Biomedical subjects
L Doyle
Publications and source records attributed to L Doyle.
Thoracoscopic mobilization of the esophagus. A 6 year experience.
BACKGROUND: Traditionally, esophageal resection has been performed using a thoracotomy to access the intrathoracic esophagus. With the aim to avoid the potential morbidity of the open thoracic approach, mobilization of the esophagus under direct vision recently has been described. We report our experience at attempting thoracoscopic mobilization of the esophagus in 162 patients during a 6-year period. METHODS: Patients with malignancy or end-stage benign disease of the esophagus considered suitable for a three-stage esophagectomy underwent a thoracoscopy with a view to endoscopic mobilization of the esophagus. Of the 162 patients in whom the procedure was attempted, it was abandoned in 9 patients (6%), and the procedure was converted to open surgery in 11 patients (7%). RESULTS: In the patients whose esophagus was mobilized, the average blood loss was 165 ml, and the average time for the thoracoscopic segment of the surgery was 104 min. In the 133 patients who underwent a resection for invasive malignancy, a limited mediastinal nodal dissection retrieved an average of 11 nodes, and the median survival was 29 months. The 30-day mortality was 3.3% and the in-hospital mortality 5.3%. CONCLUSIONS: Thoracoscopic mobilization can be performed safely with satisfactory outcomes in a center performing a large volume of esophageal surgery and possessing advanced endoscopic surgery skills. Further assessment of this technique and comparisons with traditional open procedures are needed to assess this approach further as an appropriate oncologic procedure.
Children followed with difficulty: how do they differ?
OBJECTIVE: To determine if very low birthweight children followed with ease differ in any perinatal or sociodemographic characteristics, or outcomes, compared with children followed with more difficulty. METHODOLOGY: Consecutive children of birthweight < 1000 g or with gestational ages < 28 weeks born in 1991 (n = 51) or of birthweight < 1500 g born in 1992 (n = 166) at the Royal Women's Hospital, Melbourne, surviving to 5 years of age, were assessed at 5 years of age, corrected for prematurity. Those who attended on the first mutually agreed appointment without substantial reluctance were considered to have been followed with ease. The remainder were considered to have been followed with difficulty. Outcomes included impairments such as cerebral palsy, blindness, deafness, and low IQ. Children had a disability if they had any of cerebral palsy, blindness, deafness requiring amplification, or an IQ more than 1 SD below the mean. RESULTS: Of the 217 survivors, 204 (94%) were assessed fully at 5 years of age. Of the 204 children assessed, 153 (75%) were followed with ease, and 51 (25%) with difficulty. Of data available in the perinatal period, significantly fewer children followed with more difficulty came from intact families, and more of their mothers had fewer than 12 years of schooling. More children followed with difficulty had a disability (41% compared with 19%), as they predominantly had lower IQ scores (mean difference in IQ - 12.7, 95% confidence interval - 18.0, - 7.4). The association between difficulty of assessment and both higher rates of disability and lower IQ scores remained after adjustment for significant perinatal and sociodemographic variables. CONCLUSIONS: Children followed with difficulty can partly be recognized on several sociodemographic characteristics in the perinatal period, and have substantially worse sensorineural outcomes than those followed with ease. In any longitudinal study, the more incomplete the follow up, the lower will be the rate of adverse sensorineural outcome.
Risks and benefits of steroids in preterm infants.
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Continuous positive airway pressure: randomized, controlled trial in Australia.
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Direct access day case oral surgery.
OBJECTIVE: To compare the effectiveness of direct access referrals with standard letter referrals, and also assess the impact of the direct access system on the primary care provider, secondary sector and from the patients perspective. DESIGN: Surgical and anaesthetic guidelines were agreed and 12 general dental practitioners were recruited to participate in the study. Each practitioner was given 100 envelopes which contained randomly allocated 50 direct and 50 standard referrals. For direct referrals, GDPs completed a pre-operative assessment and obtained an operation date by telephone from the day case unit while the patient was in the surgery. The clinical history sheet was faxed to the day unit and the radiographs posted. The only contact the patient had with the hospital was on the day of surgery. Standard referral patients were referred in the traditional way with a referral letter being sent to an out-patient clinic. Evaluation of the effectiveness of the direct referral system versus standard letter method were made via completion of questionnaires by the patients, dental practitioners, hospital clinicians, day case anaesthetist and co-ordinator. SETTING: The study was carried out over 2 years commencing in 1997 at the Oral Surgery Day Case Unit at Manchester Royal Infirmary. RESULTS: A greater number of direct access referrals (409; 90%) were treated in comparison with (312; 75%) standard referrals (P < 0.001). Eighty nine per cent of direct access records were adequate pre-operatively. More than 70% of dentists and hospital clinicians preferred the direct access referral method. Sixty-three per cent of standard letter patients were satisfied with their mode of referral compared with 87% of direct access patients. CONCLUSIONS: Given appropriate guidelines dental practitioners are able to refer directly to oral surgery day case operation lists. This has proved to be the favoured method of referral for dental practitioners, the secondary sector and patients.
