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Richard J. Ward

Bio: Richard J. Ward is an academic researcher from Faculdade de Filosofia, Ciências e Letras de Ribeirão Preto. The author has contributed to research in topics: Receptor & G protein-coupled receptor. The author has an hindex of 53, co-authored 242 publications receiving 9502 citations. Previous affiliations of Richard J. Ward include University of Dundee & University of São Paulo.


Papers
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Journal ArticleDOI
TL;DR: Inadequate ventilation was used to describe claims in which it was evident that insufficient gas exchange had produced the adverse outcome, but it was not possible to identify the exact cause.
Abstract: Adverse outcomes associated with respiratory events constitute the single largest class of injury in the American Society of Anesthesiology Closed Claims Study (522 of 1541 cases; 34%). Death or brain damage occurred in 85% of cases. The median cost of settlement or jury award was +200,000. Most outcomes (72%) were considered preventable with better monitoring. Three mechanisms of injury accounted for three-fourths of the adverse respiratory events: inadequate ventilation (196; 38%), esophageal intubation (94; 18%), and difficult tracheal intubation (87; 17%). Inadequate ventilation was used to describe claims in which it was evident that insufficient gas exchange had produced the adverse outcome, but it was not possible to identify the exact cause. This group was characterized by the highest proportion of cases in which care was considered substandard (90%). The esophageal intubation group was notable for a recurring diagnostic failure: in 48% of cases where auscultation of breath sounds was performed and documented, this test led to the erroneous conclusion that the endotracheal tube was correctly located in the trachea. Claims for difficult tracheal intubation were distinguished by a comparatively small proportion of cases (36%) in which the outcome was considered preventable with better monitoring. A better understanding of respiratory risks may require investigative protocols that initiate data collection immediately upon the recognition of a critical incident or adverse outcome.

969 citations

Journal ArticleDOI
TL;DR: In this paper, a preliminary review of 900 closed insurance claims for major anesthetic mishaps was conducted to determine whether recurring patterns of management may have contributed to the occurrence or outcome of these anesthetic misbehavior.
Abstract: Fourteen cases of sudden cardiac arrest in healthy patients who received spinal anesthesia were discovered in a preliminary review of 900 closed insurance claims for major anesthetic mishaps. All patients were resuscitated from the intraoperative cardiac arrest, but six suffered such severe neurologic injury that they died in hospital. Of the eight survivors, only one exhibited sufficient neurologic recovery to allow independence in daily self-care. In view of the unexpected nature of the cardiac arrests, as well as the ultimate severity of injury, these cases were analyzed in detail to determine whether there were recurring patterns of management that may have contributed to the occurrence or outcome of these anesthetic mishaps. Two patterns were identified. The first was the intraoperative use of sufficient sedation to produce a comfortable-appearing, sleep-like state in which there was no spontaneous verbalization. Cyanosis frequently heralded the onset of cardiac arrest in patients exhibiting this degree of sedation, suggesting that unappreciated respiratory insufficiency may have played an important role. The second pattern appeared to be an inadequate appreciation of the interaction between sympathetic blockade during high spinal anesthesia and the mechanisms of cardiopulmonary resuscitation. Prompt augmentation of central venous filing through the use of a potent alpha-agonist and positional change might have improved organ perfusion, shortened the duration of cardiac arrest, and lessened the degree of neurologic damage.

429 citations

Journal ArticleDOI
TL;DR: It is concluded that nerve damage is a significant source of anesthesia-related claims but that the exact mechanism of nerve injury is often unclear and in particular, ulnar nerve injuries seemed to occur without identifiable mechanism.
Abstract: The authors examined the American Society of Anesthesiologists Closed Claims Study database to define the role of nerve damage in the overall spectrum of anesthesia-related injury that leads to litigation. Of 1,541 claims reviewed, 227 (15%) were for anesthesia-related nerve injury. Ulnar neuropathy represented one-third of all nerve injuries and was the most frequent nerve injury. Less-frequent sites of nerve injury were the brachial plexus (23%) and the lumbosacral nerve roots (16%). In a large proportion of cases, the exact mechanism of injury was unclear despite evidence of intensive investigation in the claim files. Median payment for nerve damage claims involving disabling injury was $56,000, which was significantly lower than the $225,000 median payment for claims for disabling injury not involving nerve damage (P less than 0.01). The closed claims reviewers judged that the standard of care had been met significantly more often in claims involving nerve damage than in claims not involving nerve damage. The authors conclude that nerve damage is a significant source of anesthesia-related claims but that the exact mechanism of nerve injury is often unclear. In particular, ulnar nerve injuries seemed to occur without identifiable mechanism.

