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Biomedical subjects

Daniel R Brown

Publications and source records attributed to Daniel R Brown.

At least 19 recordsLinked to original sources
PubMed2006

Pain relief and functional status after vaginal hysterectomy: intrathecal versus general anesthesia.

PURPOSE: We tested the hypothesis that the use of subarachnoid block (SAB) for vaginal hysterectomy produces superior postoperative analgesia and improves functional status at 12 weeks postoperatively. METHODS: In this randomized controlled trial 89 patients received either standardized general anesthesia vs SAB with bupivacaine, clonidine, and morphine. Postoperatively, patients in both groups received multimodal pain management. Primary outcomes included evaluation of pain and functional status (SF-36 Health Survey) over the 12 postoperative weeks. RESULTS: Pain was well controlled throughout the study, as judged from the average pain numerical scale scores of < or = 3 in both groups, at all times studied. Intrathecal analgesia lessened pain and decreased the use of morphine both in the postanesthesia care unit (PACU) and over the first 12 hr after discharge from the PACU (P < 0.001). Although patients who received SAB had a lower frequency of postoperative nausea in the PACU than the patients in the general anesthesia group (P = 0.021), this effect was not extended beyond the PACU stay. Subarachnoid block did not affect the length of hospitalization. At the two-week follow-up 69% of patients in the SAB group and 48% patients in the general anesthesia group were pain free (P = 0.044). At all evaluation intervals patients' functional status was comparable between the SAB and general anesthesia group. CONCLUSIONS: A significantly better immediate postoperative analgesia was present in the SAB group, and the duration was consistent with the expected action of intrathecally administered drugs. Two weeks after surgery a higher percentage of the patients in the SAB group reported no pain. However, SAB had no effect on either length of hospitalization or patients' postoperative functional status.

Analgesics↗
PubMed2006

Acute coronary syndrome and myocardial infarction after orthopedic surgery in a patient with a recently placed drug-eluting stent.

Providing anesthesia care for patients who have recently undergone intracoronary drug-eluting stent placement presents unique clinical challenges. It is currently recommended that these patients remain on antiplatelet therapy until reendothelialization of the vessel has occurred (ie, 3-6 months, depending on the eluting medication) to prevent stent restenosis. In the setting of urgent or emergent surgery, it may not be possible to wait until a full course of antiplatelet therapy has been completed. We report an unusual case of postoperative acute coronary syndrome in a gentleman who underwent intracoronary stenting 7 weeks before nonelective revision hip arthroplasty. To our knowledge, this is the first case in the anesthesia literature to report postoperative cardiac morbidity after recent drug-eluting stent deployment.

Aged, 80 and over↗
PubMed2006

Tracheostomy after major vascular surgery.

OBJECTIVES: Major vascular surgery such as aortic aneurysm repair may be associated with prolonged in-patient hospitalization. Certain patients undergo a tracheostomy to aid in weaning from mechanical ventilation or for secretion management. The authors hypothesized that tracheostomy after aortic reconstruction for aneurysmal disease was associated with poor outcomes. DESIGN: A retrospective, observational study. SETTING: Vascular surgical intensive care unit (ICU) of a tertiary referral hospital. PARTICIPANTS: Eighty-one patients who underwent a tracheostomy after open thoracoabdominal or abdominal aortic aneurysm (AAA) repair between 1993 and 2002. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of 1,940 patients who underwent aneurysm repair, 81 (4.2%) had a tracheostomy during their index hospitalization. Of those patients, 40.7% did not survive to hospital discharge. Postoperative sepsis was associated with an increased mortality (relative risk 2.45, 95% confidence interval [CI] 1.22-4.90). Many developed postoperative renal failure and were more likely to die in the hospital (relative risk 1.53, 95% CI 1.00-2.33). The preoperative diagnosis of chronic obstructive pulmonary disease (COPD) was not associated with increased mortality (relative risk 0.471, 95% CI 0.23-0.96). Thirty-two (39.5%) patients were transferred from the ICU to a chronic ventilator dependency unit (CVDU). CONCLUSIONS: Tracheostomy in patients after aortic reconstruction for aneurysmal disease is associated with a high incidence of in-hospital mortality. Patients who survive to ICU discharge are likely to be transferred to a CVDU for further respiratory management. The preoperative diagnosis of COPD is associated with improved survival, whereas postoperative sepsis is associated with an increased mortality. These observations should be considered when counseling patients and their families regarding tracheostomy after aortic surgery.

APACHE↗
PubMed2006

Intraoperative tidal volume as a risk factor for respiratory failure after pneumonectomy.

