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Biomedical subjects

R L Gordon

Publications and source records attributed to R L Gordon.

At least 37 records · Page 2Linked to original sources
PubMed1999

Pulmonary function improves after expandable metal stent placement for benign airway obstruction.

STUDY OBJECTIVE: To determine whether expandable metal stent placement for benign airway lesions improves pulmonary function. DESIGN: Case series. SETTING: University medical center. PATIENTS: Nine patients who underwent balloon-mediated expandable metal stent deployment for airway obstruction due to benign etiologies. RESULTS: All nine patients had expandable stents deployed for benign airway lesions using fiberoptic bronchoscopy and fluoroscopic guidance. Pulmonary function improved after stent placement. The mean FVC increased by 388 mL (95% confidence interval [CI], 30 to 740 mL), the mean peak expiratory flow (PEF) increased by 1,288 mL (95% CI, 730 to 1,840 mL), the mean FEV1 increased by 550 mL (95% CI, 240 to 860 mL), and the mean forced expiratory flow between 25% and 50% of vital capacity (FEF25-75%) increased by 600 mL (95% CI, 110 to 1,090 mL). Corresponding relative measurements included increases in FVC (12%), PEF (95%), FEV1 (38%), and FEF25-75% (87%). The complete characterization of a benign airway obstruction generally required a multimodal approach. CONCLUSIONS: Expandable metal stent placement appears to be an effective therapy for benign airway obstruction.

Adult↗
PubMed1999

Aortomonoiliac endovascular grafting combined with femorofemoral bypass: an acceptable compromise or a preferred solution?

The relative merits of aortomonoiliac and bifurcated stent-graft configurations depend on the patient's arterial anatomy and clinical status. Aortomonoiliac stent-grafts are simple to make, simple to insert, and versatile. They are most useful when the iliac artery anatomy is severely distorted and the patient is old, sick, and inactive. The main problems with this approach are all consequences of femorofemoral bypass. The bifurcated stent-graft is the preferred alternative in healthy patients, because it ensures flow to both common iliac arteries, thereby eliminating the need for femorofemoral bypass. However, bifurcated stent-grafts and their delivery systems are difficult to make and difficult to deploy, especially when the iliac anatomy is distorted or emergency circumstances preclude preoperative sizing. This article addresses the advantages and disadvantages of the aortomonoiliac graft.

Aortic Aneurysm, Abdominal↗
PubMed1998

Expandable metallic stents in benign tracheobronchial obstruction.

Expandable metallic stents offer advantages over previously available techniques for treating benign tracheobronchial stenosis or obstruction. Endoluminal stent placement offers a rapid and effective means of opening up narrowed airways, and results in excellent relief of symptoms and improvement in pulmonary function. Because they are delivered in a nonexpanded state using flexible over-wire systems, they can be placed using a flexible bronchoscope and can be located in second-order bronchial branches. Metallic stents have been used to treat benign airway obstruction caused by anastomotic narrowing after lung transplantation, infection, congenital lesions, tracheobronchial malacia, inflammatory conditions including relapsing polychondritis, Wegener granulomatosis, and acquired immunodeficiency syndrome, and external compression from benign mediastinal masses or fibrosis. The stents become epithelialized, which prevents migration and permits ciliary activity to continue. Significant complications can occur, including airway inflammation, stent migration, airway erosion, and stent fracture and collapse, but more serious complications are uncommon. Computed tomography is essential in imaging patients being considered for stent placement, as it allows 1) accurate representation of airway anatomy in three dimensions. 2) measurement of airway diameter, 3) evaluation of airway anatomy distal to a narrowed segment and invisible to bronchoscopy, 4) demonstration of dynamic changes in airway morphologic features during forced exhalation in patients with airway malacia, and 5) demonstration of focal or diffuse air trapping in lung peripheral to the abnormal airway. In patients who have had stent placement, computed tomography is valuable in assessing airway morphologic features and dynamics distal to the stent, and can be valuable in assessing stent dysfunction.

Airway Obstruction↗
PubMed1998

Managed care and public health.

Both public health and managed care organizations share an interest in ensuring the health status of a defined population. We explore the existing and potential relationships between managed care organizations and public health in several major public health areas, specifically clinical preventive services, prevention-oriented social and political policies, and core public health functions. The latter include health information, health education, personal health services provision, work force and research, community partnerships, and evaluation of health care. We believe there is much potential to improve the population's health through the collaboration of these two sectors of the health care system.

Government Agencies↗
PubMed1998

Private sector health care organizations and essential public health services: potential effects on the practice of local public health.

This article focuses on the activities of eight private health care organizations undertaking public health and prevention activities. Few activities were motivated by or integrated into the business or operating strategy of the organizations and poor integration with the business strategy puts the long-term future of these activities in jeopardy. The lack of integrated activity can be attributed to: slow pace of managed care implementation; low penetrance of full-risk capitated reimbursement; and fragmented, competitive health care markets. Purchaser pressure, quality assurance requirements, community benefit standards, and government mandates are among the levers available to encourage such activities by the private sector.

