood pressure remained stable throughout the procedure. Sinus tachycardia was observed in 72% of patients. Arterial oxygen saturation decreased after the administration of intravenous sedation but remained constant during the procedure. We reached the following conclusions: (1) desaturation occurs during sedation, (2) saturation remains constant during PEG/PEJ, (3) the mean blood pressure remains constant during PEG/PEJ, and (4) PEG/PEJ are safe procedures and monitoring should be individualized.

Adolescent↗
PubMed1991

Induction of the protooncogene c-fos and recovery of cytosolic adenosine triphosphate in reperfused liver after transient warm ischemia: effect of nitrone free-radical spin-trap agents.

Ischemia and reperfusion stimulate several adenosine triphosphate (ATP)-dependent processes involving release of substances including free radicals. This cellular response is mediated through receptors responsive to transcriptional products of gene expression; c-fos acts as a transcriptional factor involved in the regulation of genes associated with cellular proliferation and differentiation. We hypothesized that nitrone free-radical spin traps promote restoration of cytosolic ATP during reperfusion and prevent c-fos induction. Four control rats had no ischemia. Global hepatic ischemia was induced in 19 rats in four groups: saline solution, phenyl-N-tert-butyl nitrone (PBN), alpha 1-pyridyl-N-oxide N-tert-butyl nitrone (POBN), and 5,5-dimethyl-1-pyrroline-N-oxide (DMPO). ATP and intracellular pH were measured at intervals before, during, and after ischemia. At 90 minutes of reperfusion, liver c-fos mRNA was measured. A fourfold elevation of c-fos occurred in the saline-treated group (p less than 0.001). PBN and POBN groups did not differ from the saline group. DMPO resulted in significantly less induction of c-fos than did NS. ATP depletion and recovery in all treatment groups was similar to that of the saline group. We conclude that (1) nitrone spin traps do not prevent c-fos induction or alter the pattern of ATP recovery after hepatic ischemia and reperfusion and (2) c-fos induction is not necessary for restoration of ATP, but the rate of ATP restoration is inversely related to c-fos induction.

Adenosine Triphosphate↗
PubMed1991

Brachial plexus injury: association with subclavian and axillary vascular trauma.

Proximal upper extremity (subclavian and axillary) vascular injury (SAVI) and brachial plexus injury (BPI) occur uncommonly. However, BPI may be associated with SAVI and frequently is an important determinant of long-term disability. The medical records of patients with traumatic SAVI, BPI, or both over a 5-year period were reviewed. A total of 31 patients were identified. The group was predominantly male (28 men/3 women) with a mean age of 30.5 +/- 1.8 years (range, 15-63 years). Blunt trauma accounted for 43.5% of SAVI cases and 77.8% of BPI cases. Thirteen patients (41.9%) sustained SAVI alone (group I), 10 patients (32.2%) had combined SAVI and BPI (group II), and 8 patients (25.9%) had BPI alone (group III). Subclavian and axilliary vascular injury occurred in 10 of 18 patients (55.6%) with a BPI. Brachial plexus injury occurred in 10 of 23 patients (43.5%) with a SAVI. Patients with SAVI from blunt trauma were significantly more likely to have an associated complete BPI than patients with penetrating trauma. All patients with a complete BPI (6 patients) had an associated SAVI regardless of mechanism of injury. Only one patient with a partial BPI from blunt trauma had an associated SAVI. The Injury Severity Score was significantly higher for patients in group II. An average of 2.8 and 3.3 associated injuries were observed in patients with SAVI (groups I and II) versus patients without SAVI (group III), respectively. No patient who had a complete BPI showed an improvement in neurologic status during a mean follow-up of 7.2 months. No late vascular sequelae occurred in group-III patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1990

The controllable lifestyle factor and students' attitudes about specialty selection.

Questionnaires were distributed to 346 fourth-year students in nine medical schools. The students were asked to state their selected specialty and to rank the importance that each of 25 influences, listed as questionnaire items, had had in making their choice of specialty. Factor analysis showed that particular items were significantly associated with particular factors. The first factor emphasized perceived lifestyle (items in this category gave importance to remuneration, personal time, and prestige); the second factor emphasized cerebral activities and a practice orientation; and the third factor stressed altruistic values and attitudes. The authors classified the selected specialties into three groups: those characterized as having a non-controllable lifestyle (NCL), those with a controllable lifestyle (CL), and surgery. (CL specialties were defined as those that allow the physician to control the number of hours devoted to practicing the specialty.) Data were analyzed using factor analysis, and analysis of variance, and the Scheffé method. Analysis indicated that the perceived lifestyle factor was most closely associated with the responses of those students choosing CL specialties. Furthermore, this factor received the highest total loading of the three factors from all the students, thus indicating the level of interest in lifestyle factors. Responses to items that defined the cerebral and practice factor were highest from the group of students choosing CL specialties and lowest from the group choosing NCL specialties. The NCL students scored highest in the altruism factor and the CL students scored the lowest. The surgery and NCL groups were similar in attitude patterns, and both were substantially different in attitude patterns from those of the CL groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Altruism↗
PubMed1990

Splenic vein thrombosis.

