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Biomedical subjects

R B Smith

Publications and source records attributed to R B Smith.

At least 145 records · Page 8Linked to original sources
PubMed1991

Focused psychiatric review: impacts on expense and utilization.

Focused Psychiatric Review, Aetna's inpatient mental health utilization review program, reduces length of stay and stabilizes admission rates and, as a consequence, reduces expenses, according to the study reported in this article. The program has greater impact on psychiatric than on substance abuse treatments. The best estimate of annual net program savings is $34.90 per covered employee, a return of $12.60 saved for each program dollar spent.

Data Collection↗
PubMed1991

Renal artery occlusive disease.

Renal artery occlusive disease, from either atherosclerosis or fibrous dysplasia, may cause hypertension or renal insufficiency. Hypertension results from increased activity of the renin-angiotensin-aldosterone system. There are several ways to evaluate this system as well as several pharmacologic agents that will intervene and modulate the hypertension that results. Percutaneous transluminal angioplasty or surgical revascularization will be necessary in some patients to control blood pressure or improve renal function. Successful evaluation and treatment of these patients are based on clinical experience, an understanding of the natural history of the various disease processes involved, and a comprehensive team approach.

Angioplasty, Balloon, Coronary↗
PubMed1990

Emphysematous pyelonephritis: case report.

We report a case of emphysematous pyelonephritis in a diabetic patient with some atypical features with a successful surgical outcome. This uncommon complication should be considered in any diabetic patient with fulminant or resistant pyelonephritis.

Diabetes Mellitus, Type 2↗
PubMed1990

Clinical and ethnic characteristics associated with urinary albumin excretion in noninsulin dependent diabetic subjects attending the Wellington Hospital diabetes clinic.

In noninsulin dependent diabetes, elevation of urinary albumin excretion above the normal range is thought to predict increased mortality. A random urinary albumin/creatinine ratio and the following clinical characteristics were recorded on 405 patients with noninsulin dependent diabetes attending the Wellington Hospital diabetes clinic; (1) ethnic origin, (2) age, (3) sex, (4) age at diagnosis, (5) duration since diagnosis of diabetes, (6) body mass index, (7) systolic blood pressure, (8) diastolic blood pressure, (9) retinopathy, (10) insulin therapy, (11) antihypertensive therapy, and (12) the presence or absence of treated cardiovascular disease. The overall prevalence of elevated urinary albumin/creatinine ratio (greater than 2.2 mg/mmol) was 45%. Stepwise regression analysis showed that 12% of the variability of urinary albumin/creatinine ratio in our clinic population could be accounted for by ethnic origin of patients, with noncaucasians (the Maori, Pacific Islanders and Asians) having a higher urinary albumin excretion than caucasians (p less than 0.001). Systolic blood pressure, retinopathy and cardiovascular disease predicted a further 8% of this variability. The cause of this ethnic difference in urinary albumin excretion and its possible relationship to excess mortality in noncaucasians is not yet known.

Adolescent↗
PubMed1990

Alprazolam in the elderly: pharmacokinetics and pharmacodynamics during multiple dosing.

Previous studies have suggested that elderly men eliminate alprazolam more slowly than young adults. This study in the elderly was designed to determine whether a change in pharmacokinetics influences the response to alprazolam during multiple dose regimens. In addition, the study was designed to determine alprazolam pharmacokinetics and the degree to which its hydroxymetabolites accumulate, the degree of psychomotor impairment, and whether tolerance to impairment and sedation develops during three different multiple dose regimens. Twenty-six subjects completed this study. The subjects were randomized into one of three treatment groups: 0.25 mg q8h, 0.5 mg q8h, and 2 mg q12h. Subjects remained in the clinic for 8 days (day -2-day 5). Day 0 was used as a drug free testing day to establish baseline scores for sedation, digit symbol substitution (DSS), card sorting (CS) tasks, and two computer tests. Subjects received the drug according to schedule on days 1 through 4, with day 5 as the washout day. Blood samples were assayed for alprazolam, alpha-hydroxyalprazolam and 4-hydroxyalprazolam. Alpha-hydroxyalprazolam concentrations were below assay detection limits in all subjects in the 0.25 and 0.5 mg q8h groups and less than or equal to 2.6 ng/ml in the 2 mg q12h group. When detectable, 4-hydroxyalprazolam concentrations were less than 10% of the corresponding alprazolam concentration. Mean alprazolam oral clearance values in the three treatment groups ranged between 0.54 and 0.62 ml/min/kg and half-lives were in excess of 21 h. Degree of sedation and impairment was dose related. Sedation and impairment was not higher on day 4 despite concentrations 2-3 times as great as on day 1, indicating development of tolerance. Subjects were not, however, back to baseline level of performance on day 4.

