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Biomedical subjects

E Currie

Publications and source records attributed to E Currie.

At least 19 recordsLinked to original sources

The incidence of flushing on induction of anaesthesia in patients who blush easily.

Flushing (reddening and blotching of the skin) is seen frequently at induction of anaesthesia, is associated with anaesthetic agents such as thiopental and muscle relaxants, and is attributed to histamine release. The changes are generally confined to the neck and upper chest (the blush area). In conscious subjects, the mechanisms responsible for blushing in the same skin distribution are well defined and neurally mediated. We investigated the relationship between a history of blushing easily and flushing after intravenous induction o f anaesthesia. We interviewed 898 patients about to undergo general anaesthesia and asked them if they blushed easily. Anaesthesia was induced with thiopental followed by suxamethonium and/or alcuronium. We noted skin colour and the presence of a flush every 5 min for 20 min. Women reported blushing more than men (47% of women, compared with 33% of men, p < 0.001), and blushing was more common in young people (p < 0.001). In those women with a history of blushing, 32% flushed on induction of anaesthesia, compared with 6% of those who did not blush. In men, a flush was seen in 22% of those who blushed, and in 0.2% of those who did not. These differences in the frequency of flushing were significant (p < 0.001). In conclusion, flushing after induction of anaesthesia appears to be related to individual predisposition and may be neurally mediated.

Adolescent↗

The management of inhibitors in haemophilia A: introduction and systematic review of current practice.

Haemophilia is the commonest bleeding disorder in the UK, affecting approximately 5400 people, almost all of them male. In haemophiliacs, reduced levels, or absence, of factor VIII (FVIII) cause bleeding episodes, typically into joint spaces or muscles. Haemophilia is generally treated with exogenous FVIII. However, in some haemophiliacs, therapeutically administered FVIII comes to be recognized as a foreign protein, stimulating the production of antibodies (inhibitors), which react with FVIII to render it ineffective. Alternative treatment strategies then have to be used to manage bleeding episodes. In addition, strategies have been developed to attempt to abolish inhibitor production through the induction of immune tolerance. A systematic review was undertaken of current international practice for the clinical management of haemophilia A patients with inhibitors to FVIII, concentrating on literature published from 1995 onwards. Although it can be difficult to determine what constitutes current practice, current guidelines indicate that immune tolerance induction is seen as desirable, with the choice of regimen dependent on patient characteristics, familiarity with regimens and cost. Various approaches, based on similar factors, are used to control bleeding episodes.

Autoantibodies↗

Clinical and cost-effectiveness of new and emerging technologies for early localised prostate cancer: a systematic review.

OBJECTIVES: To evaluate the clinical and cost-effectiveness of new and emerging technologies for early, localised prostate cancer. DATA SOURCES: Electronic databases, reference lists of relevant articles and various health services research-related resources. REVIEW METHODS: A list of new and emerging technologies was identified and agreed. A systematic review was undertaken and selected studies were reviewed against a set of criteria. An economic model was developed and used to compare the specified newer treatments with the traditional approaches. RESULTS: For neoadjuvant hormonal therapy, no evidence of benefit was seen in terms of biochemical disease-free survival. For adjuvant hormonal therapy, there was no evidence of benefit in terms of survival, but some conflicting evidence that higher risk patients may benefit. The largest number of studies reported results for brachytherapy, where some evidence suggested that it may be more effective than standard treatments for lower risk patients, although less effective for intermediate- and high-risk patients, in terms of biochemical disease-free survival. Lower quality evidence reported fewer complications than for standard treatments. Higher quality evidence suggested that disease-specific quality of life (QoL) for brachytherapy patients was lower than for patients receiving standard treatments. The review of three-dimensional conformal radiotherapy (3D-CRT) considered treatment-related morbidity, where significantly fewer gastrointestinal complications occurred than with standard radiotherapy. It was suggested that higher radiation doses achieved better disease control, although patient characteristics were often reported as independent indicators of control. The review of intensity-modulated conformal radiotherapy suggested that late gastrointestinal toxicity may be reduced compared with 3D-CRT. For cryotherapy, high rates of impotence were reported. Owing to the paucity and poor quality of evidence identified for other interventions, conclusions regarding their clinical effectiveness cannot be drawn. Cost-effectiveness estimates were based on the impact of adverse events on quality-adjusted life-years and the assessment was restricted to brachytherapy, 3D-CRT and cryotherapy compared with standard treatments. Of the new treatments included, only cryotherapy appeared not to be potentially cost-effective compared with traditional treatments, owing to the associated high incidence of impotence. CONCLUSIONS: The results of the clinical effectiveness review should be viewed in the context of the quality of the available evidence. Very few randomised controlled trials (RCTs) were identified, with the majority of included studies being descriptive case series, open to patient selection bias and measuring surrogate end-points with short-term follow-up. It is difficult therefore to draw conclusions on the relative benefits or otherwise of the newer technologies owing to the lack of substantive evidence of any quality and the lack of comparisons between the newer technologies and with standard treatments. Given the lack of high-quality clinical evidence with long-term follow-up and the uncertainty surrounding the assumptions in the economic analysis, the following areas are recommended for further research: RCTs with sufficient follow-up to measure benefits in terms of overall survival to include QoL measurement to establish trade-offs between potential adverse events and benefits of treatment; the identification of prognostic risk factors among men diagnosed with early prostate cancer; QoL studies to compare the utility of health states among patients on active monitoring, patients receiving treatment and the comparable healthy population; the relationship between surrogate end-points and survival; and the adoption of standard definitions for adverse events.

