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Biomedical subjects

R B Smith

Publications and source records attributed to R B Smith.

At least 55 records · Page 3Linked to original sources
PubMed1996

Views of Pacific Islands people with noninsulin dependent diabetes: a Wellington survey.

AIMS: The aims of the study were: (1) to ascertain the views of Pacific Islands people with diabetes on diabetes services they are receiving, and (2) to identify their perceptions on their health and diabetes related problems. METHODS: A random sample survey of Wellington and Kenepuru diabetes clinics and the Wellington Pacific Islands community was undertaken using person to person interviews by seven trained Pacific Islands interviewers. The Tokelau Migrant Study questionnaire of Dr Ian Prior formed the basis for the questions used in this study. RESULTS: The sample size was 120. Response rate 82.2%. Samoans were the main ethnic group at 62% and women the dominant gender at 75%. Mean age was 46%. Eighty eight percent presented with symptoms at diagnosis and 64% had diabetes of 5 years standing or more. Seventy eight percent were on diet and/or tablets and 73% reported having complications of which visual impairment was the most common. Twenty four percent were not happy with the current service. Fifty nine percent knew little or nothing about diabetes and 78% expressed a desire to know more. Good control was reported by 59%, and 66% reported they followed a diet. Forty five percent admitted having an overweight problem and 57% reported losing weight since diabetes diagnosed. Forty five percent knew how to test their blood sugar and 26% tested at home. Eighty nine percent favoured a specific service for Pacific Islands people with education being the major emphasis. More than a third preferred service to be near home and run by Pacific Islands health professionals. CONCLUSION: The majority of Pacific Islands people developed symptoms before going to see a doctor. It indicated that the majority have suffered from diabetes for a long time before seeking medical care for the first time. Most indicated being happy with the services they are receiving from their family doctors but if given a choice they would prefer a service specifically for themselves. Diabetes education as well as a treatment clinic were services most favoured with the preference close to home and to be delivered by Pacific Islands health professionals.

Adult↗
PubMed1996

Carotid endarterectomy in patients with contralateral carotid occlusion: review of a 10-year experience.

A total of 116 carotid endarterectomies were performed in patients with a totally occluded opposite internal carotid artery over a 10-year period from 1983 until 1992. The average age of patients was 66.4 years; 75% were men and 25% were women. The average degree of stenosis on the operated side was 76.7%. Twenty-one patients (18.1%) had had a documented previous stroke referrable to the side of the occlusion; 22 had a neurologic deficit attributable to the occluded vessel at the time of preoperative evaluation. Indications for surgery included transient ischemic attacks in 35 (30.2%), ipsilateral stroke in 10 (8.6%), amaurosis fugax in 11 (9.5%), and high-grade asymptomatic stenosis in 60 (51.7%). Forty-eight percent of the procedures were performed using local anesthesia, with intraluminal shunts inserted in all except one patient. The combined 30-day mortality and stroke morbidity in this population was 4.3%, which is comparable with a combined stroke and death rate of 4.0% among 956 patients without contralateral carotid occlusion undergoing endarterectomy during this period. This experience suggests that endarterectomy can be performed safely in the patient with internal carotid occlusion and is an important mechanism for the prevention of stroke.

Adult↗
PubMed1996

Empirical reconstruction of the renal artery: long-term outcome.

PURPOSE: Unequivocal indications for renal artery reconstruction remain the presence of significant underlying renal insufficiency or severe hypertension. Thus surgical intervention for renal artery stenosis in the absence of this clinical picture may well be considered empirical and, as a consequence, treatment recommendations are ill-defined. Our experience with reconstruction of the minimally symptomatic or asymptomatic renal artery lesion in association with primary aortic repair over a 10-year period was reviewed. METHODS: Thirty-two patients who had atherosclerotic renal artery stenosis > or = 70% underwent prophylactic renal revascularization between 1982 and 1992. The patients' median age was 63 years (range, 44 to 79 years); 23 (72%) were men and nine (28%) were women. All had preoperative serum creatinine levels < or = 1.7 mg/dl (1.29 +/- 0.24 mg/dl) and were receiving either no antihypertensive medication (22%) or only a single agent (78%). Aortoiliac occlusive disease was present in 38% of this population, and aortic aneurysmal disease either alone or in combination with occlusive disease was found in 62%. RESULTS: Operative management included unilateral renal artery repair in 21 patients (66%) and bilateral renal revascularization in the remaining 11 (34%). The median decrease in postoperative serum creatinine level (> or = 7 days after operation) was 0.81 +/- 0.05% (mean postoperative serum creatinine level 1.27 +/- 0.07 mg/dl). The 30-day operative mortality rate was 3.1% (1 of 32). Late follow-up was available for 96% of patients (30 of 31; median, 64 months). Kaplan-Meier life table analysis revealed a 5-year probability of survival of 90.2% (95% confidence interval, 0.802 to 1.00). Stability of renal function was assessed by modeling the change in serum creatinine level over time with the intraclass correlation model. A serum creatinine level (mg/dl) = 1.3348 + 0.0011 x time (months) demonstrated minimal deterioration of excretory function during the observation period. Furthermore, the blood pressure of the majority of patients (75%) remained normal either with a single agent or without medication. Recurrent stenosis in one patient required treatment by percutaneous transluminal angioplasty. CONCLUSIONS: Adjunctive repair of the renal artery may be an appropriate option in selected patients who undergo simultaneous aortic surgery, even in the absence of severe hypertension or renal insufficiency. Surgical intervention can be accomplished with acceptable perioperative morbidity rates, and stability of renal function is sustainable in the majority of patients.