Detection of Planetary Transits of the Star HD 209458 in the Hipparcos Data Set.
A search of the Hipparcos satellite photometry data for the star HD 209458 reveals evidence for a planetary transit signature consistent with the planetary properties reported by Henry et al. and Charbonneau et al. and allows further refinement of the planet's orbital period. The long time baseline (about 2926 days or 830 periods) from the best Hipparcos transit-like event to the latest transit reported by Henry et al. for the night of 1999 November 15 (UT) allows for an orbital period determination of 3.524736 days with an uncertainty of 0.000045 days (3.9 s). The transit events observed by Charbonneau et al. fall at the interim times expected to within the errors of this newly derived period. A series of statistical tests was performed to assess the likelihood of these events occurring by chance. This was crucial given the ill-conditioned problem presented by the sparse sampling of the light curve and the non-Gaussian distribution of the points. Monte Carlo simulations using bootstrap methods with the actual Hipparcos HD 209458 data set indicate that the transit-like signals of the depth observed would only be produced by chance in 21 out of 1 million trials. The transit durations and depths obtained from the Hipparcos data are also consistent with those determined by Charbonneau et al. and Henry et al. within the limitations of the sampling intervals and photometric precision of the Hipparcos data.
Postnatal corticosteroids in preterm infants: systematic review of effects on mortality and motor function.
BACKGROUND: Postnatal corticosteroid therapy has been proved in randomized controlled trials to reduce ventilator dependence and the rate of chronic lung disease in preterm infants with few serious short-term side effects. However, there are other consequences that might follow postnatal corticosteroid therapy that are more important, including mortality or cerebral palsy. OBJECTIVES: To review the evidence from reported randomized controlled trials on the effects of postnatal corticosteroid on long-term mortality and motor dysfunction, including cerebral palsy. METHODS: The methods involved a meta-analysis of reported randomized controlled trials, following guidelines of the Cochrane Collaboration, including calculation of event rate differences (ERD) and 95% confidence intervals (CI). RESULTS: The mortality rate difference was non-significant both statistically and clinically (ERD - 0.1% favouring corticosteroids, 95% CI -2.9% to 2.8%). There were no subgroups in which a beneficial effect of postnatal corticosteroids on survival could be demonstrated. The rate of motor dysfunction in survivors was significantly higher in survivors from the postnatal corticosteroid group (ERD 11.9% favouring controls, 95% CI 4.6% to 19.2%). The rate of survival, free of motor dysfunction, was significantly lower in the postnatal corticosteroid group (ERD 7.8% favouring controls, 95% CI 0.5% to 15.1%). CONCLUSIONS: Although postnatal corticosteroids have short-term benefits, they do not increase the survival rate, and they may cause motor dysfunction in survivors. A large-scale, placebo-controlled randomized trial, with survival free of sensorineural impairments and disabilities as the major endpoint, is urgently needed.
Surviving emergency social work: experience of an Australian Accident & Emergency Department.
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William Stark (1740-1770): his life, manuscript and death.
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Interleukin-6 concentrations in neonatal sepsis.
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The effect of magnesium supplementation on biochemical markers of bone metabolism or blood pressure in healthy young adult females.
OBJECTIVES: To investigate the effects of increasing Mg intakes, above the usual dietary intake, on blood pressure and on biomarkers of bone metabolism in healthy young adult females. DESIGN: A double-blind, placebo-controlled, randomised crossover Mg intervention trial. SETTING: The study was conducted in the Department of Nutrition, University College, Cork, Ireland. SUBJECTS: Twenty-six healthy (normotensive) adult females aged 20-28 y were recruited from University College, Cork. INTERVENTION: Subjects were randomly assigned to their self-selected diets (approximately 11 mmol Mg/d) or their self-selected diet with a 10 mmol/d Mg supplement as Mg(OH)2 (approximately 22 mmol Mg/d) for 28 d followed by cross-over to the alternative diet for a further 28 d. During each dietary period urines (last 3 d) and blood (morning of 27 d) were collected and blood pressure was measured on the morning of 28 d. RESULTS: Increasing Mg intake from the usual level (11 mmol/d) to 22 mmol/d for 28d increased urinary excretion of Mg by 36% and erythrocyte Mg content by 5% but had no effect on serum Mg, Ca, PTH, osteocalcin or bone-specific alkaline phosphatase (biomarkers of bone formation), urinary pyridinium crosslinks of collagen (biomarkers of bone resorption), or on blood pressure. CONCLUSION: Increasing the mean Mg intake in healthy young adult females above the usual dietary intake, which is currently above the US EAR (estimated average requirement), but below the US RDA for Mg, does not affect blood pressure or the rate of bone turnover.