375 citations

Journal ArticleDOI
01 Aug 1996-Toxicon
TL;DR: The salient structural features of the class I, II and III PLA2 are discussed with respect to their functional roles and the structural bases of other aspects of PLA2 function are still under debate.

335 citations

Journal ArticleDOI
TL;DR: A review of various anesthetic-related morbidity and mortality statistics indicates that unrecognized esophageal intubation remains a problem, even among anesthesia personnel, a medical population specifically trained in such a procedure.
Abstract: Although the first reported oral intubation of the human trachea occurred in 1878 (l), the procedure did not become standard practice until many years later. It is now a routinely performed procedure, one of the first techniques to be encountered by the anesthesia trainee. It is performed by individuals of different backgrounds and levels of training in the operating suite, emergency room, intensive care unit, hospital ward, and in the field. However, the frequency of tracheal intubation in modern anesthetic practice belies its importance, and the ability to accurately evaluate proper endotracheal tube position is crucial. A review of various anesthetic-related morbidity and mortality statistics (2-8) indicates that unrecognized esophageal intubation remains a problem, even among anesthesia personnel, a medical population specifically trained in such a procedure. An analysis of anesthetic accidents reported to the Medical Defence Union of the United Kingdom from 1970 to 1978 revealed that nearly half the cases resulting in death or cerebral damage were due to faulty technique (2). The technique most often identified as the source of mishap was tracheal intubation, with inadvertent esophageal tube placement the usual problem (2). Another review of anesthesia-related medical liability claims in the United Kingdom from 1977 to 1982 listed esophageal intubation as a ”main cause” of accidents leading to death or neurologic

319 citations


Cited by
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28 Jul 2005
TL;DR: PfPMP1)与感染红细胞、树突状组胞以及胎盘的单个或多个受体作用,在黏附及免疫逃避中起关键的作�ly.
Abstract: 抗原变异可使得多种致病微生物易于逃避宿主免疫应答。表达在感染红细胞表面的恶性疟原虫红细胞表面蛋白1(PfPMP1)与感染红细胞、内皮细胞、树突状细胞以及胎盘的单个或多个受体作用,在黏附及免疫逃避中起关键的作用。每个单倍体基因组var基因家族编码约60种成员,通过启动转录不同的var基因变异体为抗原变异提供了分子基础。

18,940 citations

Journal ArticleDOI
TL;DR: The goal of immediate post-cardiac arrest care is to optimize systemic perfusion, restore metabolic homeostasis, and support organ system function to increase the likelihood of intact neurological survival.
Abstract: There is increasing recognition that systematic post–cardiac arrest care after return of spontaneous circulation (ROSC) can improve the likelihood of patient survival with good quality of life. This is based in part on the publication of results of randomized controlled clinical trials as well as a description of the post–cardiac arrest syndrome. 1–3 Post–cardiac arrest care has significant potential to reduce early mortality caused by hemodynamic instability and later morbidity and mortality from multiorgan failure and brain injury. 3,4 This section summarizes our evolving understanding of the hemodynamic, neurological, and metabolic abnormalities encountered in patients who are initially resuscitated from cardiac arrest. The initial objectives of post–cardiac arrest care are to ● Optimize cardiopulmonary function and vital organ perfusion. ● After out-of-hospital cardiac arrest, transport patient to an appropriate hospital with a comprehensive post–cardiac arrest treatment system of care that includes acute coronary interventions, neurological care, goal-directed critical care, and hypothermia. ● Transport the in-hospital post–cardiac arrest patient to an appropriate critical-care unit capable of providing comprehensive post–cardiac arrest care. ● Try to identify and treat the precipitating causes of the arrest and prevent recurrent arrest.

