Does clinical epidemiology have a role in clinical practice?
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Clinical Competence↗
Biomedical subjects
M Williams
Publications and source records attributed to M Williams.
Diseases of the submandibular gland as demonstrated using high resolution ultrasound.
In this review the high resolution ultrasound appearances of the normal anatomy and pathology involving the submandibular gland are demonstrated. The submandibular gland is affected by a number of disease processes that may be difficult to distinguish clinically. Its superficial location makes it ideal for ultrasound evaluation and a useful adjunct to clinical examination. In the assessment of submandibular pathology ultrasound allows intraglandular and extraglandular lesions to be localized and differentiated. These lesions can be further characterized as being benign or malignant and the extent of any extraglandular extension determined. Ultrasound is the first-line investigation in the assessment of sialolithiasis due to its high specificity and sensitivity. In severe infective sialadenitis ultrasound can confirm the presence and guide drainage of abscesses. Ultrasound also has an important role in the assessment of chronic inflammatory disorders such as sarcoidosis and Sjogren's syndrome.
Acute Disease↗
The incidence of red cell alloantibodies underlying panreactive warm autoantibodies.
A recognized hazard of administering blood transfusions to patients with panreactive warm autoantibodies is that alloantibodies may be masked. Studies have shown the incidence of underlying alloantibodies to be 30 to 40 percent. Adsorption procedures can be used to remove autoantibodies and allow detection and identification of underlying alloantibodies. This study contains data from 126 patients referred to the Red Cell Immunohaematology laboratory at the National Blood Service, Newcastle upon Tyne, United Kingdom. These patients were from the northeast of England, a population for which data have not previously been reported. Samples identified as containing panreactive warm autoantibodies were subjected to adsorption procedures (95 by alloadsorption and 31 by autoadsorption). Absorbed sera were then tested to identify underlying alloantibodies. Of 126 samples, 39 (31%) contained a total of 61 RBC alloantibodies; 15 (12%) contained 2 or more antibody specificities; and 14 (11%) contained alloantibodies not found within the Rh or Kell blood group systems. Antibodies identified included the following specificities: E (19), D (9), c (7), C (6), S (5), Fy(a) (3), Jk(a) (2), Jkb (2), K (2),Kp(a) (2), Fy(b),C(w),N, and f (ce). This study reinforces the value of adsorption studies, whether using autologous or allogeneic RBCs, when panreactive warm autoantibodies are present. In addition, this study confirms that it is not appropriate in these cases simply to issue blood which is "least incompatible" or Rh phenotype- and K antigen-matched.
Autoantibodies↗
Paediatric empyema: a case report and literature review.
OBJECTIVE: To present a case of bilateral parapneumonic effusions in a child with Pneumococcal pneumonia and bacteraemia managed aggressively with early thoracotomies. The literature from peer reviewed journals is summarized and the different management strategies are discussed. METHODS: Articles and reviews from peer reviewed journals on the management of empyema in children and adults. RESULTS: Staging of parapneumonic pleural effusions is difficult to assess clinically and radiologically. Most cases can be successfully managed with simple chest tube drainage, plus appropriate antibiotic therapy. However, based on the available evidence for children, thoracotomy with decortication and direct drainage may provide the most effective treatment in terms of length of hospital stay and duration of chest tube insertion, when compared with video assisted thoracoscopic surgery (VATS) or chest tube drainage, with or without intrapleural fibrinolytic therapy. CONCLUSIONS: More conservative approaches to treatment of empyema may be appropriate initially to avoid the cosmetic and other disadvantages of thoracotomy. However, delayed surgical drainage increases morbidity and may potentially increase mortality.
Journal Article↗
Air pollution and policy--1952-2002.
This review examines the main events, pressures and constraints in the evolution of air quality policy over the past 50 years. At the start of that period, there was little explicit recognition of air quality monitoring, modelling, control or policy; currently, the emphasis is on targets with implementation underpinned by legislation. The European Union and other international organisations exert strong influence. Data collection and information dissemination have had major impacts as has the involvement of stakeholders.
Air Pollutants↗
Closed versus partially ventilated endotracheal suction in extremely preterm neonates: physiologic consequences.
