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Biomedical subjects

Robert B Smith

Publications and source records attributed to Robert B Smith.

16 recordsLinked to original sources

Monitoring super-volcanoes: geophysical and geochemical signals at Yellowstone and other large caldera systems.

Earth's largest calderas form as the ground collapses during immense volcanic eruptions, when hundreds to thousands of cubic kilometres of magma are explosively withdrawn from the Earth's crust over a period of days to weeks. Continuing long after such great eruptions, the resulting calderas often exhibit pronounced unrest, with frequent earthquakes, alternating uplift and subsidence of the ground, and considerable heat and mass flux. Because many active and extinct calderas show evidence for repetition of large eruptions, such systems demand detailed scientific study and monitoring. Two calderas in North America, Yellowstone (Wyoming) and Long Valley (California), are in areas of youthful tectonic complexity. Scientists strive to understand the signals generated when tectonic, volcanic and hydrothermal (hot ground water) processes intersect. One obstacle to accurate forecasting of large volcanic events is humanity's lack of familiarity with the signals leading up to the largest class of volcanic eruptions. Accordingly, it may be difficult to recognize the difference between smaller and larger eruptions. To prepare ourselves and society, scientists must scrutinize a spectrum of volcanic signals and assess the many factors contributing to unrest and toward diverse modes of eruption.

Chemistry↗

Metabolic mimics: thiol responsive drug release.

A new approach to the design of selective release interfaces is assessed in which a hydrophobic component is functionalised with a receptor reactive toward reduced thiol peptides-principally glutathione. The assembly has been characterised using electrochemical techniques and its ability to form a coherent, water insoluble coating is demonstrated. The subsequent reaction with glutathione creates a supramolecular conjugate that exploits the hydrophilic nature of the amino acid chain as a route through which the protective coating can be eroded and hence the underlying substrate exposed. The efficacy of the release process has been critically assessed with a view to establishing the action and selectivity of the trigger mechanism.

Adamantane↗

Secondary conversion of the Gore Excluder to operative abdominal aortic aneurysm repair.

OBJECTIVE: Reports continue to document the occurrence of major adverse events after endovascular aortic aneurysm repair. Although many of these problems can be successfully managed through endovascular salvage, operative conversion with explantation of the endoprosthesis remains necessary in some patients. We report herein a review of all patients initially enrolled in multicenter US clinical trials of the Excluder endograft who underwent secondary conversion to open surgical repair. METHODS: Clinical data and relevant medical records of patients enrolled in phase I and II multicenter US clinical trials of the Excluder endograft were retrospectively reviewed for adverse events and further narrowed to those patients who underwent secondary operative conversion. Hospital records, operative and anesthesia reports, and all imaging studies were analyzed at initial implantation and at the time of subsequent open surgical repair. RESULTS: Late open conversion was performed in 16 (2.7%) of the 594 patients enrolled in the Excluder clinical trials. Presumed endotension accounted for 8 of 16 of secondary conversions. In two of these patients, however, an endoleak was identified at the time of open surgical repair. Of the remaining eight patients, two underwent conversion for device infection, five for persistent endoleak, and one for aneurysm rupture. The overall 30-day mortality was 6.25% (1/16), with one death occurring in a patient with a ruptured aneurysm. Of patients who underwent conversion because of endotension, the maximal abdominal aortic aneurysm diameter (mean +/- SD) at the time of initial implantation and subsequent graft removal was 61 +/- 11 mm and 70 +/- 10 mm, respectively. The mean time to open conversion for treatment of endotension was 37 +/- 12 months (range, 20-50 months; median, 42 months). Freedom from conversion was 98.6% and 96.7% at 24 and 48 months, respectively. CONCLUSIONS: Endotension in the absence of a demonstrable endoleak has been a major indication for late surgical conversion in patients treated with the Excluder endograft. Given the potential presence of an undetected endoleak and the possible effects of progressive sac enlargement on long-term device stability, continued close surveillance of patients with assumed endotension is required. Should changes in device design eliminate endotension, a further reduction in the already low incidence of late open conversion of the Excluder endograft can be anticipated.