BACKGROUND: Respiratory failure is a leading cause of postoperative morbidity and mortality in patients undergoing pneumonectomy. The authors hypothesized that intraoperative mechanical ventilation with large tidal volumes (VTs) would be associated with increased risk of postpneumonectomy respiratory failure. METHODS: Patients undergoing elective pneumonectomy at the authors' institution from January 1999 to January 2003 were studied. The authors collected data on demographics, relevant comorbidities, neoadjuvant therapy, pulmonary function tests, site and type of operation, duration of surgery, intraoperative ventilator settings, and intraoperative fluid administration. The primary outcome measure was postoperative respiratory failure, defined as the need for continuation of mechanical ventilation for greater than 48 h postoperatively or the need for reinstitution of mechanical ventilation after extubation. RESULTS: Of 170 pneumonectomy patients who met inclusion criteria, 30 (18%) developed postoperative respiratory failure. Causes of postoperative respiratory failure were acute lung injury in 50% (n = 15), cardiogenic pulmonary edema in 17% (n = 5), pneumonia in 23% (n = 7), bronchopleural fistula in 7% (n = 2), and pulmonary thromboembolism in 3% (n = 1). Patients who developed respiratory failure were ventilated with larger intraoperative VT than those who did not (median, 8.3 vs. 6.7 ml/kg predicted body weight; P < 0.001). In a multivariate regression analysis, larger intraoperative VT (odds ratio, 1.56 for each ml/kg increase; 95% confidence interval, 1.12-2.23) was associated with development of postoperative respiratory failure. The interaction between larger VT and fluid administration was also statistically significant (odds ratio, 1.36; 95% confidence interval, 1.05-1.97). CONCLUSION: Mechanical ventilation with large intraoperative VT is associated with increased risk of postpneumonectomy respiratory failure.

Aged↗
PubMed2006

Serotonin syndrome from the interaction of cyclobenzaprine with other serotoninergic drugs.

Serotonin syndrome is a potentially lethal adverse drug reaction that may occur in patients taking proserotoninergic medications. Drug interactions are often responsible for the causation of this syndrome. We report two cases of severe serotonin syndrome induced by the administration of cyclobenzaprine in postoperative patients already receiving another proserotoninergic drug (phenelzine in one case and duloxetine in the other). In both cases, symptoms of autonomic instability and severe agitation started within hours of initiation of cyclobenzaprine and fully resolved within 3 days after discontinuing the proserotoninergic drugs. We conclude that cyclobenzaprine should be used with extreme caution in patients receiving other serotonin-enhancing drugs; these patients should be closely monitored for manifestations of serotonin syndrome.

Aged↗
PubMed2006

Prolonged coma from refractory status epilepticus.

OBJECTIVE: Status epilepticus is a life-threatening medical condition. In its most severe form, refractory status epilepticus (RSE) seizures may not respond to first and second-line anti-epileptic drugs. RSE is associated with a high mortality and significant medical complications in survivors with prolonged hospitalizations. METHODS: We describe the clinical course of RSE in the setting of new onset lupus in a 31-year-old male who required prolonged barbiturate coma. RESULTS: Seizure stopped on day 64 of treatment. Prior to the resolution of seizures, discussion around withdrawal of care took place between the physicians and patient's family. Medical care was continued because of the patient's age, normal serial MRI studies, and the patient's reversible medical condition. CONCLUSION: Few evidence-based data exist to guide management of RSE. Our case emphasizes the need for continuous aggressive therapy when neuroimaging remains normal.

Adult↗
PubMed2006

A comparison of intensive care unit physician staffing costs at the 3 Mayo Clinic sites.

OBJECTIVES: To determine the provider cost of administering intensive care unit (ICU) services, comparing 3 different staffing models for ICU coverage, and to compare the costs of using house staff vs nonphysician providers (NPPs). METHODS: Data were collected on total staff composition and number of beds In ICUs from January 1, 2004, through December 31, 2004, at the 3 Mayo Clinic sites: Rochester, Minn; Jacksonville, Fla; and Scottsdale, Ariz. Institutional or national average staff salaries were used to determine total staffing costs per ICU bed per year at each site. Medicare medical education reimbursements were also taken into account. RESULTS: Costs per ICU bed for physician staffing were $18,630 in Rochester, $37,515 in Jacksonville, and $38,010 in Scottsdale. When NPPs were substituted for house staff, the costs per bed were $72,466 in Rochester, $61,291 in Jacksonville, and $49,909 in Scottsdale. Incremental costs per ICU bed using NPPs were $53,836 in Rochester, $23,776 in Jacksonville, and $11,899 in Scottsdale. CONCLUSION: Use of residents and fellows in ICU staffing at a major tertiary health center is more cost-efficient than use of NPPs. This finding could have Implications for the cost of physician services in nonteaching community hospitals and the methods by which care is provided.