This randomized cross over study aimed to compare the severity and incidences of desaturation and bradycardia between the partially ventilated endotracheal suction method (PVETS) and closed tracheal suction system (CTSS) in extremely preterm neonates. Fifteen intubated and ventilated extremely low birth weight preterm infants (mean birth weight 689g) randomly underwent both suction techniques within a 12-h period to obtain a paired reading group. The process was repeated 24-48h apart until three pairs of reading groups were collected. Changes in oxygen saturation measured with pulse oximetry and heart rate changes measured with electrocardiogram were recorded using Hewlett-Packard m240A monitor trending software. The mean of each parameter's variation from baseline was obtained using SPSS descriptive statistics and analyzed using SPSS repeated measures ANOVA. Fisher Exact Test was used to analyze the incidence of desaturation and bradycardia. The closed tracheal suction system reported a significantly smaller degree of oxygen saturation fall (P<0.005) and significantly fewer incidences of desaturation. There was also a significantly smaller degree of heart rate reduction although episodes of bradycardia were not significantly different between the two methods. Oxygen saturation and heart rate were significantly more stable during the use of CTSS compared to PVETS in the extremely low birth weight preterm population.
Analysis of Variance↗
Salivary IgA response to prolonged exercise in a hot environment in trained cyclists.
UNLABELLED: The aim of this study was to determine the effects of prolonged exercise in hot conditions on saliva IgA (s-IgA) responses in trained cyclists. On two occasions, in random order and separated by 1 week, 12 male cyclists cycled for 2 h on a stationary ergometer at 62 (3)% V(.)O(2 max) [194 (4) W; mean (SEM)], on one occasion (HOT: 30.3 degrees C, 76% RH) and on another occasion ( CONTROL: 20.4 degrees C, 60% RH). Water was available ad-libitum. Venous blood samples and 2-min whole unstimulated saliva samples were collected at pre, post and 2 h post-exercise. The s-IgA concentration was determined using a sandwich-type ELISA. Exercising heart rate, rating of perceived exertion, rectal temperature, corrected body mass loss (P<0.01) and plasma cortisol (P<0.05) were greater during HOT. The decrease in plasma volume post-exercise was similar on both trials [HOT: -6.7 (1.1) and CONTROL: -6.6 (1.3)%; P<0.01]. Saliva flow rate decreased post-exercise by 43% returning to pre-exercise levels by 2 h post-exercise (P<0.05) with no difference between trials. Saliva IgA concentration increased post-exercise (P<0.05) with no difference between trials. Saliva IgA secretion rate decreased post-exercise by 34% returning to pre-exercise levels by 2 h post-exercise (P<0.05) with no difference between trials. These data show that a prolonged bout of exercise results in a reduction in s-IgA secretion rate. Additionally, these data demonstrate that performing prolonged exercise in the heat, with ad libitum water intake, does not influence s-IgA responses to prolonged exercise.
Adaptation, Physiological↗
A community based programme to improve access to dental services for drug users.
In 1999 South Lancashire Health Authority published their Oral Health Improvement Plan in which they specifically identified drug users as a target group. In this paper the authors outline the development of a project, which aimed to improve access to dental services for this group. Essential to the relative success of the project was the inclusion of drug users and service providers at the outset. In addition perceived barriers, which exist between drug users and the profession have started to be broken down.
Community Dentistry↗
Giving patients a choice improves quality of life: a multi-centre, investigator-blind, randomised, crossover study comparing letrozole with anastrozole.
AIMS: Although the third-generation aromatase inhibitors are generally well tolerated, side-effects still occur in up to 40% of women. As more women are taking these drugs for longer, the issue as to which version is better tolerated is now a significant patient concern. This study aimed to assess whether tolerance for either letrozole or anastrozole can differ for each individual in terms of early quality of life (QoL), whether patients welcome being given a preference and whether this correlated with formal toxicity scoring. MATERIALS AND METHODS: A single-blind, crossover trial, with 72 women with breast cancer who had experienced tamoxifen failure. Randomised to either letrozole 2.5 mg or anastrozole 1 mg, for 4 weeks, 1 week off, then crossover for 4 weeks. RESULTS: Patients were confidently able to choose which drug suited them best (letrozole 68%, anastrozole 32%; P < 0.01). Fewer patients, when taking letrozole, experienced adverse events than when taking anastrozole (43% vs 65%; P = 0.0028). QoL was better when patients were taking letrozole than when they took anastrozole (P = 0.02). CONCLUSIONS: As toxicity and QoL strongly correlated with patient preference for either drug, albeit with a tendency towards letrozole, this suggests that patient preference is now a legitimate and useful end point for future crossover studies. In routine practice, women would warmly welcome extra involvement in the decision-making process via a crossover manoeuvre if side-effects develop, whichever aromatase inhibitor is prescribed initially.
Administration, Oral↗
Sonographic assessment of the submandibular space.