Adult↗
PubMed1996

Secondary recurrent carotid stenosis.

PURPOSE: Recurrent carotid stenosis after carotid endarterectomy has been extensively reported. The occurrence, however, of another ipsilateral restenosis that requires a third carotid operation is rare. The purpose of this study was to evaluate possible risk factors and the most efficacious management of the patient with "secondary" recurrent carotid stenosis. METHODS: A survey of the Southern Association for Vascular Surgery was performed, and 31 patients who had had surgery for secondary recurrent carotid stenosis were identified. RESULTS: The mean interval between the recurrent stenosis operation and secondary recurrent carotid stenosis was 39.8 months (range, 9 to 83 months). At the third operation, 21 patients underwent carotid patch angioplasty and 10 underwent carotid resection with an interposition saphenous vein graft. No postoperative strokes or deaths occurred; three patients (10%) had a peripheral nerve injury. Nine early (< 24 mo) secondary recurrent carotid stenoses occurred, and these patients underwent patch angioplasty. Twenty-three female, cigarette-smoking patients and 20 patients with elevated lipid levels had early restenosis and were identified as being at high risk for the development of another stenosis. A fourth significant stenosis developed in five of these high-risk patients who had saphenous vein patch angioplasty at their third carotid operation; eight other high-risk patients had carotid resection with an interposition saphenous vein graft, and no other stenosis developed. CONCLUSION: Patients who have secondary recurrent carotid stenoses can safely undergo a third carotid operation. Female habitual smokers with elevated lipid levels and an early restenosis appear to be at high risk of secondary recurrent carotid stenoses. When surgery is necessary, carotid resection with an interposition saphenous vein graft appears more durable than patch angioplasty.

Adult↗
PubMed1996

Tracheal gas insufflation combined with high-frequency oscillatory ventilation.

OBJECTIVES: To determine the efficacy of tracheal insufflation delivered by two different catheter designs on CO2 elimination when used in conjunction with high-frequency oscillatory ventilation. DESIGN: A nonrandomized before and after trial. Each animal served as his own control. SUBJECTS: Ten mongrel dogs weighing 20.9 +/- 1.9 kg. Four animals were assigned to a normal lung group and six animals underwent lung injury by large volume saline lavage. INTERVENTION: Permissive hypercapnia was allowed to occur by selecting oscillator settings that would lead to alveolar hypoventilation. Proximal mean airway pressure was kept constant. Tracheal gas was insufflated at 1 cm above the carina for 30 min periods at gas flows of 5 to 15 L/min. MEASUREMENTS AND MAIN RESULTS: Carinal pressure, hemodynamic parameters (cardiac output, mean arterial pressure, pulmonary artery occlusion pressure), and gas exchange parameters (PaCO2, PaO2, PaO2/FIO2, shunt fraction, D O2) were measured. For the normal dogs, at catheter flow of 15 L/min; the forward thrust catheter increased carinal pressure and Pao2/FIO2 BY 30% (p<.003) and 105% (p<.005), respectively. The forward thrust catheter reduced Paco2 by 40% (p<.04). The reverse thrust catheter increased PaO2/FIO2 by 102% (p<.001) and decreased pressure and PaCO2 by 44% (p<.001) and 34% (p<.003), respectively. For the injured dogs, at catheter flow rate of 15 L/min, the forward thrust catheter increased carinal pressure, PaO2, and PaO2/FIO2 by 6% (p<.001), 23% (p<.001), and 24% (p<.02), respectively. The forward thrust catheter reduced PaCO2 by 29% (p<.002). The reverse thrust catheter increased PaO2 and PaO2/FIO2 both by 11% (p<.02) and reduced carinal pressure and PaCO2 by 23% (p<.001) and 18% (p<.002), respectively. CONCLUSIONS: Tracheal gas insufflation is capable of improving oxygenation and ventilation in acute lung injury when combined with high-frequency oscillatory ventilation. The addition of this second gas flow at the level of the carina raises or lowers distal airway pressure, the magnitude of which is dependent on the direction and rate of gas flow. The beneficial effects of tracheal gas insufflation may be tempered by the long-term effects of altering distal airway pressure; lowering distal airway pressure may lead to atelectasis, whereas raising distal airway pressure may lead to an auto-positive end-expiratory pressure (auto-PEEP) effect.

