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Biomedical subjects

D G Stewart

Publications and source records attributed to D G Stewart.

At least 19 recordsLinked to original sources
PubMed2005

Chronic actinic dermatitis treated with mycophenolate mofetil.

Chronic actinic dermatitis (CAD) is a persistent photodermatosis that usually affects elderly men. We report two male patients, aged 55 years (patient A) and 49 years (patient B), who presented with an eczematous eruption on sun-exposed skin. Phototesting revealed a markedly reduced 24-h minimal erythema dose (MED). Both patients had refractory disease and developed significant side-effects to conventional therapies, including topical steroids, prednisolone, psoralen with ultraviolet A, azathioprine and ciclosporin. They had each received at least 6 years of treatment prior to commencing mycophenolate mofetil (MMF). Each noted a significant improvement in symptoms within 6 weeks and subsequent clearing of the eczematous lesions. Patient A still requires continuous treatment with MMF 500 mg twice daily to prevent relapses. Patient B maintains remission by using MMF 1 g twice daily only during the spring and summer months. Both patients have tolerated the treatment well with no abnormalities in blood cell counts or liver biochemistry. Since commencing MMF, their quality of life has significantly improved. These observations suggests that MMF should be considered as an alternative treatment to conventional therapies for refractory CAD.

Chronic Disease↗
PubMed2004

Treatment of erosive oral lichen planus with topical tacrolimus.

BACKGROUND: Erosive oral lichen planus (LP) is a painful chronic inflammatory condition that is frequently resistant to immunosuppressive agents. Topical tacrolimus has been reported as a safe and effective treatment. OBJECTIVE: To evaluate the efficacy and safety of topical tacrolimus in the treatment of symptomatic erosive oral LP. METHODS: A retrospective review of consecutive patients with oral LP treated with topical tacrolimus between June 1999 and November 2003 was performed. Clinical improvement and adverse events were recorded by the physician. Patients were asked retrospectively to rate their symptoms immediately prior to and after tacrolimus therapy using a visual analogue scale. RESULTS: Physician-observed clinical improvement was found in 21 of 23 patients (91.3%) within 6 weeks. Six patients (26.1%) remained asymptomatic after stopping treatment and 15 patients (65.2%) required maintenance therapy to prevent subsequent flares. Patients' self-reported symptom scores were significantly better (p<0.001) with tacrolimus treatment, which supported physician-observed clinical improvement. There was no evidence of systemic absorption and only minor local side effects were noted. CONCLUSIONS: Topical tacrolimus is an effective treatment for erosive oral LP. The majority of patients require long-term therapy to maintain remission.

Administration, Topical↗
PubMed2003

Panniculitis secondary to extravasation of clarithromycin in a patient with alpha 1-antitrypsin deficiency (phenotype PiZ).

alpha 1-Antitrypsin deficiency (AATD) is known to be associated with panniculitis. Although reports of this association are rare, the true incidence may be unappreciated because of underdiagnosis of AATD. We report a case of panniculitis occurring in a 34-year-old woman with severe AATD following the extravasation of clarithromycin infused intravenously for treatment of community-acquired pneumonia. Resolution occurred with conservative management. The histopathology and management of this unusual condition are discussed, with a review of the literature.

Adult↗
PubMed2001

Severe recalcitrant pyoderma gangrenosum responding to a combination of mycophenolate mofetil with cyclosporin and complicated by a mononeuritis.

We describe a 17-year-old boy with severe recalcitrant pyoderma gangrenosum. Healing was achieved with a combination of mycophenolate mofetil and cyclosporin, negative pressure dressings and split-skin grafts. His recovery was complicated by a sciatic nerve palsy, which we believe was caused by direct involvement of the nerve at the level of the sciatic notch.

Adolescent↗
PubMed2001

Benefits of an inpatient pulmonary rehabilitation program: a prospective analysis.