Arizona↗
PubMed2006

Lesions associated with a novel Mycoplasma sp. in California sea lions (Zalophus californianus) undergoing rehabilitation.

From July 1999 to November 2001, Mycoplasma sp. was cultured from lesions in 16 California sea lions (Zalophus californianus) undergoing rehabilitation. The Mycoplasma sp. was the likely cause of death of four animals in which it was associated with either pneumonia or polyarthritis. The most common lesion associated with this bacterium was subdermal abscessation, found in 12 animals. Other lesions included intramuscular abscesses, septic arthritis, and lymphadenopathy. Infection was associated with a leukocytosis and left shift in 12 animals. Animals with abscesses improved clinically after surgical lancing, irrigation, and systemic antibiotic therapy. The mycoplasma isolates had a consistent 16S rRNA sequence dissimilar from other Mycoplasma spp. and represent a novel species, Mycoplasma zalophi proposed sp. nov.

Abscess↗
PubMed2006

Mechanical ventilation in patients with Guillain-Barré syndrome.

BACKGROUND: Patients with Guillain-Barré syndrome are commonly exposed to prolonged mechanical ventilation. Specific data on ventilatory management of these patients have been limited. OBJECTIVE: To describe the practice of mechanical ventilation in patients with Guillain-Barré syndrome and evaluate risk factors for morbidity and mortality. METHODS: We describe a historical cohort of mechanically ventilated patients with Guillain-Barré syndrome in a tertiary-care center. We extracted database information on demographics, severity of illness, pulmonary function, and ventilatory management for the period 1976 to 1996. Primary outcomes were development of pulmonary complications, duration of ventilatory support, and mortality. RESULTS: Fifty-four patients met the inclusion criteria. After 1990, lower tidal volume (p = 0.031) and higher positive end-expiratory pressure (p = 0.003) were used than during the 1976 to 1990. Outcomes did not change significantly during the studied period. Forty-six patients (85%) survived to hospital discharge, and 39 (72%) were alive at 1-year follow-up. Ventilator-associated pneumonia was the most frequent complication (56%) and was associated with prolonged mechanical ventilation (p < 0.01). Atelectasis developed in 49%, and acute lung injury in 13%. All but 6 patients (89%) received tracheostomy. In 14 patients (30%) tracheostomy was placed > or = 14 days after intubation. When adjusted for atelectasis and severity of illness in a stepwise logistic regression analysis, delayed tracheostomy was associated with the development of ventilator-associated pneumonia (odds ratio 8.2, p = 0.029). CONCLUSIONS: Changes in ventilator practice did not affect outcomes of mechanically ventilated patients with Guillain-Barré syndrome. The majority of patients received tracheostomy, which should be considered early in the course of respiratory failure.

Adult↗
PubMed2004

Perioperative antibiotics and practice: little things that make a big difference.

Perioperative antibiotic administration and anesthetic practice have major impacts on infectious complications. Anesthesiologists need to place high importance on perioperative antibiotic administration to allow patients to receive optimal benefit from this therapy and to minimize risk. Many aspects of perioperative care ranging from thermoregulation to glycemic control may have profound longterm affects on infection rate and thereby patient outcome.

Anesthesia↗
PubMed2004

Intrathecal anesthesia and recovery from radical prostatectomy: a prospective, randomized, controlled trial.

BACKGROUND: Previous studies suggest that intraoperative anesthetic care may influence postoperative pain and recovery from surgery. The authors tested the hypothesis that the addition of intrathecal analgesia to general anesthesia would improve long-term functional status and decrease pain in patients undergoing radical retropubic prostatectomy. METHODS: One hundred patients received either general anesthesia supplemented with intravenous fentanyl or general anesthesia preceded by intrathecal administration of bupivacaine (15 mg), clonidine (75 microg), and morphine (0.2 mg). Patients and providers were masked to treatment assignment. All patients received multimodal pain management postoperatively. Primary outcomes included pain and functional status over the first 12 postoperative weeks. RESULTS: Patients receiving intrathecal analgesia required more intravenous fluids and vasopressors intraoperatively. Pain was well controlled throughout the study (mean numerical pain scores < 3 in both groups at all times studied). Intrathecal analgesia decreased pain and supplemental intravenous morphine use over the first postoperative day but increased the frequency of pruritus. Pain and functional status after discharge from the hospital did not differ between groups. Intrathecal analgesia significantly decreased the duration of hospital stay (from 2.8 +/- 2.0 to 2.1 +/- 0.5 days; P < 0.01) as a result of five patients in the control group who stayed in the hospital more than 3 days. CONCLUSIONS: The benefits of improved immediate analgesia and decreased morphine requirements resulting from intrathecal analgesia must be weighed against factors such as pruritus, increased intraoperative requirement for fluids and vasopressors, and resources needed to implement this modality. Further studies are needed to determine the significance of the decrease in duration of hospital stay.