There is a wide variety of pathological processes which may present with swelling in the submandibular space. Although the submandibular gland is the most important structure in this region, there are a number of extraglandular causes of swelling which frequently mimic submandibular gland enlargement. In this review the use of high-resolution ultrasound in the assessment of the submandibular gland and adjacent structures is discussed and illustrated.
Humans↗
Long-term follow-up of Anglian Germ Cell Cancer Group surveillance versus patients with Stage 1 nonseminoma treated with adjuvant chemotherapy.
OBJECTIVES: To study survival and late events after adjuvant chemotherapy in Stage 1 nonseminoma. METHODS: From 1978 to 1986, all patients had surveillance. From 1986, adjuvant chemotherapy (initially a 3-day regimen of etoposide, bleomycin, and cisplatin, but, more recently, bleomycin, Oncovin, and cisplatin) was offered to patients at a high risk of relapse (greater than 30%). RESULTS: A total of 382 patients with Stage 1 nonseminoma treated between 1978 and 2000 were reviewed. Of the 234 patients treated by surveillance, 71 (30%) had relapses (5 after 2 years), 6 died (2.6%) of germ cell cancer, and 3 developed second primary testicular cancer. Of the 148 men treated with adjuvant chemotherapy, 6 (4%) had relapses and 2 (1.4%) died of chemoresistant cancer. After one course of etoposide, bleomycin, and cisplatin, 3 (6.5%) of 46 developed a relapse; after two courses, 1 (3.6%) of 28 did so; and after bleomycin, Oncovin, and cisplatin every 10 days x2, 2 (2.7%) of 74 patients did so. Of the high-risk patients who were offered adjuvant treatment, 24% declined. As a consequence, the relapse rate of the surveillance patients only fell from 36% to 27% after the introduction of adjuvant therapy, although for the total cohort treated in the adjuvant era, the relapse rate was 16%. CONCLUSIONS: Adjuvant chemotherapy is more effective than retroperitoneal lymph node dissection for reducing the relapse risk in high-risk Stage 1 nonseminoma. However, given the uncertainty about the incidence of postchemotherapy late events, surveillance and retroperitoneal lymph node dissection remain justified alternatives. With positron emission tomography and laparoscopy showing increasing promise in these cases, quality-of-life studies and greater patient involvement in treatment selection are needed.
Antineoplastic Combined Chemotherapy Protocols↗
Evaluation of academic and community surgery clerkships at a Midwestern medical school.
BACKGROUND: The equivalency of surgical clerkship experience between academic and community sites is an issue that is assessed with difficulty. We examined the objective performance of 222 medical students after completion of the 8-week surgical clerkship. Six different consecutive semesters were analyzed. There were two objective examinations reviewed, the National Board of Medical Examiners' subject examination and the surgical subportion of the Objective Structured Clinical Examination (OSCE) given at the end of the third year. METHODS: Medical students were classified into three separate groups based on the site of their surgical clerkship. The medical students were in either academic (100), community (79), or combined (academic and community) (43) locations. Medical student performance on the subject examination and OSCE was examined after completion of the general surgical clerkship. Single-factor analysis of variance testing was done to compare each of the three groups with respect to subject examination test score, or OSCE score. Significance was defined as P < 0.05. RESULTS: The combined group scored highest on the subject examination (73.6%). The community group scored highest on the OSCE (80.7%). However, no statistical significance exists between the three groups with regard to subject examination (P = NS) or OSCE (P= NS). Subject examination scores did not correlate with OSCE scores (r = 0.095). Objective measurements of surgical subject examination and OSCE were not statistically different between academic, community, and academic and community surgical clerkship participants. CONCLUSIONS: No statistically significant differences exist between the three groups with regards to OSCE failure rates, but the small amount of failures may have caused Type 2 error. Surgical clinical skills as tested by an OSCE and surgical knowledge as tested by a subject examination are equally attained by an academic or community surgical clerkship.
Academic Medical Centers↗
[Imaging of neuro-ophthalmological emergencies].
MRI often is mandatory in the diagnostic work-up of visual loss, visual field alterations and oculomotor problems. It is performed emergently in patients with painful diplopia associated to mydriasis, to exclude aneurysm, or in patients with painful Horner syndrome to exclude dissection of the internal carotid artery. CT scan in emergency remains useful in case of acute lateral hemianopsia or acute post traumatic visual loss. Progressive neuro-ophthalmological symptoms may require imaging examination in a short delay to define the therapeutic strategy: monocular transient blindness (dissection or carotid stenosis), progressive visual loss (optic nerve compression), bitemporal hemianopsia (optic chiasm lesion), painful visual loss (optic neuritis). A very precise clinical indication is helpful for the choice of imaging protocol and to improve its diagnosis value.