Animals↗
PubMed1996

Unique case presentations of acute epiglottic swelling and a protocol for acute airway compromise.

Acute epiglottitis is a well-described life-threatening disease. Since the generalized use of the Haemophilus influenzae type B (HIB) vaccine, presentations of this disorder have decreased dramatically in children. Presentations of this and other acute epiglottic swelling can vary remarkably and may easily be misdiagnosed by physicians who have little or no experience with the acutely obstructed airway. Early suspicion and a proper evaluation is mandatory to prevent a life-threatening crisis. Six patients are presented with unusual presentations of acute epiglottic swelling from differing etiologies; these include the following: case 1, recurrent epiglottitis; case 2, chronic epiglottitis; case 3, traumatic epiglottitis; case 4, caustic ingestion; and cases 5 and 6, simultaneous infection of family members. Because the incidence of acute epiglottitis is decreasing, it has become rare at most institutions. To help primary care and emergency room physicians, a formal written protocol should be available at medical facilities that might be faced with patients presenting with acute airway obstruction. An "acute airway obstruction protocol" used successfully for the last decade is offered. Use of such a written document might be life-saving for patients with impending upper airway obstruction. The otolaryngologist is a key member of the recommended multidisciplinary team.

Acute Disease↗
PubMed1996

Cost-efficient radical prostatectomy with a clinical care path.

PURPOSE: We assessed changes in hospital costs and resource use among patients undergoing radical prostatectomy following implementation of a clinical care path. MATERIALS AND METHODS: A standardized clinical care path for patient management before and after radical prostatectomy was developed and implemented at a large academic medical center in California. All 577 consecutive patients undergoing radical prostatectomy during the 3 years before and 1 year after implementation of the care path were included in the study. Each patient was entered prospectively into a hospital-wide financial data base, which served as the source for observations on hospital costs, hospital charges and length of stay. RESULTS: After implementation of the radical prostatectomy care path hospital costs decreased by 12% ($7,916 versus $6,934, p < 0.001), hospital charges decreased by 20% ($17,005 versus $13,524, p < 0.0001) and length of stay decreased by 28% (5 versus 3.6 days, p < 0.0001). Decreases were noted in all categories of the hospital patient financial profile, except operating room charges. CONCLUSIONS: By standardizing preoperative and postoperative management for patients undergoing radical prostatectomy, significant savings can be achieved over and above existing trends toward shorter hospital stays and lower hospital costs.

Aged↗
PubMed1995

Clinical audit and standardised follow up improve quality of documentation in diabetes care.

AIM: High quality of follow up data is important in improving diabetes care. Our aim was to improve quality of documentation and diabetes care by using a combination of clinical audit and standardised follow up. METHODS: During 2 months in 1991-2 the records of all patients attending the diabetes clinic were reviewed. Quality of documentation was assessed for diabetic medication, hypoglycaemia, glycoprotein level, body weight, smoking history, blood pressure, albuminuria, visual acuity, fundi examination, neuropathy, foot inspection, peripheral vascular disease, cerebrovascular disease, ischaemic heart disease and serum cholesterol. For all parameters results and documented interventions were noted. A standardised follow up form was then introduced and the audit was repeated in 1993-4. RESULTS: 156 patients were included in 1991-2 and 138 in 1993-4. There were no differences between the two groups with regards to baseline demographic data. Follow up data for 10 parameters were between 1.15 and 5.35 times more likely to have been recorded in 1993-4. The other 5 items were as likely to have been recorded in 1991-2 as in 1993-4. However, the differences between the two audits were less convincing and inconsistent for number of abnormalities detected in each group and whether abnormal results led to documented actions. CONCLUSIONS: These results show that repeated audit and standardised follow up can improve the quality of documentation of diabetic follow up, but that this does not necessarily mean that a higher proportion of abnormal results will be detected and acted upon. Additional practice protocols may be necessary to achieve this.

Diabetes Mellitus↗
PubMed1995

Morbidity and mortality associated with carotid endarterectomy: effect of adjunctive coronary revascularization.