Adult↗
PubMed2004

Hypoglycemia associated with preoperative metoprolol administration.

Perioperative beta(1)-selective-adrenergic antagonist administration has been shown to decrease morbidity and mortality in patients with cardiac disease undergoing surgical procedures. We report a case of a patient receiving the selective beta(1)-adrenergic antagonist, metoprolol, immediately before surgery that was associated with severe hypoglycemia. We postulate that an underlying abnormality in energy requirements or metabolism may allow for beta(1)-selective-adrenergic antagonists to precipitate hypoglycemia.

Adrenergic beta-Antagonists↗
PubMed2004

Health literacy: universal precautions needed.

Inadequate health literacy adversely affects health care outcomes and the quality of life of 90 million Americans and costs the health care system dollars 73 billion annually. Current strategies addressing inadequate health literacy primarily target physicians, nurses, and pharmacists but omit the allied health practitioners responsible for providing most patient services. The 2003 Coalition for Allied Health Leadership Health Literacy Project team undertook a survey of allied health professionals and educators to assess their awareness and needs concerning inadequate health literacy. Less than one third of all respondents were aware of the issues surrounding health literacy or that health literacy resources are available or had institutional policy or goals to address health literacy. Brochures and videos were identified most frequently as new resources needed to establish or increase the effectiveness of health literacy awareness programs. The results of this project indicated that there is substantial opportunity to increase awareness of the impact of health literacy, to develop and assess institutional policies toward health literacy, and to create new resources to promote health literacy within the allied health professions. Any approach to improving health literacy must be universal by involving all health care professionals and all patients in the intervention.

Allied Health Occupations↗
PubMed2003

Alginate as a new biomaterial for the growth of porcine retinal pigment epithelium.

OBJECTIVE: Determine the effect of a 3-dimensional alginate matrix on the growth and differentiation of cells isolated from porcine retinal pigment epithelium (RPE). PROCEDURES: Porcine RPE cells were harvested from enucleated eyecups, isolated by differential gravity sedimentation and cultured in either alginate alone (Group 1) or on plastic tissue culture plates followed by alginate (Group 2). Group 1 cells were cultured in alginate to evaluate the efficacy of the matrix as a culture medium. Group 2 cells were initially cultured on plastic to induce dedifferentiation. The cells were then harvested, suspended in alginate beads, and incubated for a second culture period to determine if the induced dedifferentiation was reversible. RESULTS: The number of Group 1 cells was significantly greater (P < or = 0.01) at the end of the culture period. The amount of pigment and cell morphology of Group 1 cells at the end of the culture period was similar to that seen at initial cell isolation. The initial culture of Group 2 cells on plastic showed characteristic features of dedifferentiation marked by the loss of pigment and alterations in microscopic appearance. Secondary culture of dedifferentiated Group 2 cells in alginate beads resulted in a return to pigmentation and characteristic morphology for a majority of the cultured cells. CONCLUSIONS: Porcine RPE cells can be propagated in alginate culture with a significant increase in cell numbers while maintaining normal morphology. Under the conditions described in the present study, the dedifferentiation of porcine RPE induced by standard in vitro culture methods is reversible.

Alginates↗
PubMed2002

Mycoplasmosis and immunity of fish and reptiles.

Advances in molecular phylogenetics have enabled reconstruction of the most likely chronology of events in prokaryotic evolution and correlation with the paleontologic record with increasing precision. Mycoplasmas probably evolved from clostridial ancestors by genome reduction leading to obligate parasitism of host cells. The vertebrate hosts present at the time of the origin of mycoplasmas about 400 million years ago were fish, and later amphibians and reptiles, whose descendants possess most elements of vertebrate innate and adaptive immunity. Successful colonization of those poikilothermous ("cold-blooded") hosts must have involved adaptation to those defenses, shaping mycoplasma-host interactions for more than 125 million years before the earliest emergence of mammals. That history illuminates one aspect of the potential significance of mycoplasmosis of poikilothermous vertebrates to health and disease of other hosts including humans.

Animals↗
PubMed2002

Thoracic cavity irrigation: an unusual cause of acute ST segment increase.

IMPLICATIONS: We describe an unusual case of acute ST segment increase secondary to warm saline thoracic cavity irrigation during thoracotomy. Temperature-mediated alteration of myocyte repolarization should be considered in addition to myocardial ischemia when ST segment changes occur.

Arrhythmias, Cardiac↗