Aged↗
PubMed1990

Characterization of [3H]alprazolam binding to central benzodiazepine receptors.

The binding of the triazolobenzodiazepine [3H]alprazolam was studied to characterize the in vitro interactions with benzodiazepine receptors in membrane preparations of rat brain. Studies using nonequilibrium and equilibrium binding conditions for [3H]alprazolam resulted in high specific to nonspecific (signal to noise) binding ratios. The binding of [3H]alprazolam was saturable and specific with a low nanomolar affinity for benzodiazepine receptors in the rat brain. The Kd was 4.6 nM and the Bmax was 2.6 pmol/mg protein. GABA enhanced [3H]alprazolam binding while several benzodiazepine receptor ligands were competitive inhibitors of this drug. Compounds that bind to other receptor sites had a very weak or negligible effect on [3H]alprazolam binding. Alprazolam, an agent used as an anxiolytic and in the treatment of depression, acts in vitro as a selective and specific ligand for benzodiazepine receptors in the rat brain. The biochemical binding profile does not appear to account for the unique therapeutic properties which distinguish this compound from the other benzodiazepines in its class.

Alprazolam↗
PubMed1990

Comparison of urinary albumin excretion between Maoris, Pacific Island Polynesians and Europeans with non-insulin-dependent diabetes.

Elevated urinary albumin excretion is a marker for increased mortality and morbidity in European subjects with non-insulin-dependent diabetes. Urinary albumin excretion was compared in 32 Maoris, 34 Pacific Island Polynesians and 66 subjects of European origin with non-insulin-dependent diabetes attending a diabetes clinic in Wellington, New Zealand. The random urinary albumin to creatinine ratio was used as an estimation of urinary albumin excretion rate. The random urinary albumin to creatinine ratio was significantly higher in Maori and Pacific Island Polynesian subjects, compared to diabetic Europeans (geometric mean urinary albumin to creatinine ratios were 13.13, 12.00 and 2.79 mg/mmol respectively, P less than 0.05). These findings would be consistent with the high mortality and morbidity seen in the Maori and Pacific Island Polynesian diabetic populations. The correlation between hypertension and increased urinary albumin excretion was stronger in the Europeans than in the Maoris and Pacific Island Polynesians studied, suggesting that differences in blood pressure alone are unlikely to account for the observed differences in albumin excretion. Follow-up studies are required to determine whether diabetic Maoris and Pacific Island Polynesians with increased urinary albumin excretion have a similar prognosis to their European counterparts.

Albuminuria↗
PubMed1990

Primary popliteal venous aneurysm with recurrent pulmonary emboli.

Primary venous aneurysms are infrequently noted and rarely have clinical significance. An important exception, however, is an aneurysm of the popliteal vein that is known to be a source for pulmonary emboli. We present the case of a previously healthy 57-year-old man with recurrent episodes of occult pulmonary embolism. Initial diagnostic investigations were compatible with multiple pulmonary emboli, but no source was identified. Subsequently, an indium 111-labeled platelet scan confirmed a site of active thrombus formation in the right lower extremity above the knee. Magnetic resonance imaging defined a saccular aneurysm of the popliteal vein, which was confirmed by contrast venography. Thereafter, the patient had resection of the venous aneurysm and tangential venorrhaphy. After operation duplex scanning confirmed patency of the venous repair. This is the eleventh report in the English-language literature of pulmonary emboli suspected of having originated from a popliteal venous aneurysm.

Aneurysm↗
PubMed1990

The value of pulmonary artery and central venous monitoring in patients undergoing abdominal aortic reconstructive surgery: a comparative study of two selected, randomized groups.

One hundred two patients undergoing abdominal aortic reconstructive surgery were prospectively, randomly allocated to two groups, one of which was monitored with a central venous catheter and the other with a pulmonary artery catheter. Patients with uncompensated cardiopulmonary or renal disease were excluded from the study. General anesthesia was administered for the surgical procedure, and the patients were followed through hospital discharge. No statistically significant differences occurred between the two groups with regard to morbidity (perioperative cardiac, pulmonary or renal sequelae), mortality rate, duration of intensive care, postoperative hospital stay, or cost of hospitalization. The one statistically significant difference between groups was the professional fee charged for anesthetic care, which was higher for patients with pulmonary artery catheters than for those with central venous catheters. In conclusion, we prospectively gathered data from most patients presented for abdominal aortic reconstructive surgery. Our data seem to indicate that the choice of central venous catheter or pulmonary artery catheter monitoring makes little difference in outcome after abdominal aortic reconstructive surgery, and that for many patients pulmonary artery catheters are not necessary to give appropriate, adequate care. Because of the size of the sample, however, declarations of epidemiologic significance would be unfounded. Therefore large-scale, multicenter studies addressing such outcomes remain necessary.