A retrospective review of all admissions to the University of Kentucky Medical Center from 1977 to 1987 revealed six persons in whom splenic vein thrombosis could be documented. The patients had either upper gastrointestinal bleeding from gastroesophageal varices or abdominal pain. Pancreatic disease was present in five patients (83%), three (50%) had splenic enlargement, and five (83%) had normal results of liver function tests. Angiography showed an occluded splenic vein with collateral flow and a patent portal vein in each of the four patients studied. All patients had splenectomy, with or without additional procedures. After a mean follow-up period of 9 1/2 months, five patients (83%) were alive, and none has had further gastrointestinal bleeding. One patient had died of recurrent pancreatic carcinoma at nine months. Our data suggest that localized portal hypertension induced by splenic vein thrombosis is appropriately treated by splenectomy.

Acute Disease↗
PubMed1990

Prolonged labetalol infusion for management of severe hypertension and tachycardia in a critically ill trauma patient.

A trauma victim sustained multiple injuries including cervical spine injuries, splenic laceration, and left kidney fracture. His recovery was complicated by acute renal failure, resistant hypertension, and tachycardia refractory to multiple therapies. The patient was ultimately managed with continuous infusions of labetalol 2-3 mg/min for 14 days, with adequate control of both blood pressure and heart rate. The sustained labetalol infusion was not associated with clinically significant adverse effects although a progressive decrease in heart rate was noted near the end of therapy. This downward trend in heart rate was not associated with hemodynamic compromise and returned to pretreatment baseline of 90-110 beats/min upon discontinuation of parenteral therapy and initiation of oral labetalol. The prolonged use of labetalol infusions may be beneficial in certain patients. Further work needs to be done to identify the safety and efficacy of labetalol infusions.

Adult↗
PubMed1989

Pentoxifylline increases extremity blood flow in diabetic atherosclerotic patients.

Pentoxifylline, a new trisubstituted methylxanthine derivative known for its hemorrheologic action, has been shown to improve exercise tolerance in atherosclerotic patients. We examined the responses of diabetic atherosclerotic patients to pentoxifylline administration, measured by Doppler waveform analysis and exercise tolerance. Standard exercise tolerance and Doppler waveform analytic studies of the lower extremity, specifically the right dorsalis pedis artery, were performed before and after three months of pentoxifylline administration (400 mg three times a day). The study group comprised ten subjects (six men and four women) with a mean (+/- SD) age of 60 +/- 3.3 years. Data were analyzed using a paired Student t test. All ten subjects showed a significant increase in exercise tolerance after pentoxifylline treatment. Eight of ten subjects demonstrated a significant increase in right dorsalis pedis arterial flow.

Arteries↗
PubMed1989

Career change: in quest of a controllable lifestyle.

Over the past decade, top medical students are selecting "controllable lifestyle" (CL) specialties at an increasing rate. CL specialties include anesthesiology, dermatology, emergency medicine, neurology, ophthalmology, pathology, psychiatry, and radiology. The choice of "noncontrollable lifestyle" (NCL) specialties such as family practice, internal medicine, obstetrics/gynecology, and pediatrics was negatively affected by this trend. The effect of CL on the selection of surgical training by top medical students was variable. The purpose of this study was to determine if CL is a factor in career change by young surgeons during and after residency. Graduates of the University of Kentucky College of Medicine from 1975 to 1983 (n = 796) were questioned regarding the specialty they entered after graduation and whether they remained in that specialty as of March, 1988. NCL and surgery specialties showed a net loss of practitioners during the study period (P less than 0.005) and CL showed a net gain (P less than 0.005). When physicians changed specialties, the direction of change occurred from NCL and surgery to CL (P less than 0.05). Change from CL to NCL and surgery occurred infrequently.

Career Choice↗
PubMed1989

Monokine depression of bile flow in the isolated perfused rat liver.

Multiple system organ failure (MSOF) is a progressive dysfunction of vital organs that may develop in clinical settings such as sepsis or multiple trauma. One component of this syndrome is cholestasis and impaired liver function. The mechanism(s) for this liver failure (and the failure of other organs) remains obscure. Macrophages and Kupffer cells have been shown to secrete cytokines such as interleukin-1 and tumor necrosis factor. These cytokines mediate many aspects of the acute phase response, and they also can produce cellular injury. The purpose of this study was to evaluate the effects of a semipurified murine monokine preparation having interleukin-1 activity on bile flow in the rat isolated perfused liver (IPL). The monokine preparation produced a significant reduction of bile flow in the IPL system. The effect could not be explained by a venoocclusive phenomenon or residual endotoxin in the monokine preparation. We conclude that a semipurified monokine preparation having interleukin-1 but not tumor necrosis activity produced a significant depression of bile flow in the IPL, and we suggest that macrophage secretory product(s) may be responsible for the cholestasis in MSOF.