Cost-Benefit Analysis↗

Treatment of hepatic metastases of neuroendocrine malignancies: a 10-year experience.

BACKGROUND: Liver metastases from neuroendocrine tumours may give rise to symptoms due to hormone production or mass effect. Accepted management options include administration of somatostatin-analogues, selective chemoembolisation or hepatic resection. The aim of this study was to review the management of hepatic neuroendocrine metastases in our unit. METHODS: Patients with neuroendocrine tumours presenting between 1989 and 1999 were identified from pathology, radiology and surgical databases. Case notes were retrospectively reviewed for demographic data, treatment modality and outcome. Response to treatment was based on biochemistry, radiology or symptoms, and response rates were defined accordingly. RESULTS: Thirty patients with a mean age of 55 years presented with, or later developed liver metastases. The most frequent presenting symptoms were abdominal pain (63%), diarrhoea (40%), weight loss (33%) and flushing (13%). Five patients underwent liver resection with complete symptomatic response, nine underwent chemoembolisation with a 75% response rate (either biochemically, radiologically or symptomatic) and fifteen were treated with a somatostatin-analogue, with a response rate of 86%. Median survival from detection of metastases was 45 months. CONCLUSIONS: Liver resection provides good symptomatic relief, but it is only indicated in a small proportion of patients with metastatic neuroendocrine tumours. Both chemoembolisation and somatostatin-analogues offer useful symptomatic control for these patients with good survival prospects.

Adult↗

Evaluation of an antiseptic triple-lumen catheter in an intensive care unit.

OBJECTIVE: To evaluate a decrease in catheter-related bloodstream infection rate in patients with antiseptic triple-lumen catheters in an intensive care unit. DATA SOURCES: Retrospective review of surveillance records, patient medical records, laboratory and microbiological reports, and antibiotic administration records. STUDY SELECTION: Patients admitted to the intensive care unit with triple-lumen catheters. DATA EXTRACTION: A subset of one entry per patient was extracted from 2 yrs of primary bloodstream infection surveillance data. Data collection included risk factors, laboratory and microbiological data, and insertion sites and dates of all intravascular catheters present during triple-lumen catheterization. DATA SYNTHESIS: The catheter-related bloodstream infection rate was 5.4 and 11.3 per 1000 catheter days in antiseptic and nonantiseptic triple-lumen catheter groups, respectively (p = .06). By multivariate analysis using a Cox Proportional Hazards Model, the antiseptic triple-lumen catheters were associated with a significant reduction in catheter-related bloodstream infection (p = .03). Model expansion to include intrajugular site was significant by a likelihood ratio test [2(log likelihood diff) = 4.26 P<.05 chi2(1)] CONCLUSIONS: The use of antiseptic triple-lumen catheters may substantially reduce catheter-related bloodstream infections in an intensive care population and may be subsequently associated with a decrease in length of stay.