Anesthesia, General↗
PubMed1990

Modified system outcome score and outcome index--method of monitoring patient care in a special care area.

A scoring system intended both to assess mortality risk and permit surveillance, evaluation, and comparison of medical care was developed in our surgical ICU. Five simple clinical indices of organ system failure were selected and weighted according to their statistically validated relationship to mortality, resulting in a daily System Outcome Score (SOS). Cluster analysis was used to divide the creation data set of 2,777 patients into suitable groupings of scores to predict mortality; the clustering was confirmed for reproducibility with a validation set of an additional 2,860 patients. Based on this validation of the scoring system, two computer-controlled patient care surveillance techniques were developed. The first involved the definition of three unfavorable SOS patterns evolving during the course of a patient's admission. Detection of one or more of these patterns, described by the acronym SDL, permits review of the care administered to the specific patient generating the pattern. A global assessment of care is achieved with the Outcome Index (OI), which relates overall mortality risk in the ICU to the actual mortality rate over a given time period. Effectiveness of care can then be compared between different time periods within the one unit or between different units with similar patient mix. The overall system offers the potential for a surveillance-based quality assurance system with widespread applicability.

Hospital Information Systems↗
PubMed1990

The relationship of alprazolam dose to steady-state plasma concentrations.

Alprazolam is a widely used antianxiety agent, yet relatively little is known about the relationship between chronic oral doses and steady-state plasma levels. This study examines the relationship over a wide range of therapeutic doses. We conducted a parallel, double-blind, placebo-controlled study in 36 patients with agoraphobia with panic attacks, or panic disorder with limited phobic avoidance based on DSM-III criteria. Patients received alprazolam (N = 25) or placebo (N = 11) beginning at 1 mg/day and increased weekly until either a maximum tolerated dose or 10 mg/day was achieved. Dosages were then gradually tapered according to a predetermined schedule. The entire study period lasted 14 weeks. Laboratory and clinical assessments were conducted weekly. Doses up to 6 mg/day were tolerated by 80% of patients on alprazolam and doses of 10 mg/day were tolerated by 40% of patients. Twenty-seven percent of the placebo patients reached 10 tablets/day. In the alprazolam group, the principal cause of intolerance was sedation. Throughout the study no significant changes in vital signs or laboratory parameters were observed. Steady state alprazolam, 4-hydroxy alprazolam, and alpha-hydroxy alprazolam plasma levels were linearly related to dose. A 1 mg dosage increment produced, on the average, a corresponding 10 ng/ml increase in steady state level of the parent drug. Significant response was observed in subjects who achieved concentrations greater than 20 ng/ml, with a maximum of 81% of the samples classified as responders within the 60 ng/ml and above group.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1990

The effect of colestipol dose on postprandial serum bile acid concentration: assessment by an enzymic bioluminescence procedure.

A dose-response study was performed with three doses of colestipol, using postprandial serum bile acid levels to assess bile acid sequestering activity in 40 volunteers with asymptomatic hyperlipidaemia. Subjects who entered the study had total serum cholesterol concentrations greater than 220 mg/dl and triglyceride concentrations less than 200 mg/dl. They were randomly assigned to one of four parallel treatment groups: (a) placebo b.d., (b) colestipol (as Colestid hydrochloride granules) 2.5 g b.d., (c) colestipol 5 g b.d., and (d) colestipol 7.5 g b.d. Subjects were maintained on a constant repeating solid diet throughout the 6-day study period, and colestipol was ingested 30 min before breakfast and dinner. No drug was administered on Days 1-3; baseline (pre-treatment) serum bile acid concentration profiles were determined on Day 3. The above treatments were given on Days 4-6, and total serum bile acid concentrations were determined at 30- or 60-min intervals for 10 h on Days 4 and 6. Serum bile acids were measured using a bioluminescence procedure which enzymically measures total 3 alpha hydroxy bile acids. Serum bile acid concentrations were significantly decreased from the pretreatment period by 5.0 and 7.5 g/day as compared to 2.5 g/day or placebo. Differences from the pre-treatment period in the area under the serum bile acid time curve revealed the same trends in the data as analysis of percentage difference (Day 6 vs pre-treatment period) in serum bile acid concentrations. These results indicate that postprandial serum bile acid concentrations are influenced by colestipol in a dose-related manner, with doses of 5 and 7.5 g b.d. having a significantly greater effect than 2.5 g b.d. The dose of 7.5 g b.d. had an identical effect on serum bile acid patterns as a dose of 5.0 g t.d.s., which was previously reported. Our findings also show that changes in serum bile acid concentrations may be used to follow the immediate effects of bile acid sequestration in hypercholes terolaemic subjects, and that the bioluminescence enzyme technique is sufficiently sensitive to detect such changes.