Tocolytic magnesium sulphate and paediatric mortality.
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Cutaneous tape stripping to accelerate the anesthetic effects of EMLA cream: a randomized, controlled trial.
UNLABELLED: Most medications are not absorbed topically due to the stratum corneum barrier. While effective as a topical anesthetic, EMLA cream is absorbed slowly, delaying its effects for up to one hour, thereby limiting its usefulness. OBJECTIVE: To determine whether removal of the cornified layer of the skin by tape stripping (TS) would allow more rapid onset of anesthesia after topical application of EMLA cream prior to IV catheterization (IVC). METHODS: This was a prospective, randomized, controlled trial comparing the levels of pain of IVC 15 minutes after topical application of EMLA cream in patients who had TS vs patients who did not. The setting was a suburban university-affiliated ED. A convenience sample of 68 alert adult patients requiring IVC were enrolled. The primary outcomes measured were pain of IVC and pain of TS using a previously validated 100-mm visual analog scale as well as the IVC success rate. RESULTS: The pain of IVC was less for TS vs control patients [29.7 mm (95% CI=20.4 to 39.0 mm) vs 15.9 mm (95% CI=9.1 to 22.6 mm), p=0.017]. The mean pain of TS was 4.8+/-7.4 mm. The IVC success rate for TS vs control patients was 91% vs 74% (p=0.056). There were no adverse events after TS. CONCLUSIONS: Removal of the cornified layer of the skin resulted in a more rapid anesthetic effect of EMLA cream as evidenced by lower IVC pain scores after TS. The effectiveness of TS for enhanced absorption of other medications should be investigated.
Randomised, controlled trial of nasal continuous positive airway pressure in the extubation of infants weighing 600 to 1250 g.
AIM: To determine whether extubation to nasal continuous airway pressure (NCPAP) results in a greater proportion of infants remaining free of additional ventilatory support for one week after extubation compared with those extubated directly to headbox oxygen. METHODS: A randomised, controlled, clinical trial was conducted at the neonatal intensive care unit of the Royal Women's Hospital, Melbourne, of infants with birthweights between 600 and 1250 g, ventilated via an endotracheal tube for more than 12 hours, requiring less than 50% oxygen, a ventilator rate < or = 20/minute, considered by the clinical management team to be ready for extubation. Infants were randomly allocated either to NCPAP or to oxygen administered via a headbox. Success was defined by no requirement for additional ventilatory support over the week following extubation. Failure criteria were (i) apnoea; (ii) absolute increase in oxygen requirement greater than 15% above than required before extubation; or (iii) respiratory acidosis (pH < 7.25 with pCO2 > 6.67 kPa). RESULTS: Thirty one of 47 (66%) infants were successfully extubated to NCPAP compared with 18 of 45 (40%) for headbox oxygen. The increase in failure rate in the headbox group was due primarily to increased oxygen requirements in this group. Of the 27 who failed headbox oxygen, 26 were given a trial of NCPAP and 13 did not require endotracheal reintubation. There was no significant difference between the groups in the total number of days of assisted ventilation or the duration of inpatient stay. CONCLUSIONS: NCPAP applied prophylactically after endotracheal extubation reduces the incidence of adverse clinical events that lead to failure of extubation in the seven days after extubation. This reduction is clinically important. The benefits of NCPAP do not seem to be associated with an increased incidence of unwanted side effects.
Delayed delivery of the second twin after premature previable delivery of the first twin.
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Comparison of two-dimensional time-of-flight dynamic magnetic resonance angiography with digital subtraction angiography in popliteal artery entrapment syndrome.
OBJECTIVE: To assess dynamic magnetic resonance angiography (MRA) as an alternative to catheter angiography in patients with popliteal artery entrapment syndrome (PAES). PATIENTS AND METHODS: Nine patients with surgically proven PAES underwent provocation digital subtraction angiography (DSA) and 2-dimensional time-of-flight dynamic MRA of the popliteal fossae (total of 17 limbs). Eight normal volunteers also underwent dynamic MRA (total of 16 limbs). Two observers blinded to the surgical findings and the results of DSA independently evaluated the 33 limbs of the 17 subjects on the basis of maximum-intensity projection images and transverse MRA source images. The degree of stenosis was graded and compared with that indicated by DSA. RESULTS: Among the 17 limbs of patients with surgically proven PAES, dynamic MRA suggested the correct diagnosis in 13 (76%) by indicating stenosis greater than 50%. Dynamic MRA indicated stenosis of 1% to 50% for 4 (25%) of the 16 normal limbs and no stenosis in the other 12 normal limbs (i.e., no false positive results). CONCLUSION: Catheter angiography is not necessary if dynamic MRA indicates stenosis of greater than 50% in patients with clinical suspicion of PAES, but is recommended if dynamic MRA indicates stenosis of 1% to 50%.
Antenatal phenobarbitone and neonatal outcome.
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