Age Factors↗

Endovascular abdominal aortic aneurysm repair in the octogenarian.

The aim of this study was to analyze patient outcomes following endovascular repair of infrarenal abdominal aortic aneurysms (EAR) among patients 80 years of age or older. In this study, reporting standards of the Ad Hoc Committee for Standardized Reporting Practices for Endovascular Aortic Aneurysm Repair of the Society of Vascular Surgery/American Association for Vascular Surgery (SVS/AAVS) were followed. Between August 8, 1996 and February 12, 2001 EAR was performed in 31 patients (29 male and 2 female) with an average age of 83 +/- 3 years and an average maximum aneurysm diameter of 59 +/- 7 mm. Overall technical success was 90% (28/31) with a single acute conversion and a 6% (2/32) incidence of major morbidity. There were no in-hospital deaths, but two patients (6%) died within 30 days of intervention. Four endoleaks, two type I and two type II, were observed within the first 30 days after endograft implantation and three new type II endoleaks were noted after implant periods that exceeded 1 month. Average follow-up was 16 months, with a single aneurysm-related death that occurred after late conversion to open repair, 2 years following initial endovascular treatment. Kaplan-Meier analysis revealed 3-, 12-, and 24-month estimated survivals of 93% (+/-5), 75% (+/-8), and 68% (+/-10), respectively. Clinical success rates were 90% (+/-5), 90% (+/-5), and 72% (+/-17) at 12, 24, and 36 months, respectively. We conclude that, in the octogenarian with mild to moderate medical comorbidities, endovascular aneurysm repair provides an alternative to open AAA repair with low operative morbidity and good clinical success rates. Elevated SVS/AAVS medical comorbidity scores were not associated with increased operative mortality rates, but they did show a trend toward decreased mid-term survival. Careful consideration of life expectancy and the probability of rupture, as with traditional AAA repair, should dictate necessity for intervention.

Aged↗

Ketorolac-based analgesia improves outcomes for living kidney donors.

BACKGROUND: To reduce the morbidity of living kidney donors we introduced ketorolac-based analgesia for patients undergoing open donor nephrectomy in August 1999. There are no prior reports on the use of ketorolac for patients undergoing donor nephrectomy. METHODS: We conducted a retrospective review of all 198 consecutive patients who underwent open living donor nephrectomy between January 1998 and July 2000 at our institution. We compared patients who underwent surgery before and after introduction of ketorolac-based analgesia. RESULTS: The introduction of ketorolac-based analgesia resulted in a reduction in length of postoperative stay from 3.7+/-0.1 to 3.1+/-0.1 days (P<0.001). Patients who underwent surgery after ketorolac introduction required 58% less narcotics (P<0.001), recalled having less postoperative pain, and stopped taking pain medications sooner than patients before routine ketorolac use. Moreover, these patients drank 38% more liquids on the first postoperative day (P<0.001) and were able to resume a regular diet sooner than patients who were not managed with ketorolac. Patients who received ketorolac had a slightly lower creatinine clearance on the second postoperative day relative to patients who did not (66 vs. 72% of preoperative calculated creatinine clearance, P=0.05). However at a minimum of 3 months postoperatively, creatinine clearance did not differ between the two groups (70 vs. 73%, P=0.92). There were no differences in the rates of complications between the two groups. CONCLUSIONS: The use of ketorolac to control postoperative pain for patients undergoing open donor nephrectomy reduced morbidity and was not associated with any effect on long-term renal function or increased risk of complications. This is the first study to demonstrate the safety of using ketorolac at the time of donor nephrectomy.

Adult↗

Endovascular aortic aneurysm operations.

Options for the treatment of abdominal and thoracic aortic aneurysms are in a state of evolutionary change. The development and continued refinement of the endoluminal approaches has decreased the need for open aortic aneurysm surgery. Endovascular stent graft technology is an area of active research in which both the delivery systems and the endografts are undergoing continued improvement so that patients with what was previously thought to be unfavorable anatomy may be treated by these means. The design and deployment techniques of the currently available endografts, as well as those in clinical trials, are presented.