The occurrence of significant carotid disease in patients requiring coronary revascularization results in the dilemma of whether simultaneous or staged operations should be performed. To determine appropriate therapy we reviewed this experience at Emory University Hospital. During a 10-year period from 1983 to 1992, 110 patients underwent carotid endarterectomy during the same hospitalization or simultaneously with coronary artery bypass; 907 patients underwent carotid endarterectomy alone during the same period. The combined 30-day postoperative stroke and death rate was 18.2% for the 110 patients undergoing concomitant procedures. When comparing morbidity and mortality rates for those having simultaneous carotid endarterectomy and coronary artery bypass with those having delayed coronary artery bypass, the latter group was found to have a 6.6% combined risk of postoperative stroke or death within 30 days, whereas those undergoing simultaneous procedures had a 26.2% rate. In the control group of 907 patients undergoing carotid endarterectomy alone during the same period, the combined 30-day mortality and stroke morbidity rate was 2.1%. Although the patient population undergoing simultaneous carotid and coronary revascularization may have more severe disease, we believe that combining the procedures during the same operative setting results in an increased perioperative stroke and death rate. Consequently only extremely high-risk patients are selected for simultaneous procedures; otherwise our experience suggests that delaying coronary artery bypass by several days will reduce overall postoperative mortality and stroke morbidity.

Cerebrovascular Disorders↗
PubMed1995

The occluded renal artery: an ongoing surgical challenge.

Nephrectomy and revascularization are currently the preferred options in the management of the chronically occluded renal artery in patients with renovascular hypertension or renal insufficiency. We review our experience with these two options including early and late functional outcome. Between December 1982 and August 1993, chronic occlusion of the main renal artery was documented in 30 patients. Patients were categorized with respect to surgical intervention: group I underwent nephrectomy (on the occluded side) plus contralateral revascularization and group II underwent revascularization of the occluded renal artery. The median age at the time of operative intervention was 63 years; 53% of the patients were women and 47% were men. Hypertension was poorly controlled (> or = 3 medications) in 19 patients, and the preoperative serum creatinine level was > 1.8 mg/dl in 24 patients (mean 2.6 +/- 1.4 mg/dl). There were 16 patients in group I and 14 patients in group II, and there were no perioperative deaths. Estimated glomerular filtration rate (> or = 7 days after operation) was either unchanged or improved in 15 of 16 patients in group I and in 13 of 14 in group II, one of whom became dialysis dependent. Follow-up data were available for 25 of 30 (83%) patients (mean 45 months; range 1 to 108 months). Excluding one early failure, 10 of 13 patients in group I and 7 of 11 in group II did not have end-stage renal disease at last follow-up. Overall, hypertension was cured or improved in 16 of 21 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1995

Peripheral vascular complications of aortic dissection.

BACKGROUND: The incidence and management of peripheral vascular complications of aortic dissection is unsettled. PATIENTS AND METHODS: Peripheral vascular complications of spontaneous aortic dissection were examined in a 5-year retrospective review. Patients who had peripheral vascular complications were categorized as group A; those without as group B. RESULTS: Thirty-eight major vessels were affected in 18 patients. No patient underwent a peripheral vascular procedure for complications of the carotid, subclavian, celiac, mesenteric, or renal arteries. Three patients underwent femorofemoral bypass for acute iliofemoral occlusion due to dissection. A fourth patient had repair of an iliac aneurysm that developed as a complication of chronic dissection. The mortality rate was 17% for group A, 9% for group B, and 10% overall. Following repair of the aortic dissection, the majority of the peripheral vascular complications resolved. CONCLUSIONS: Peripheral revascularization is infrequently required in aortic dissection following primary dissection repair.

Adult↗
PubMed1995

Carotid artery shortening: a safe adjunct to carotid endarterectomy.

PURPOSE: Kinks and coils of the extracranial carotid artery system have been described in conjunction with atherosclerotic disease of the internal carotid artery. The purpose of this study was to determine whether adding a carotid artery shortening procedure to carotid endarterectomy affected perioperative mortality and stroke-morbidity rates or late restenosis. METHODS: A retrospective chart review of all patients who concurrently underwent carotid endarterectomy and ipsilateral carotid artery shortening between 1983 and 1992 was performed. Long-term follow-up was obtained by contacting the primary physician or patient, and carotid artery duplex scans were obtained. RESULTS: One hundred seven patients were found to have undergone concurrent carotid endarterectomy and carotid artery shortening. The age range was 47 to 89 years, with 53 female and 54 male patients. Indications for surgery in this group were transient ischemic attacks in 28%, stroke in 18%, amaurosis fugax in 7%, and high-grade asymptomatic stenosis in 47%. Shortening procedures were performed by use of a variety of techniques at the completion of endarterectomy. The combined 30-day mortality and stroke morbidity rate was 2.7%, with two postoperative deaths and one stroke. In this same period, a total of 1072 carotid endarterectomies were performed, and the combined 30-day mortality and stroke morbidity rate was 4.0%. During late follow-up there were no ipsilateral strokes, recurrent symptoms, or significant restenoses. CONCLUSIONS: This experience suggests that the addition of a shortening procedure to carotid endarterectomy can be performed without increased morbidity and mortality rates and, when deemed appropriate, is a procedure with which the vascular surgeon should be familiar.