2,590 citations

Journal ArticleDOI
13 Dec 1996-Science
TL;DR: The structure proves the heptameric subunit stoichiometry of the α-hemolysin oligomer, shows that a glycine-rich and solvent-exposed region of a water-soluble protein can self-assemble to form a transmembrane pore of defined structure, and provides insight into the principles of membrane interaction and transport activity of β barrel pore-forming toxins.
Abstract: The structure of the Staphylococcus aureus α-hemolysin pore has been determined to 1.9 A resolution. Contained within the mushroom-shaped homo-oligomeric heptamer is a solvent-filled channel, 100 A in length, that runs along the sevenfold axis and ranges from 14 A to 46 A in diameter. The lytic, transmembrane domain comprises the lower half of a 14-strand antiparallel β barrel, to which each protomer contributes two β strands, each 65 A long. The interior of the β barrel is primarily hydrophilic, and the exterior has a hydrophobic belt 28 A wide. The structure proves the heptameric subunit stoichiometry of the α-hemolysin oligomer, shows that a glycine-rich and solvent-exposed region of a water-soluble protein can self-assemble to form a transmembrane pore of defined structure, and provides insight into the principles of membrane interaction and transport activity of β barrel pore-forming toxins.

2,238 citations

Journal ArticleDOI
TL;DR: In contrast to adults, cardiac arrest in infants and children does not usually result from a primary cardiac cause, more often it is the terminal result of progressive respiratory failure or shock, also called an asphyxial arrest.
Abstract: In contrast to adults, cardiac arrest in infants and children does not usually result from a primary cardiac cause. More often it is the terminal result of progressive respiratory failure or shock, also called an asphyxial arrest. Asphyxia begins with a variable period of systemic hypoxemia, hypercapnea, and acidosis, progresses to bradycardia and hypotension, and culminates with cardiac arrest.1 Another mechanism of cardiac arrest, ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT), is the initial cardiac rhythm in approximately 5% to 15% of pediatric in-hospital and out-of-hospital cardiac arrests;2,–,9 it is reported in up to 27% of pediatric in-hospital arrests at some point during the resuscitation.6 The incidence of VF/pulseless VT cardiac arrest rises with age.2,4 Increasing evidence suggests that sudden unexpected death in young people can be associated with genetic abnormalities in myocyte ion channels resulting in abnormalities in ion flow (see “Sudden Unexplained Deaths,” below). Since 2010 marks the 50th anniversary of the introduction of cardiopulmonary resuscitation (CPR),10 it seems appropriate to review the progressive improvement in outcome of pediatric resuscitation from cardiac arrest. Survival from in-hospital cardiac arrest in infants and children in the 1980s was around 9%.11,12 Approximately 20 years later, that figure had increased to 17%,13,14 and by 2006, to 27%.15,–,17 In contrast to those favorable results from in-hospital cardiac arrest, overall survival to discharge from out-of-hospital cardiac arrest in infants and children has not changed substantially in 20 years and remains at about 6% (3% for infants and 9% for children and adolescents).7,9 It is unclear why the improvement in outcome from in-hospital cardiac arrest has occurred, although earlier recognition and management of at-risk patients on general inpatient units …

1,846 citations

Journal ArticleDOI
TL;DR: It is now apparent that autophagy is deregulated in the context of various human pathologies, including cancer and neurodegeneration, and its modulation has considerable potential as a therapeutic approach.
Abstract: Autophagy is a highly conserved catabolic process induced under various conditions of cellular stress, which prevents cell damage and promotes survival in the event of energy or nutrient shortage and responds to various cytotoxic insults. Thus, autophagy has primarily cytoprotective functions and needs to be tightly regulated to respond correctly to the different stimuli that cells experience, thereby conferring adaptation to the ever-changing environment. It is now apparent that autophagy is deregulated in the context of various human pathologies, including cancer and neurodegeneration, and its modulation has considerable potential as a therapeutic approach.

1,701 citations