Editorial: Basic research and clinical practice.
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Animals↗
Biomedical subjects
David Johnson
Publications and source records attributed to David Johnson.
The neurological outcome of non-accidental head injury.
PURPOSE: The literature regarding the outcome of non-accidental head injury (NAHI) is scarce and lacks specific detail even though it is generally considered to be poor. The purpose of this study is to review the literature to date and report the neurological outcome of these children in detail. METHODS: A cross-sectional and prospective study of children admitted to hospital with NAHI in Scotland. RESULTS: Twenty-five children were enrolled and 68% of children were neurologically abnormal at an average follow-up of 59 months. A wide range of abnormalities and outcomes was seen. Speech and language difficulties were present in 64% including autistic spectrum disorder. Cranial nerve abnormalities were present in 20%. Visual deficits and epilepsy compounded learning difficulties in 25% of survivors. Consent for follow-up was more likely to be obtained where the perpetrator was known. CONCLUSIONS: The spectrum and degree of severity of neurological abnormalities in survivors of NAHI is extremely variable, with the majority of these children being moderate or severely abnormal. These children require the support of a multi-disciplinary team in the community. Further study regarding the process of follow-up, where complex medicolegal issues exist, are needed in order to facilitate maximum neurological development.
Child, Preschool↗
Marked lability in urinary cortisol levels in subgroups of combat veterans with posttraumatic stress disorder during an intensive exposure treatment program.
OBJECTIVE: The objective of this study was to obtain longitudinal data on lability of cortisol levels in posttraumatic stress disorder (PTSD) because previous studies have largely been based on sampling at a single time point and have yielded varying results. METHODS: This study measured urinary cortisol levels at admission, midcourse, and discharge during a 90-day hospitalization period in male Vietnam combat veterans with PTSD (N = 51). RESULTS: Although there were no significant differences in the mean +/- SEM urinary cortisol levels between the admission (59.4 +/- 3.0 microg/d), midcourse (55.6 +/- 3.9 microg/d), and discharge (53.4 +/- 3.4 microg/d) values, marked lability of cortisol levels in individual patients was observed over time, with changes ranging from +93 to -58 microg/d from admission to midcourse. In addition, this hormonal lability defined discrete subgroups of patients on the basis of the longitudinal pattern of cortisol change during exposure treatment, and there were significant psychometric differences in the level of social functioning between these subgroups. CONCLUSIONS: The findings do not support the concept of either a static "hypocortisolism" or "hypercortisolism" in PTSD, but rather suggest a psychogenic basis for cortisol alterations in PTSD in relation to psychosocial stress and indicate a central regulatory dysfunction of the hypothalamic-pituitary-adrenal axis characterized by a dynamic tendency to overreact in both upward and downward directions. The longitudinal findings fit with recent observations that cortisol elevations occur when acutely superimposed stressful conditions emotionally engage patients and overwhelm the usually dominating disengaging coping mechanisms associated with suppression of cortisol levels in PTSD. The findings emphasize the importance of longitudinal data in studies of the hypothalamic-pituitary-adrenal axis in PTSD.
Adult↗
Utility of impedance cardiography to determine cardiac vs. noncardiac cause of dyspnea in the emergency department.
Determining the correct diagnosis of patients with dyspnea can be challenging. Early and accurate determination of the cause of dyspnea is vital in instituting timely and appropriate interventions. Hemodynamic parameters may aid in the evaluation of dyspnea, but are difficult to assess by physical exam. Impedance cardiography (ICG) is a newly validated method of determining hemodynamic parameters noninvasively. The purpose of this study was to determine the accuracy in differentiating cardiac from noncardiac causes of dyspnea utilizing ICG-derived hemodynamic parameters compared with that of emergency department (ED) physicians after initial history, physical, and laboratory tests. The final diagnosis, which was made retrospectively after review of the patient's hospital record by a senior ED physician blinded to the ICG data, was compared with the treating ED physician's and the ICG diagnoses. Thirty-eight patients who presented with dyspnea to a community ED were included in the study. There were significant differences in values of cardiac index by ICG (2.2 vs. 3.1; p<0.0001), systolic time ratio (0.52 vs. 0.37; p<0.01) and velocity index (32.9 vs. 42.7; p<0.01) between the cardiac and noncardiac groups, respectively. ICG measurements demonstrated greater sensitivity (92 vs. 83%), specificity (88 vs. 77%), and positive and negative predictive values (79 vs. 63% and 96 vs. 91%, respectively) compared with the ED physician in distinguishing cardiac from noncardiac cause of dyspnea. ICG can aid ED physicians in making more rapid and accurate determinations of cardiac vs. noncardiac cause of dyspnea.
Adult↗
Guidelines for colonoscopy surveillance after polypectomy: a consensus update by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society.