Animals↗
PubMed1989

Colonoscopic decompression of pseudo-obstruction and volvulus.

Flexible fiberoptic endoscopy has an integral role in the management of colonic pseudo-obstruction and volvulus. Colonoscopic decompression is the primary method for diagnosis and treatment of colonic pseudo-obstruction. Some patients require repeat endoscopic decompression, but few require tube cecostomy. In the case of sigmoid volvulus, endoscopic examination is useful as a temporizing measure to allow preparation of the colon and patient for elective definitive operative treatment.

Colonic Diseases↗
PubMed1989

Cause of death in carcinoma of the esophagus.

Carcinoma of the esophagus continues to carry a very poor prognosis. Previous studies have rarely reported the exact cause of death in these patients. Twenty-five autopsies were retrospectively reviewed in patients with the diagnosis of carcinoma of the esophagus, noting the cause of death. Two-thirds of all patients with unresected middle-third lesions ultimately died as a result of direct extension of the tumor into the aorta or tracheobronchial tree. Other findings included a high incidence of second neoplasms (12%) and the lack of an antemortem diagnosis of esophageal cancer in three of four females in the series.

Aged↗
PubMed1989

Controllable lifestyle: a new factor in career choice by medical students.

To determine whether control of work hours (controllable lifestyle) was becoming an increasingly important factor in choices of specialties by medical students, data from three medical schools over the past ten, ten, and six years, respectively, were reviewed for the types of specialty training entered by students in the top 15% of their classes. Since students in the upper 15% of the class are likely to obtain the specialties of their choice, any change in the pattern of their specialty preferences probably reflects a general trend. Specialties that feature a controllable lifestyle (CL) were defined as anesthesiology, dermatology, emergency medicine, neurology, ophthalmology, otolaryngology, pathology, psychiatry, and radiology. Non-CL specialties were surgery, medicine, family practice, pediatrics, and obstetrics-gynecology. The results showed that the percentages of students entering CL specialties increased significantly at all three schools, the percentages of students entering non-CL specialties decreased significantly at all three schools, and there was no significant change in the percentage of students entering surgical specialties.

Achievement↗
PubMed1989

A prospective study of clinically and endoscopically documented colonic ischemia in 100 patients undergoing aortic reconstructive surgery with aggressive colonic and direct pelvic revascularization, compared with historic controls.

Clinically and endoscopically proved ischemia of the colon complicates elective aortic reconstruction in 1% to 2% and 6% to 7% of cases, respectively. Operative mortality exceeds 60% when transmural infarction occurs. A prospective study of colonic ischemia was undertaken in 100 male patients (mean age, 62.4 +/- 7.9 years) undergoing operation for aortic aneurysms (58) or aortoiliac occlusive disease (42). Conventional aortic surgery was undertaken in 88 patients, and in 12 patients adjunctive procedures to enhance colonic perfusion were performed 14 times, including IMA reimplantation (8), direct bypass to the internal iliac artery (4), and anastomosis of an aortofemoral bypass limb to adjacent common iliac artery (2). Colonoscopy was performed within 24 to 48 hours of aortic reconstruction. Three patients had endoscopic evidence of colonic ischemia. Transmural infarction did not develop in any patient, and bowel resections or diverting colostomies were not necessary. Three patients died, none manifesting colonic ischemia. The 12% utilization of adjunctive procedures to enhance blood flow in the colon was substantially greater than the 4% frequency of an earlier experience from our institution in which nearly half of the 5.7% operative mortality was attributed to colonic infarction. Attention to factors contributing to ischemia of the colon, and more frequent adjunctive revascularization of the colon, may lessen this complication of aortic reconstructive surgery.

Angiography↗
PubMed1989

Gastrointestinal disconnection and the treatment of intra-abdominal sepsis.

Current operative treatment for intra-abdominal sepsis secondary to internal gastrointestinal fistulas is aimed at wide drainage of septic foci and elimination of continued peritoneal soilage. Although methods for surgical drainage of abscesses and fistulous tracts are well established, the optimal method for surgical prevention of continued peritoneal soilage remains controversial. The authors applied the principle of complete gastrointestinal disconnection and performed diversion of the gastrointestinal tract and tube decompression proximal to the fistulous opening in the treatment of 22 critically ill patients with intra-abdominal sepsis from gastric or small bowel fistulas. Patient survival varied according to the level of the site of gastrointestinal leakage. All patients (5 out of 5) who had leakage in the distal small bowel survived. Six of nine (66%) patients with leakage from the proximal jejunum and six of eight (75%) of patients with gastroduodenal leakage survived. The overall survival rate of 77 per cent observed in this group of patients supports the authors' hypothesis that complete gastrointestinal disconnection is a valuable adjunct in the treatment of these severely ill patients.

Abdomen↗