Bile Acids and Salts↗
PubMed1990

Value of a centralised approach in the management of haematemesis and melaena: experience in a district general hospital.

All patients presenting with acute upper gastrointestinal bleeding between November 1986 and April 1988 were admitted to a centralised joint medical/surgical unit, with a policy of early clinical and endoscopic assessment and rapid surgical intervention in those at high risk. Of the 430 patients admitted 69.5% were over the age of 60 and 30% had significant additional medical conditions. 50.4% were bleeding from peptic ulcers and one third had been taking non-steroidal anti-inflammatory agents. Fifty five patients underwent surgery, which in two thirds was carried out within 24 hours of admission, usually for continued bleeding. In patients with peptic ulcer the operation rate was 21.6%. Overall mortality was 3.7%, and in those with bleeding gastric or duodenal ulcers 5.5%; surgical mortality in the later group was 15.2%. All patients who died had serious concomitant pathology and 87% were over 70 years of age. Adoption of a centralised approach to management of haematemasis and melaena is feasible in a District General Hospital and associated with an improved survival.

Adult↗
PubMed1990

A general practice study to compare the efficacy and tolerability of a spray ('Otomize') versus a standard drop formulation ('Sofradex') in the treatment of patients with otitis externa.

In an open, multi-centre study in general practice, a comparison was made of the efficacy, tolerability and acceptability of a neomycin/dexamethasone preparation administered by metered-dose spray ('Otomize') and a framycetin/gramicidin/dexamethasone preparation ('Sofradex') administered as drops in 60 patients with otitis externa. Patients were allocated at random to receive one or other preparations 3-times daily for 10 days and were followed-up again 14 days after cessation of therapy. Clinical assessments were carried out under observer blind conditions on entry (Day 0) and on Days 10 and 24 of the severity of erythema, swelling and debris in the affected ear(s). A global assessment of clinical outcome was made by the doctor on Day 10. There were no significant differences in the two groups at the start of treatment. Significant improvement occurred in both groups from Day 0 to Day 10 and from Day 10 to Day 24 in all symptoms, with the proportion symptom-free in the 'Otomize' group significantly greater than in the 'Sofradex' group at 24 days, and approaching significance at 10 days. Significantly more patients in the 'Otomize' group were rated as having a good clinical outcome by the physician, and fewer patients experienced discomfort on application. Few side-effects were reported by either treatment group, none necessitating discontinuation of therapy.

Adolescent↗
PubMed1990

Comparative efficacy and tolerability of two antibacterial/anti-inflammatory formulations ('Otomize' spray and 'Otosporin' drops) in the treatment of otitis externa in general practice.

An open, multi-centre study was carried out in general practice to compare the efficacy, tolerability and acceptability of a neomycin/dexamethasone preparation administered by spray ('Otomize') and neomycin/polymyxin B/hydrocortisone administered as drops ('Otosporin') in the treatment of 187 patients with otitis externa. Patients were allocated at random to receive one or other preparation 3-times daily for 10 days irrespective of response and were followed up again 14 days after cessation of therapy. Assessments were made on entry and at Days 10 and 24 of the severity of erythema, swelling and debris. A global assessment of clinical outcome was made by the doctor on Day 10. There were no significant differences between the two groups at the start of treatment. Significant improvement occurred in both groups from Day 0 to Day 10 and from Day 10 to Day 24 in all symptoms, but no statistically significant differences were recorded between the two drugs. However, significantly more patients in the 'Otomize' group were rated as having a good clinical outcome by the physicians, and a highly significant number of patients, with previous experience of the use of ear drops, expressed a preference for the spray preparation. Few side-effects were reported by either treatment group, none necessitating discontinuation of therapy.

Administration, Topical↗