Aortic Aneurysm↗

Distal septic emboli and fatal brachiocephalic artery mycotic pseudoaneurysm as a complication of stenting.

The use of percutaneous angioplasty with subsequent intravascular metallic stent placement has gained increasing acceptance over the past decade. Infections of these stents appear to be uncommon; however, the rarity of this complication may in part be the result of a lack of availability of long-term follow-up data. A number of examples of infected cardiac and peripheral vascular stents have been reported, often with fatal consequences. Herein, we report a 74-year-old woman who underwent subclavian and brachiocephalic artery angioplasty and stent placement for symptomatic stenoses. Six months after the initial intervention, the patient returned with restenosis of the stents and underwent repeat angioplasty to restore full patency. Two weeks later, the patient was readmitted with generalized malaise and multiple erythematous, macular lesions on the right forearm and hand. Blood cultures grew Staphylococcus aureus, and a computed tomographic scan of the chest showed a large brachiocephalic artery pseudoaneurysm with surrounding hematoma. Despite prompt surgical intervention, this complication proved ultimately fatal. Infections of metallic endovascular stents are potentially life-threatening complications and must be addressed urgently, including possible surgical intervention.

Aged↗

Endovascular repair of abdominal aortic aneurysms: risk stratified outcomes.

OBJECTIVE: The impact of co-morbid conditions on early and late clinical outcomes after endovascular treatment of abdominal aortic aneurysm (AAA) was assessed in concurrent cohorts of patients stratified with respect to risk for intervention. SUMMARY BACKGROUND DATA: As a minimally invasive strategy for the treatment of AAA, endovascular repair has been embraced with enthusiasm for all prospective patients who are suitable anatomical candidates because of the promise of achieving a durable result with a reduced risk of perioperative morbidity and mortality. METHODS: From April 1994 to March 2001, endovascular AAA repair was performed in 236 patients using commercially available systems. A subset of patients considered at increased risk for intervention (n = 123) were categorized, as such, based on a preexisting history of ischemic coronary artery disease, with documentation of myocardial infarction (60%) or congestive heart failure (35%), or due to the presence of chronic obstructive disease (21%), liver disease, or malignancy. RESULTS: Perioperative mortality (30-day) was 6.5% in the increased-risk patients as compared to 1.8% among those classified as low risk (P = NS). There was no difference between groups in age (74 +/- 9 years vs. 72 +/- 6 years; mean +/- SD), surgical time (235 +/- 95 minutes vs. 219 +/- 84 minutes), blood loss (457 +/- 432 mL vs. 351 +/- 273 mL), postoperative hospital stay (4.8 +/- 3.4 days vs. 4.0 +/- 3.9 days), or days in the ICU (1.3 +/- 1.8 days vs. 0.5 +/- 1.6 days). Patients at increased risk of intervention had larger aneurysms than low-risk patients (59 +/- 13 mm vs. 51 +/- 14 mm; P <.05). Stent grafts were successfully implanted in 116 (95%) increased-risk versus 107 (95%) low-risk patients (P = NS). Conversion rates to open operative repair were similar in increased-risk and low-risk groups at 3% and 5%, respectively. The initial endoleak rate was 22% versus 20%, based on the first CT performed (either at discharge or 1 month; P = NS). To date, increased-risk patients have been followed for 17.4 +/- 15 months and low-risk patients for 16.3 +/- 14 months. Kaplan-Meier analysis for cumulative patient survival demonstrated a reduced probability of survival among those patients initially classified as at increased risk for intervention (P <.05, Mantel-Cox test). Both cohorts had similar two-year primary and secondary clinical success rates of approximately 75% and 80%, respectively. CONCLUSIONS: Early and late clinical outcomes are comparable after endovascular repair of AAA, regardless of risk-stratification. Notably, 2 years after endovascular repair, at least one in five patients was classified as a clinical failure. Given the need for close life-long surveillance and the continued uncertainty associated with clinical outcome, caution is dictated in advocating endovascular treatment for the patient who is otherwise considered an ideal candidate for standard open surgical repair.