Delivery of Health Care↗
PubMed1998

Ureteral obstructions and leaks after renal transplantation: outcome of percutaneous antegrade ureteral stent placement in 44 patients.

PURPOSE: To analyze the outcome of percutaneous antegrade ureteral stent placement for treatment of ureteral stenoses and leaks after renal transplantation. MATERIALS AND METHODS: Antegrade pyelography and percutaneous ureteral stent placement were performed in 45 patients with ureteral obstruction (n = 40), leak (n = 3), or both (n = 2). Obstructions were graded as mild, moderate, or complete, and as early (< or = 3 months after transplantation) or late (> 3 months). RESULTS: The outcome of stent placement was successful in 25 (57%) patients (average follow-up, 30 months). The ureteroneocystostomy (UNC) was the most common site of obstructions (22 of 41), leaks (four of five), and successful outcomes (16 of 22). Moderate obstructions were most common (29 of 41) and responded best to treatment (17 of 29). Eighteen (69%) of 26 early obstructions and five (33%) of 15 late obstructions were successfully managed percutaneously. All complications (12 of 45 patients) were minor, with infections the most common (n = 7). No mortality or allograft loss was attributable to stent placement. CONCLUSION: Ureteral stents are safe and effective for the treatment of obstructions and leaks and are particularly effective for early and UNC obstructions. These stents may also be useful for temporary drainage.

Adolescent↗
PubMed1998

Prolonged central intravenous ketorolac continuous infusion in a cancer patient with intractable bone pain.

OBJECTIVE: To report the case of a prolonged intravenous ketorolac continuous infusion given via a central line in a cancer patient with intractable bone pain. CASE SUMMARY: A 56-year-old Hispanic man with stage IV non-small-cell lung cancer and multiple bone metastases was admitted to the hospital for intractable pain inadequately controlled at home by conventional therapy. He was treated with an intravenous continuous infusion of ketorolac 120 mg in 250 mL of NaCl 0.9% infused over 24 hours. The ketorolac was given via a central line for 14 days in addition to fentanyl patient-controlled analgesia. Over this time period the patient reported his pain to be well controlled. His requests for bolus doses of fentanyl decreased dramatically and the dose of the continuous intravenous fentanyl was reduced by 22%. In addition, the total daily dose of ketorolac was reduced following a change from intermittent bolus dosing to a continuous infusion. DISCUSSION: The management of cancer pain secondary to bone metastasis is a difficult and challenging problem frequently encountered by the healthcare team. The use of nonsteroidal antiinflammatory drugs (NSAIDs) as adjuvant therapy is a common practice. However, many terminally ill patients are unable to take oral medications, thus limiting NSAID treatment options. Ketorolac tromethamine is approved by the Food and Drug Administration (FDA) as a parenteral NSAID. As with other NSAIDs, the risk of adverse drug reactions must be considered when using this class of medication. The FDA has approved ketorolac for the short-term (< or = 5 d) management of moderately severe acute pain that requires analgesia at the opioid level, usually in the postoperative setting. However, certain patients may benefit from long-term use exceeding the FDA-recommended guidelines of 5 days of maximum therapy. CONCLUSIONS: A prolonged central intravenous ketorolac continuous infusion was successful in treating a cancer patient with intractable bone pain secondary to widely metastatic non-small-cell lung cancer.

Analgesics, Non-Narcotic↗
PubMed1997

Selective arterial embolization for the control of lower gastrointestinal bleeding.

BACKGROUND: Transcatheter embolization is accepted as a safe method for treating acute bleeding from the upper gastrointestinal (GI) tract. Hesitancy persists using this technique below the ligament of Treitz, based on the belief that the risk of intestinal infarction is unacceptably high, despite mounting clinical evidence to the contrary. METHODS: A series of 17 consecutive patients with angiographically demonstrated small intestinal or colonic bleeding was retrospectively reviewed. The success and complication rate of subselective embolization was assessed. RESULTS: Bleeding was stopped in 13 of 14 patients (93%) in whom embolization was possible, and in 13 of 17 patients (76%) where there was an intention to treat. Sufficiently selective catheterization to permit embolization could not be achieved in 3 patients. No clinically apparent bowel infarctions were caused. CONCLUSION: Subselective embolization is a safe treatment option for lower GI bleeding, suitable for many patients and effective in most. Careful technique and a readiness to abandon embolization when a suitable catheter position cannot be achieved are important.

Adolescent↗
PubMed1997

Determinants of US local health department expenditures, 1992 through 1993.

OBJECTIVES: This study examined local health department expenditures and their relationship to several departmental characteristics, including the size of the population in the department's jurisdiction. METHODS: Local health department characteristics were obtained from a 1992/93 nationwide mail survey and modeled by means of multiple linear regression. RESULTS: Great variability existed in the per capita expenditures of local health departments, and approximately 70% of the variability was accounted for by differences in jurisdiction population size. Additional characteristics of the health departments explained another 11%. The average unadjusted per capita expenditure by local health departments nationwide was $26. CONCLUSIONS: Local health department expenditures that support essential public health services average a dime a day per person.