OBJECTIVE: To examine the effect of an inpatient pulmonary rehabilitation program on functional outcome, supplemental oxygen use, quality of life (QOL), and rehospitalization. DESIGN: A prospective study. SETTING: Inpatient pulmonary rehabilitation unit. PATIENTS: One hundred fifty-seven patients with moderate to severe chronic obstructive pulmonary disease (COPD) admitted to an inpatient pulmonary rehabilitation program over a 3-year period. INTERVENTION: Comprehensive interdisciplinary inpatient pulmonary rehabilitation program with an average length of stay of 21 days. MAIN OUTCOME MEASURES: Improvements in QOL questionnaire scores, COPD knowledge questionnaire scores, 6-minute walking test (with 3 ambulation categories: bed-bound, household ambulators, community ambulators), and supplemental oxygen use. Rehospitalization 1 year after completion of the program was also assessed and compared with hospital days for the year before the program. RESULTS: On discharge from the program, 88% of individuals walked farther (p <.0001), and community ambulators doubled their walking distance, whereas bed-bound patients decreased 10-fold; supplemental oxygen use dropped 33% during the day (p <.0001) and 57% during the night (p <.0001); 82% showed improved QOL (p <.0001); 67% showed improved knowledge of COPD (p <.0001); and 67% of the sample spent less time in the hospital during the 12 months after program completion compared with the 12 months before admission (p <.001). CONCLUSIONS: An inpatient pulmonary rehabilitation program leads to improved endurance and functional ambulation, decreased supplemental oxygen use, and fewer hospitalizations 1 year after discharge for patients with COPD.

Aged↗
PubMed2000

A comparison of the costs and efficacy of ondansetron versus dolasetron for antiemetic prophylaxis.

UNLABELLED: The optimal dose and timing of 5-HT(3) antagonist administration for prophylaxis against postoperative nausea and vomiting (PONV) remains controversial. Although 5-HT(3) antagonists seem to be most effective when administered near the end of surgery, there are no data on the comparative efficacy or costs associated with the 5-HT(3) antagonists dolasetron and ondansetron when administered at the end of the operation. In this double-blinded study, 200 outpatients undergoing otolaryngologic procedures with a standardized general anesthetic received 4 (O4) or 8 mg (O8) of ondansetron or 12.5 (D12.5) or 25 mg (D25) of dolasetron IV within 30 min before the end of surgery. A blinded observer recorded the emetic episodes, maximum nausea score, recovery room resource and drug use, nursing time spent managing PONV, times to achieve discharge criteria from the Phase 1 and 2 recovery units, postdischarge emesis, and patient satisfaction. Total costs were calculated by using the perspective of a free-standing surgicenter. There were no differences in patient demographics, incidence of PONV, need for rescue medications, time spent in the recovery areas, unanticipated hospital admissions, or patient satisfaction among the four treatment groups. The mean total costs (95% confidence intervals) to prevent PONV in one patient were lowest in the D12.5 group: $23.89 (17.18-28.79) vs $37.81 (30.29-45.32), $33.91 (28.92-39.35), and $75.18 (61.13-89.24) for D25, O4, and O8, respectively. Excluding nursing labor costs did not alter this finding: $18.51 (14.18-22.85), $34.77 (28.03-41.49), $31.77 (28. 92-39.35), and $71.76 (58.17-85.35) for D12.5, D25, O4, and O8, respectively. We conclude that 12.5 mg of dolasetron IV is more cost effective than 4 mg of ondansetron IV for preventing PONV after otolaryngologic surgery and is associated with similar patient satisfaction. IMPLICATIONS: When administered at the end of surgery, 12.5 mg of dolasetron IV is as effective as 25 mg of dolasetron IV, 4 mg of ondansetron IV, and 8 mg of ondansetron IV in preventing emetic symptoms after otolaryngologic surgery and was associated with similar patient satisfaction at a reduced cost. There were no differences in the antiemetic efficacy of the 4 and 8 mg doses of ondansetron.

Ambulatory Surgical Procedures↗
PubMed1999

Stroke rehabilitation. 1. Epidemiologic aspects and acute management.