Acute Disease↗
Concept mapping for meaningful learning.
The complexity of teaching, learning and assessment strategies remains a problem in nurse education especially with the changes in new curricula. This article explains one solution, which was considered and explored prior to implementation for the assessment of an inquiry-based module in nurse education. The overall aim for selecting this method of assessment was to provide consolidation of prior learning from the core content of the module and to give the students an opportunity to gain further, wide and varied knowledge on a number of concepts in a short period. Concept mapping has proved to be one of the most challenging learning experiences for nursing students. It has been identified as a stimulating learning and assessing tool as predominantly acknowledged over the last year, by nursing students on the Inquiry-Based Learning (IBL) BSc and Dip HE nursing education programmes, and also nurse educators who have the responsibility of facilitating the learners.
Concept Formation↗
The Hemoclip: a novel approach to endoscopic therapy for esophageal perforation.
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Adenocarcinoma↗
Measuring information strategies in oncology - developing an information satisfaction questionnaire.
The benefits of providing accurate and culturally sensitive information for patients are now undisputable and information strategies are generally being adopted nationally. Measuring their benefits and adapting strategies to local needs is now a new challenge. Although questionnaires to measure global satisfaction are available, no concise tool has previously existed to specifically measure the information aspects of care. The aims of this study are: to establish which aspects of information were most important to the patients during their cancer pathway; to develop a robust single-page questionnaire that is sensitive to patient priorities to measure and compare satisfaction between patient groups; and to audit information provision within routine clinical practice. Seventy-seven consecutive patients were asked to complete a priority list of which aspects of information were most important to them during their recent cancer care. A total of 303 answers were categorized into five final categories of equal weighting. The data were combined with demographic issues to produce a robust one-page questionnaire which has been adopted formally by the West Anglia Cancer Network. One hundred consecutive patients were then audited to highlight the information shortcomings of a busy community oncology department and the findings are reforming information services. We recommend the use of this practical audit tool in routine clinical practice, which can be downloaded free from cancernet.co.uk in seven languages.
Adult↗
Inspiratory resistive loading improves cycling capacity: a placebo controlled trial.
BACKGROUND: Respiratory muscle training has been shown to improve both its strength and endurance. The effect of these improvements on whole-body exercise performance remains controversial. OBJECTIVE: To assess the effect of a 10 week inspiratory resistive loading (IRL) intervention on respiratory muscle performance and whole-body exercise endurance. METHODS: Fifteen apparently healthy subjects (10 men, 5 women) were randomly allocated to one of three groups. One group underwent IRL set at 80% of maximum inspiratory pressure with ever decreasing work/rest ratios until task failure, for three days a week for 10 weeks (IRL group). A second placebo group performed the same training procedure but with a minimal resistance (PLA group). IRL and placebo training were performed at rest. The remaining five control subjects performed no IRL during the 10 week study period (CON group). Cycling endurance capacity at 75% VO(2)peak was measured before and after the intervention. RESULTS: After the 10 week IRL intervention, respiratory muscle strength (maximum inspiratory pressure) and endurance (sum of sustained maximum inspiratory pressure) had significantly improved (by 34% and 38% respectively). An increase in diaphragm thickness was also observed. These improvements translated into a 36% increase in cycling time to exhaustion at 75% VO(2)peak. During cycling trials, heart rate, ventilation, and rating of perceived exertion were attenuated in the IRL group. No changes were observed for the PLA or CON group either in the time to exhaustion or cardiorespiratory response to the same intensity of exercise. CONCLUSION: Ten weeks of IRL attenuated the heart rate, ventilatory, and perceptual response to constant workload exercise, and improved the cycling time to exhaustion. Familiarisation was not a factor and the placebo effect was minimal.
Adult↗
Telepaediatrics and diabetic retinopathy screening of young people with diabetes in Queensland.
We have examined the feasibility of a telemedicine-enabled screening service for children and adolescents with diabetes in Queensland. There are approximately 1400 young people with diabetes in Queensland and only about two-thirds of them are screened in accordance with international guidelines. A regional retinal screening service was established using a nonmydriatic digital retinal camera. Seven centres volunteered to participate in the study. During a five-month pilot trial, 83 of the young people with diabetes who attend these centres underwent digital retinal screening (3.7%). Retinal images were sent via email to a paediatric ophthalmologist for review and results were returned via email. A copy of each participant's results was forwarded by mail to the referring diabetes doctor and the participant and family. The majority of the image files (96%) were rated as excellent or good. Only one participant was identified as having an abnormal result. Participants and their families expressed satisfaction with the digital retinal screening process.
Adolescent↗