Aged↗
PubMed1995

Treatment of recurrent cerebrovascular disease. Review of a 10-year experience.

OBJECTIVE: The authors determined whether carotid endarterectomy in patients with recurrent cerebrovascular disease poses a greater perioperative risk than for those individuals undergoing first-time carotid endarterectomy. SUMMARY BACKGROUND DATA: A percentage of patients undergoing carotid endarterectomy for atherosclerosis experience recurrent cerebrovascular disease. Reoperation may be difficult because of postoperative scarring of the soft tissues of the neck and the carotid artery itself. Such patients were believed to be at greater risk for perioperative morbidity than those undergoing first-time carotid endarterectomy. METHODS: To address this concern, the authors retrospectively reviewed their experience with 69 patients who underwent repeat carotid endarterectomies over a recent 10-year period of time. This subgroup represented 6.4% of 1072 total carotid endarterectomies performed during the same time period. The average extent of stenosis on the operated side was 81% and the time elapsed after previous endarterectomy averaged 83 months. Twelve patients (17.4%) had contralateral internal carotid occlusion, and 30 patients (43.5%) had undergone previous endarterectomies on the contralateral side. RESULTS: Complications within 30 days of operation included two deaths (2.9%) and one stroke (1.4%), for a combined stroke and death rate of 4.3%. Six patients developed cervical hematomas requiring drainage; one of these had rupture of a saphenous vein patch. No patient had a significant cranial nerve injury in the reoperative group, whereas 2.0% of patients undergoing first-time carotid endarterectomy had cranial nerve injuries. Overall, these results compared favorably with a combined stroke and death rate of 4.0% among 1003 patients who underwent first-time carotid endarterectomy during the same period. CONCLUSIONS: This review suggests that repeat carotid endarterectomy can be performed safely in individuals with severe recurrent carotid stenosis, with morbidity and mortality rates similar to those for patients undergoing first-time carotid endarterectomies. For this population, reoperative carotid endarterectomy represents a safe and important mechanism for the prevention of stroke.

Aged↗
PubMed1995

Orally administered progesterone enhances sensitivity to triazolam in postmenopausal women.

An endogenously formed metabolite of progesterone, 3 alpha-hydroxy-5 alpha-dihydroprogesterone (3 alpha-OH-5 alpha-DHP) modulates the gamma-aminobutyric acid receptor complex and plays a physiologic role in brain excitability regulation. On the basis of in vitro observations of 3 alpha-OH-5 alpha-DHP-enhanced [3H]flunitrazepam binding, we investigated the potential clinical effect of coadministering oral progesterone and triazolam. Sixteen postmenopausal women were randomly assigned to receive either intravenous triazolam plus oral progesterone 300 mg (TRZPROG) or intravenous triazolam plus oral placebo (TRZ). Triazolam was infused until 0.5 mg was given or until a predetermined maximal response was attained. Pharmacodynamic evaluation included DSST, continuous performance test, hand-eye coordination, short-term memory, and sedation. Effect ratios were calculated as the ratio of area under the effect-time curve to area under the curve (AUC). Variants of the sigmoid Emax model were fit to the data from the three psychomotor performance tests. A triazolam dose of less than 0.5 mg was administered to seven of eight subjects in the TRZPROG and five of eight subjects in the TRZ group, resulting in lower triazolam AUC values for the TRZPROG than for the TRZ group (p = 0.0275). There was clear evidence for a pharmacodynamic interaction. Mean effect ratios for all tests were greater in the TRZPROG group than in the TRZ group (DSST, p = 0.0097; continuous performance test, p = 0.0338; hand-eye coordination, p = 0.0041). The TRZPROG group had lower EC50 values than the TRZ group (DSST, p = 0.0435; continuous performance test, p = 0.0381; hand-eye coordination, p = 0.0154).(ABSTRACT TRUNCATED AT 250 WORDS)

Administration, Oral↗