This self-directed learning module highlights recent epidemiologic and acute management issues for stroke. It is part of the chapter on stroke rehabilitation in the Self-Directed Physiatic Education Program for practitioners and trainees in physical medicine and rehabilitation. This article contains sections on epidemiologic features of stroke, pathophysiologic aspects of stroke, and advances in acute medical management in stroke.

Cerebrovascular Disorders↗
PubMed1999

Factors affecting functional outcome after stroke: a critical review of rehabilitation interventions.

A comprehensive review of the medical literature from 1950 to 1998 revealed 79 articles examining associations between rehabilitation interventions and functional outcome after stroke. This body of literature was critically analyzed, using established techniques, to reveal factors that were consistently associated with functional outcome after stroke. The following rehabilitation interventions after stroke appear to have a strong relationship with improved functional outcome at hospital discharge and follow-up: increased functional skills on admission to rehabilitation, early initiation of rehabilitation services, and rehabilitation in an interdisciplinary versus multidisciplinary setting. The following rehabilitation interventions after stroke appear to have a weak relationship with improved functional outcome at hospital discharge and follow-up: use of specialized types of therapy services and greater intensity of therapy services. The current literature is too limited to allow an assessment of the relationship of the following factors after stroke and functional outcome: specific types of non-inpatient rehabilitation services.

Ambulatory Care↗
PubMed1998

Progression from conduct disorder to antisocial personality disorder following treatment for adolescent substance abuse.

OBJECTIVE: This study investigated the progression from conduct disorder to antisocial personality disorder among individuals treated for adolescent substance abuse. This issue is important because of the poor outcomes observed among individuals with antisocial pathology after treatment for alcohol and drug problems. The utility of factors assessed at the time of treatment in predicting progression to adult antisocial personality disorder was evaluated in the context of developmental models of antisocial behavior. METHOD: This was a prospective longitudinal study of 137 substance-abusing adolescents (53 female and 84 male), whose average age was 15.9 years and who met the DSM-III-R criteria for conduct disorder. Consecutively admitted patients were recruited from two adolescent inpatient alcohol and drug treatment facilities. Participants were interviewed again 4 years after treatment. RESULTS: Four years after treatment, 61% of the study group met the DSM-III-R criteria for antisocial personality disorder. Results of a logistic regression analysis indicated that onset of deviant behavior at or before age 10, a greater diversity of deviant behavior, and more extensive pre-treatment drug use best predicted progression to antisocial personality disorder. At 4-year follow-up, the subjects with an antisocial personality disorder diagnosis exhibited more involvement with alcohol and drugs and poorer functioning across important life domains than the subjects without antisocial personality disorder. CONCLUSIONS: This study found a high rate of progression to antisocial personality disorder among substance-abusing adolescents and identified factors predictive of this progression. Careful assessment of conduct disorder history at the time of treatment may be valuable for treatment planning and intervention.

Adolescent↗
PubMed1998

Psychometric evaluation of the Customary Drinking and Drug Use Record (CDDR): a measure of adolescent alcohol and drug involvement.

OBJECTIVE: The present study was undertaken to assess the psychometric characteristics of the Customary Drinking and Drug Use Record (CDDR), an interviewer-administered questionnaire. The CDDR provides current (past 3 months) and lifetime measures of four alcohol- and other drug-related domains: level of involvement, withdrawal characteristics, psychological/behavioral dependence symptoms, and negative consequences. The present report describes the evaluation of the psychometric properties of the instrument with youth between the ages of 13 and 22 years who had markedly variable histories of involvement with alcohol and other psychoactive substances. METHOD: The sample assessed was composed of 166 adolescents recruited from two inpatient substance abuse treatment programs and 115 adolescents recruited from the community. Of the 281 subjects, 150 were male. Follow-up interviews with each adolescent and a resource person were conducted 6, 12, 24 and 48 months after the initial assessment. RESULTS: Reliability of the CDDR was assessed by examination of internal consistency, test-retest reliability and interrater reliability. Convergent, discriminant and construct validity were evaluated for each of the CDDR domains, and gender and ethnic differences on substance involvement were examined. The CDDR was found to be internally consistent and reliable over time and across interviewers for each major domain assessed. The findings supported the validity of the four domains of alcohol and other drug involvement assessed on the CDDR. CONCLUSIONS: The present results demonstrated convergent validity of the CDDR, ability to differentiate abusing from nonabusing youth and strong diagnostic specificity when compared to other standard instruments. The solid psychometric characteristics of the CDDR support its use for both research and clinical purposes.