Aged↗

Will claims workers dislike a computerized fraud detector?

The computerized fraud detector (CFRD) assigns suspicion scores to questionable automobile insurance claims. Evaluators pilot tested this algorithm in three offices, comparing its effects with three matched offices. Observers uncovered that in two target offices and one comparison office, Millennium 2000 (M2K) also was being installed. The study design thus became as follows: Two offices had two interventions, one office had CFRD but not M2K, another office had M2K but not CFRD, and two offices had neither. Hierarchical linear models document that offices with both new computer systems will have the most unfavorable employee attitudes toward computerized fraud detection, followed by offices with only one new system. Employees with jobs of higher rank and employees not receptive to innovation will dislike computerized fraud detection. Implementation of one computer system, CFRD or M2K, may have minor negative fixed effects on employee attitudes, but their effects on the between-office variance are inconsequential.

Algorithms↗

Coil embolization combined with carotid-subclavian bypass for treatment of subclavian artery aneurysm.

PURPOSE: To report 2 cases of proximal subclavian artery aneurysm treated with carotid-subclavian bypass and coil embolization. CASE REPORTS: A subclavian artery aneurysm was discovered incidentally during presurgical coronary angiography in 2 men (72 and 63 years of age). Both patients underwent planned carotid endarterectomy, during which a carotid-subclavian bypass was created with a Dacron graft; the distal subclavian artery was also ligated. The aneurysm was completely excluded from the circulation by coil embolization in a separate procedure. The patients were discharged after 3 days with no adverse events. Magnetic resonance angiography at 6 months showed continued aneurysm exclusion in both cases. The patients continue to be well >1 year after treatment. CONCLUSIONS: Embolization with supraclavicular bypass represents a viable alternative to traditional thoracotomy and subclavian artery reconstruction for treatment of subclavian artery aneurysms.

Aged↗

The return of the heart hospital. A hospital that specializes in providing cardiovascular services can meet community needs but will compete with existing community hospitals for market share.

A hospital that provides cardiovascular services and embraces a heart-hospital brand and strategy can achieve competitive advantage. Providers that want to compete aggressively for cardiovascular services are developing a specialty-based carve-out strategy. A heart-hospital initiative can cannibalize revenues from a hospital's other programs and services. A successful heart-hospital strategy requires physician buy-in. A heart hospital needs a brand that customers will value.

Biomedical Technology↗

Conservatism and new technology: the impact on abdominal aortic aneurysm repair.

The last decade has represented a time of fundamental change in the treatment of abdominal aortic aneurysms (AAAs). Potentially, vascular surgeons will either acquire catheter-based skills or relinquish the care for many patients with infrarenal AAA. We investigated AAA referral patterns and method of AAA repair after the establishment of an endovascular AAA program at our institution. We conducted a retrospective review of elective AAA repairs after the initiation of an endovascular AAA program in April 1994. Six vascular surgeons performed all procedures with a clear distinction between the surgeons (n=3) who performed traditional AAA repair only and those (n=3) who managed AAAs by means of either endovascular or traditional treatment. From April 1994 through December 2000, 740 elective AAA repairs were performed. During this time the mean number of AAA repairs has been 106/year ranging from 75 to 155/year. More notable however is the steady increase in the percentage of endovascular AAA repairs from 6 per cent of all AAA repairs in 1994 to 61 per cent in 2000. During this time traditional surgeons have experienced a plateau in total AAA repairs performed per year with their number of open repairs decreasing by 36 per cent. At the same time endovascular surgeons have seen a progressive rise in total AAA cases including an increase of 200 per cent in open repairs and of 1367 per cent in endovascular repairs. Our vascular surgeons who repair AAA utilizing both endovascular and open techniques have experienced an increase in aneurysm referrals since the advent of an endovascular AAA program. Those who have not adopted endovascular skills have seen a decline in their aneurysm practice. The larger question about whether or not to embrace new technology before the availability of long-term follow-up remains unanswered.

Aortic Aneurysm, Abdominal↗