Health Expenditures↗
PubMed1996

Superselective arterial embolization in the liver transplant recipient: a safe treatment for hemobilia caused by percutaneous transhepatic biliary drainage.

Transcatheter arterial embolization is widely used to treat life-threatening iatrogenic hemobilia, although in the transplanted liver its use has only been reported in two cases. To evaluate more fully whether transcatheter embolization is safe and effective in transplant recipients, we retrospectively reviewed eight cases of severe hemobilia. These occurred after 128 percutaneous transhepatic biliary drainage procedures performed during a 6-year period. In each case, angiography localized the bleeding to a specific intrahepatic branch that was then subselectively catheterized and occluded by transcatheter embolization. Bleeding was successfully controlled by this method in all eight patients with no immediate complications. The main, right, and left hepatic arteries were shown to be patent immediately after embolization by angiography in all patients. Duplex sonography performed in each case (1 to 4 months) after the procedure confirmed that patency was maintained in all patients. No patients developed liver abscesses, sepsis, or clinical liver infarctions after the embolization. No patients underwent retransplantation after embolization. Our experience shows that superselective transcatheter embolization is a safe, effective therapy to correct iatrogenic hemobilia in the liver transplant recipient without threatening the patency of the major hepatic arteries, the viability of the liver, or the integrity of the biliary tree.

Adolescent↗
PubMed1996

Prevention and the reforming U.S. health care system: changing roles and responsibilities for public health.

This review presents historical and cost-effectiveness perspectives of prevention in health care; discusses the nature, extent, and determinants of health system change, particularly the transition to managed care with large integrated health care corporations; and identifies implications for public health agencies and opportunities for prevention within the reforming health system.

Cause of Death↗
PubMed1996

Recent changes in local health department spending.

This study determined differences in U.S. local health department (LHD) expenditures between 1989 and 1993 and examined the factors that were associated with those changes. Adjusted to constant 1993 dollars, nearly half (48%) of the studied LHDs experienced budget decreases and 52% experienced budget increases. The median change in LHD budgets was 0.2% growth per year. Significant associations were found between the likelihood of a department experiencing a budget increase and several measures describing the LHD's administrative and economic environment.

Budgets↗
PubMed1995

Two-year outcome following transjugular intrahepatic portosystemic shunt for variceal bleeding: results in 90 patients.

BACKGROUND/AIMS: Transjugular intrahepatic portosystemic shunt (TIPS) is a new therapy for variceal bleeding. Immediate technical and short-term clinical results have been reported. This study was undertaken to evaluate mid-term outcome after TIPS in patients who successfully underwent the procedure for variceal bleeding. METHODS: Ninety patients were followed up prospectively by clinical examination and radiological shunt evaluation including Doppler sonography and transjugular portal venography. RESULTS: The average follow-up in surviving patients was 2.2 years. The cumulative survival rate was 60% at 1 year and 51% at 2 years. The rate of cumulative rebleeding was 26% at 1 year and 32% at 2 years. A shunt abnormality was noted in all rebleeding patients. Rebleeding was successfully controlled in all but 1 of the patients who underwent shunt revision. Cumulative detection of stenosis or occlusion was 31% at 1 year and 47% at 2 years. Thirty-eight percent of shunt abnormalities were detected by routine surveillance. Percutaneous shunt revision was attempted in 22 patients and was successful in 21 (95%). CONCLUSIONS: Although mid-term primary patency is limited in many patients by the development of a shunt stenosis or occlusion, shunt function can be maintained in most patients by careful surveillance and periodic percutaneous intervention.

Adolescent↗
PubMed1995

Transjugular intrahepatic portosystemic shunts: current status.

The management of acute variceal hemorrhage from portal hypertension has traditionally included pharmacologic agents, mechanical compression with tamponading balloons, and endoscopic techniques including sclerotherapy and variceal banding. The role of operative portosystemic shunting has diminished in the past several years because of unpredictable postoperative morbidity from hepatic failure or encephalopathy [1-8]. Although orthotopic liver transplantation provides a unique and effective solution to these problems, it is often impractical in the emergent setting and may not be necessary if the hemorrhage can be reliably controlled by other means. The transjugular intrahepatic portosystemic shunt (TIPS) was developed to relieve portal hypertension without the mortality and morbidity of an open surgical procedure. This review summarizes the salient history, technique, and results of this procedure. The evolving role of TIPS in the management of portal hypertension, including indications, contraindications, and the durability of the procedure, is assessed.

Adult↗
PubMed1994

Inadvertent catheterization of the hepatic artery during placement of transjugular intrahepatic portosystemic shunts.

Inadvertent catheterization of the hepatic artery may occur during placement of transjugular intrahepatic portosystemic shunts (TIPS). The authors treated this complication in three patients (one man, aged 60 years; two women, aged 50 and 52 years) by embolizing the transparenchymal tract leading to the hepatic artery and performing hepatic angiography after completion of TIPS placement. No sequelae were noted at follow-up of any of these patients.

Catheterization↗