Adolescent↗
PubMed1996

Vitamin D analogues and psoriasis.

Over recent years there has been increasing interest in the effects of vitamin D3 and its analogues upon the skin, with particular relevance to the treatment of psoriasis. As well as offering an alternative therapeutic option, research into the mode of action of vitamin D3 upon the psoriatic lesion has provided insight into the pathogenesis of psoriasis. This article reviews the effects of vitamin D3 and its analogues upon normal skin and on psoriasis.

Humans↗
PubMed1996

A cost effectiveness analysis of cyclosporine in rheumatoid arthritis.

OBJECTIVE: To perform a cost effectiveness analysis of cyclosporine (CyA) in the treatment of rheumatoid arthritis (RA). METHODS: Five randomized controlled parallel group clinical trials were selected for metaanalysis. A fixed effects model was used to calculate the treatment effects among the studies. An incremental economic analysis was performed from both a societal perspective and the perspective of Ontario Ministry of Health (MOH). A placebo comparison and 2 head to head comparisons were performed. The total treatment cost was calculated for a typical patient based on a modified intent to treat approach modelled over a one year period. RESULTS: CyA produced a 25% or greater improvement in tender joint account in 35% of the patients relative to 17% of patients receiving placebo. There was no significant difference in improvement between CyA and azathioprine (Aza) or D-penicillamine (D-Pen). From the perspective of the Ontario MOH, the annual incremental cost of achieving the same level of improvement between CyA and Aza was found to be $1,473, and between CyA and D-Pen, $1,618; the annual incremental cost effectiveness ratio per patient improved of adopting CyA over placebo was $11,547. From a societal perspective, the incremental cost of CyA was $2,886 and $3,731 between Aza and D-Pen, respectively. The annual incremental cost effectiveness ratio against placebo was $20,698. CONCLUSION: Given budgetary constraints on provincial drug plans, guidelines identifying patients in whom the cost effectiveness of CyA may be expected to be most favorable need to be explored. When CyA is the last option available to alleviate RA, whether it is "good value for money" depends upon the importance placed on patient improvement by the patients and/or by society, and on the alternative uses of the same scarce resources.

Antirheumatic Agents↗
PubMed1995

Cost-effectiveness analysis of the Ottawa Ankle Rules.

STUDY OBJECTIVE: To conduct an incremental cost-effectiveness analysis of implementation of the Ottawa Ankle Rules in emergency departments in the United States and Canada. DESIGN: A decision analytic approach to technology assessment. Clinical decision rules that allow physicians to be more selective in their use of radiography were compared with current practice in a decision analytic model. SETTING: A university hospital adult ED. PARTICIPANTS: ED physicians instructed in the use of the Ottawa Ankle Rules for adult patients with ankle injury. RESULTS: Radiography, waiting time, lost productivity, and medicolegal costs were calculated. In the United States, the savings varied between US$614,226 and US$3,145,910 per 100,000 patients, depending on the charge rate for radiography. In Ontario, Canada, the total savings were CAN$730,145 per 100,000 patients. One- and two-way sensitivity analyses that varied the rate of missed fractures, cost of radiography, probability of lawsuits, and cost of lawsuits did not change the results substantially. CONCLUSION: Implementation of the Ottawa Ankle Rules would result in significant savings of health care dollars despite the cost of missed fractures including litigation costs.

Adult↗
PubMed1995

Withdrawal and dependency symptoms among adolescent alcohol and drug abusers.