Adenomatous polyps are the most common neoplastic findings uncovered in people who undergo colorectal screening or have a diagnostic workup for symptoms. It was common practice in the 1970s for these patients to have annual follow-up surveillance examinations to detect additional new adenomas as well as missed synchronous adenomas. As a result of the National Polyp Study report in 1993, which demonstrated clearly in a randomized design that the first postpolypectomy examination could be deferred for 3 years, guidelines published by a gastrointestinal consortium in 1997 recommended that the first follow-up surveillance be 3 years after polypectomy for most patients. In 2003, these guidelines were updated, colonoscopy was recommended as the only follow-up examination, and stratification at baseline into lower and higher risk for subsequent adenomas was suggested. The 1997 and 2003 guidelines dealt with both screening and surveillance. However, it has become increasingly clear that postpolypectomy surveillance is now a large part of endoscopic practice, draining resources from screening and diagnosis. In addition, surveys have demonstrated that a large proportion of endoscopists are conducting surveillance examinations at shorter intervals than recommended in the guidelines. In the present paper, a careful analytic approach was designed addressing all evidence available in the literature to delineate predictors of advanced pathology, both cancer and advanced adenomas, so that patients can be more definitely stratified at their baseline colonoscopy into those at lower or increased risk for a subsequent advanced neoplasia. People at increased risk have either three or more adenomas, or high-grade dysplasia, or villous features, or an adenoma > or =1 cm in size. It is recommended that they have a 3-year follow-up colonoscopy. People at lower risk who have one or two small (< 1 cm) tubular adenomas with no high-grade dysplasia can have a follow-up in 5 to 10 years, whereas people with hyperplastic polyps only should have a 10-year follow-up as average-risk people. Recent papers have reported a significant number of missed cancers by colonoscopy. However, high-quality baseline colonoscopy with excellent patient preparation and adequate withdrawal time should minimize this and reduce clinicians' concerns. These guidelines were developed jointly by the US Multi-Society Task Force on Colorectal Cancer and the American Cancer Society to provide a broader consensus and thereby increase utilization of the recommendations by endoscopists. Adoption of these guidelines nationally can have a dramatic impact on shifting available resources from intensive surveillance to screening. It has been shown that the first screening colonoscopy and polypectomy produces the greatest effects on reducing the incidence of colorectal cancer in patients with adenomatous polyps.
Adenomatous Polyps↗
Guidelines for colonoscopy surveillance after cancer resection: a consensus update by the American Cancer Society and US Multi-Society Task Force on Colorectal Cancer.
Patients with resected colorectal cancer are at risk for recurrent cancer and metachronous neoplasms in the colon. This joint update of guidelines by the American Cancer Society (ACS) and US Multi-Society Task Force on Colorectal Cancer addresses only the use of endoscopy in the surveillance of these patients. Patients with endoscopically resected Stage I colorectal cancer, surgically resected Stage II and III cancers, and Stage IV cancer resected for cure (isolated hepatic or pulmonary metastasis) are candidates for endoscopic surveillance. The colorectum should be carefully cleared of synchronous neoplasia in the perioperative period. In nonobstructed colons, colonoscopy should be performed preoperatively. In obstructed colons, double contrast barium enema or computed tomography colonography should be done preoperatively, and colonoscopy should be performed 3 to 6 months after surgery. These steps complete the process of clearing synchronous disease. After clearing for synchronous disease, another colonoscopy should be performed in 1 year to look for metachronous lesions. This recommendation is based on reports of a high incidence of apparently metachronous second cancers in the first 2 years after resection. If the examination at 1 year is normal, then the interval before the next subsequent examination should be 3 years. If that colonoscopy is normal, then the interval before the next subsequent examination should be 5 years. Shorter intervals may be indicated by associated adenoma findings (see Postpolypectomy Surveillance Guideline). Shorter intervals are also indicated if the patient's age, family history, or tumor testing indicate definite or probable hereditary nonpolyposis colorectal cancer. Patients undergoing low anterior resection of rectal cancer generally have higher rates of local cancer recurrence, compared with those with colon cancer. Although effectiveness is not proven, performance of endoscopic ultrasound or flexible sigmoidoscopy at 3- to 6-month intervals for the first 2 years after resection can be considered for the purpose of detecting a surgically curable recurrence of the original rectal cancer.
American Cancer Society↗
Early discharge of Alberta mothers post-delivery and the relationship to potentially preventable newborn readmissions.
OBJECTIVE: To determine whether early maternal discharge increases newborn readmission rates. METHODS: Singleton vaginal deliveries weighing at least 2500 grams were extracted from April 1, 1997 to March 31, 2000 Alberta hospital abstracts and linked to records of birth. Potentially preventable readmissions were for dehydration, jaundice, feeding problems, inadequate weight gain, and social reasons. RESULTS: The most common reason for readmission is jaundice (74%). In order of importance, influencing factors were: length of gestation, Aboriginal treaty status, first live birth, delivering in region of residence, number of deliveries done in the hospital, newborn sex, maternal smoking, birthweight, previous abortions, and delivering in nearest hospital. Post-delivery length of stay was associated with readmissions in the first 6 days post discharge (25% greater in those < 27 hours compared to those > 48 hours) but not in the first 28 days post discharge. CONCLUSION: Early maternal discharge is a minor determinant of potentially preventable newborn readmissions.
Adolescent↗