Aged↗

Sociologic perspectives on juvenile violence.

In sum, there are four sets of social factors that help us understand why juvenile violence appears when, and where, it does, and why some communities and entire societies are persistently wracked by youth violence whereas others are largely spared its worst expressions. When it comes to the first three factors in particular--deprivation, disorganization, and brutalization--the evidence for these links is as strong as anything in social science, and that evidence is supported by a variety of sources and a variety of methods of investigation. Such investigation includes the knowledge we gain through social intervention. Some of the most effective violence prevention programs are successful precisely because they confront and deflect the social forces that otherwise often lead to violence. Consider, for example, the home-visiting programs that work with poor parents in disorganized communities to lower the risks of child abuse; and some of the more "holistic" or "multisystemic" efforts to work with violent juvenile offenders. The best of these programs work by tackling the problems of social isolation and lack of supports in the community, as well as immediate issues of economic survival for vulnerable families and children. More generally, we know that the availability of steady and rewarding work in the future, of the kind that can reliably sustain a family, is one of the most important factors allowing some youths to "desist" from violence as they mature. These conclusions give us much to be encouraged about, and much to be alarmed about. On the one hand, understanding that youth violence often is rooted in a set of adverse social conditions that are identifiable, and potentially modifiable, is a fundamentally optimistic message. It reminds us that the level of juvenile violence we suffer in America today is neither fated nor inevitable. Other societies that are in many respects much like us suffer far less of it; so could we, and we increasingly understand some of the ways in which we could make that happen. We know that some programs designed to increase opportunities and supports for high-risk youth and families do work, and we know that there are broader social and economic policies--policies that are not abstract visions, but have actually been put into place in societies much like our own--that can significantly diminish the pressures toward violence that are bred by poverty and social insecurity among the young. But knowing what to do is one thing, and actually doing it is another. In this there is much reason for concern. The 7-year economic boom that began in the early 1990s has had salutary effects on youth violence, mainly by providing improved economic opportunities for low-income youth and, accordingly, diminishing the appeal of illegal activities. Despite that extraordinary burst of sustained prosperity, however, too many of America's youth remain impoverished, sometimes desperately so: the boom has had only limited effect on our disturbingly high rates of family poverty, which continue to tower above those of comparable industrial societies. And if the boom should come to an end, and we enter again into a period of rising joblessness for youth and young adults, then much, or all, of the recent gains could be quickly lost. The positive economic trends that have helped take the edge off serious juvenile violence in the past few years, in short, are both partial and fragile. Worse, some of our recent social and economic policies, at both state and federal levels, are working in the opposite direction. Some variants of welfare reform, for example, have tossed many vulnerable families off of public assistance without offering solid economic opportunities in its place. Many more families face this future as federal time limits on public welfare increasingly come into play. Given what we know about the links between deprivation and youth violence, this is not a development we can celebrate. (ABSTRACT TRUNCATED)

Adolescent↗

An 8-year experience of hepatic resection: indications and outcome.

BACKGROUND: Most reports highlighting decreasing operative morbidity and mortality rates following hepatic resection have focused on the management of metastatic disease. Information on the full range of hepatic disease is lacking. METHODS: The indications for hepatic resection in a specialist hepatobiliary unit have been reviewed and the operative morbidity and mortality rates assessed. RESULTS: Among 129 patients undergoing 133 hepatic resections between October 1988 and September 1996, the principal indication for resection was hepatic malignancy (102 resections), metastatic in 66 cases. Other indications included contiguous tumour (n = 20), primary tumour (n = 16) and benign disease (n = 31). Some 116 procedures were classical anatomical resections. Blood transfusion was required in 40 per cent of cases but major morbidity occurred in 20 per cent. There were six deaths following surgery, five of which were due to hepatic failure and followed resection for malignancy or trauma. The 3-year survival rate in patients resected for colorectal metastases was 65 per cent. CONCLUSION: This experience has demonstrated an increasing role for hepatic resection in a wide variety of hepatobiliary pathologies. Despite the low postoperative mortality rate, the significant risk of complications in the postoperative period serves to emphasize the need for careful selection of patients for such surgery, which should be undertaken in specialist centres.

Adult↗