Due to differences in duration, intensity and topography of alcohol and drug use patterns, the withdrawal and dependency symptoms of adolescent substance abusers may differ from those of adult substance abusers. To explore these potential differences, 166 adolescents recruited from inpatient alcohol and drug treatment programs in the USA were assessed for alcohol and other drug withdrawal and dependency symptoms. Teens were administered the Customary Drinking and Drug Use Record following 2 weeks of abstinence and evaluated for recent (< 3 months) DSM-III-R psychoactive substance withdrawal and dependency symptoms. Adolescents were all multiple substance users with a life-time average of 4.27 drugs used in addition to alcohol. Amphetamines were the most frequently used drug (50% of sample) and the most prevalent withdrawal symptoms were those associated with central stimulant use. However, the number of different withdrawal symptoms (M = 11.27) was greater than expected for uncomplicated stimulant withdrawal or withdrawal from any single substance. On average, participants reported dependency symptoms more than DSM-III-R criteria for the diagnosis of alcohol dependency (M = 3.30), as well as dependency on their two most frequently used drugs. Heavy alcohol and cigarette use were found to exacerbate withdrawal symptoms of other drugs. These findings highlight the importance of assessing adolescent substance abusers for withdrawal from and dependency on multiple substances.

Adolescent↗
PubMed1993

Abnormal expression of MHC class II and ICAM-1 by melanocytes in vitiligo.

The relationship between damage to cutaneous melanocytes and antimelanocyte autoimmunity in vitiligo is unclear. We have demonstrated abnormal expression of MHC class II molecules by perilesional melanocytes in 13/21 patients with vitiligo and a six-fold increase in the number expressing the intercellular adhesion molecule ICAM-1. These molecules have important roles in normal antigen presentation and activation of helper T lymphocytes, and their expression by melanocytes may contribute to the abnormal immune response in vitiligo. MHC class II is not expressed by melanocytes in psoriasis and is unlikely to be induced in vitiligo by cytokines released from activated non-melanocyte-specific T lymphocytes.

Autoimmune Diseases↗
PubMed1993

An immunohistological study of cutaneous lymphocytes in vitiligo.

In a study of 49 biopsies from the margins of depigmented cutaneous lesions in 18 patients with vitiligo, highly significant overall increases were found in CD3+, CD4+, and CD8+ T cells, though cell numbers in individual cases were often within the normal range. Many of the T cells were activated (MHC class II+, interferon gamma+), of CD45RO (UCHL1+) memory subset, and many expressed the cutaneous lymphocyte-associated antigen (HECA-452+) typical of skin-homing T cells. Immunohistologically, the most intense epidermal T-cell infiltration was present within 0.6 mm of the edge of the lesion in 10 of 13 double-stained sections with a clearly defined zone of melanocyte depletion. In 40 lesions from 17 patients seen 11-64 weeks after biopsy, no apparent association was found between T-cell numbers and disease activity as assessed by Köbnerization of biopsy wounds or spread of depigmentation. These findings are consistent with the hypothesis that lesional T cells rather than circulating antimelanocytic antibody may be responsible for the supposedly autoimmune but characteristically patchy destruction of cutaneous melanocytes in vitiligo. Nevertheless, many of the infiltrating T cells are probably innocent bystanders attracted by upregulated cell adhesion molecules near sites of melanocyte damage.

Biopsy↗
PubMed1991

The health of Travellers' children in Northern Ireland.

A study was carried out to examine aspects of the health status of children from a group of 'travelling people' in Northern Ireland. A total of 350 children, aged under 16 years, were included in the study. Data were gathered by community health doctors and health visitors using a standardised questionnaire. The study revealed that this community has a high degree of consanguinity and points to higher levels of congenital abnormalities than in the settled community. Uptake of immunisation was less than the settled community and hospital admissions in the younger age group were particularly due to infectious diseases. The authors conclude that provision of health services for travelling people in Northern Ireland should be urgently reviewed with consideration of the needs and lifestyle of this group. The provision of suitable sites for travelling people with adequate water and sewage facilities to reduce potential risks to health is also advocated.

Child↗