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Biomedical subjects

P M Clarke

Publications and source records attributed to P M Clarke.

At least 19 recordsLinked to original sources
PubMed2006

Botulinum neurotoxin for management of intractable central leakage through a voice prosthesis in surgical voice restoration.

Rehabilitation of voice and speech after total laryngectomy has become established practice in recent years. A voice prosthesis is placed within a surgically produced fistula between the trachea and upper oesophagus and acts as a one way valve, allowing passage of pulmonary air from the trachea into the oesophagus and preventing aspiration of food and fluid from the oesophagus into the trachea. Persistent leakage through or around these prostheses is a recognized complication, the aetiology of which can vary widely, from mechanical issues with the prostheses themselves to anatomical and physiological issues associated with the reconstructed pharynx. We report a new technique of using Dysport in the management of intractable central leakage due to premature and forceful closure of the upper oesophageal sphincter during swallowing. This resulted in the pooling of fluids around the posterior flange of the prosthesis. This, along with the increased pressure from the muscle contraction, led to central leakage, as identified on videofluoroscopy. An injection of Dysport paralysed the upper oesophageal sphincter, preventing pooling of fluids around the prosthesis and the forcing open of the valve. The effect was to eliminate the leakage, and the patient did not require further injections over the following 22 months.

Botulinum Toxins, Type A↗
PubMed2006

Myxoid liposarcoma metastatic to the thyroid gland: a case report and literature review.

We present the second reported case of a myxoid liposarcoma metastatic to the thyroid gland in a 51-year-old gentleman with previous liposarcoma of the right thigh. Myxoid liposarcoma has a relatively good prognosis but tends to recur locally. Metastases affecting the thyroid gland are a rare entity and most commonly arise from the kidney, lung or breast. Clinical presentation, patterns of recurrence and prognosis of myxoid liposarcoma and metastases to the thyroid gland are discussed.

Antineoplastic Agents↗
PubMed2006

Metastasizing pleomorphic salivary adenoma.

OBJECTIVE: To address questions about the etiology, behavior, optimal treatment, and prognosis of metastasizing pleomorphic adenoma (MPA), we undertook a review of the literature (1953-2005) and constructed a virtual series of all identified cases of MPA, metastatic lesions that are very occasionally identified in patients with a history of pleomorphic salivary adenoma and, on detailed pathological evaluation, found to exhibit all the histological hallmarks of the preceding benign lesions. DATA SOURCES: A review of the English-language literature between 1953 and 2005 using MEDLINE, secondary references identified from bibliographies of pertinent articles, and a further case from one of our institutions. DATA SYNTHESIS: A virtual case series was constructed and quantitatively analyzed. Forty-two patients with an average age of 33 years were identified. There were 20 male and 22 female patients. There was an overwhelming history of incomplete surgery for pleomorphic salivary adenoma. Most patients had locoregional recurrences before metastasis, and the mean presentation-to-metastasis latency was 16 years. Bone was the most common site for metastases (45%), followed by the head and neck (43%) and lung (36%). There was significant morbidity and mortality from distant disease, with 5-year disease-specific and disease-free survival of 58% and 50%, respectively. Developing distant lesions within 10 years of the primary tumor and presence of metastases in multiple sites were independent predictors of survival on Cox regression analysis. Metastasectomy conferred significant survival advantage over nonoperative treatment (log-rank analysis, P<.02). Chemotherapy and radiotherapy were of limited value. CONCLUSIONS: Meticulous surgery is crucial in preventing MPA. Metastatic disease carries significant morbidity and mortality and should be treated surgically when feasible.

Adenoma, Pleomorphic↗
PubMed2006

A new combined approach to the nasopharynx in head and neck plastic surgery: technique and application.

This article presents a combined approach to the nasopharynx, which has not been previously described. The technique is applicable to cases of recurrent nasopharyngeal carcinoma which exhibit lateral extension. We describe the technique and report a case in which it was used. A review is presented of all other techniques currently described. The authors would not advocate the use of a combined approach to the nasopharynx in all cases, but there certainly appears to be a place for this technique.

Adenocarcinoma↗
PubMed2005

Cost-utility analyses of intensive blood glucose and tight blood pressure control in type 2 diabetes (UKPDS 72).

AIMS/HYPOTHESIS: This study estimated the economic efficiency (1) of intensive blood glucose control and tight blood pressure control in patients with type 2 diabetes who also had hypertension, and (2) of metformin therapy in type 2 diabetic patients who were overweight. METHODS: We conducted cost-utility analysis based on patient-level data from a randomised clinical controlled trial involving 4,209 patients with newly diagnosed type 2 diabetes conducted in 23 hospital-based clinics in England, Scotland and Northern Ireland as part of the UK Prospective Diabetes Study (UKPDS). Three different policies were evaluated: intensive blood glucose control with sulphonylurea/insulin; intensive blood glucose control with metformin for overweight patients; and tight blood pressure control of hypertensive patients. Incremental cost : effectiveness ratios were calculated based on the net cost of healthcare resources associated with these policies and on effectiveness in terms of quality-adjusted life years gained, estimated over a lifetime from within-trial effects using the UKPDS Outcomes Model. RESULTS: The incremental cost per quality-adjusted life years gained (in year 2004 UK prices) for intensive blood glucose control was 6,028 UK pounds, and for blood pressure control was 369 UK pounds. Metformin therapy was cost-saving and increased quality-adjusted life expectancy. CONCLUSIONS/INTERPRETATION: Each of the three policies evaluated has a lower cost per quality-adjusted life year gained than that of many other accepted uses of healthcare resources. The results provide an economic rationale for ensuring that care of patients with type 2 diabetes corresponds at least to the levels of these interventions.

Adult↗
PubMed2005

A study of out-of-hours facilities in otolaryngology: current provision and problems.

'Action on ENT' has recently published advice as to the minimum requirements for equipment required to provide a safe and suitable out-of-hours service in ENT. Our objectives were to determine the availability of a dedicated ENT treatment room for seeing patients out of hours, appropriately maintained specialized ENT equipment and availability of appropriate assistance. In addition, the mechanism for disinfection of nasoendoscopes out of hours was determined. Telephone questionnaires of 106 ENT units in England, which provide an out-of-hours ENT service, were taken. At each unit the standard questionnaire was answered by the first on-call ENT doctor. One hundred and one units (95 percent) had access to a dedicated treatment room out of hours. The number of units with a microscope was 91 (86 percent), headlight/lamp and mirror was 105 (99 percent), flexible nasoendoscope was 86 (81 percent) and cautery (electrical or chemical) was 105 (99 percent). Seventy-nine units (75 percent) found that their treatment rooms were adequately stocked, and 62 units (58 per cent) had assistance available when needed. Twenty-four units (23 percent) sterilized their scopes adequately, 22 units (21 percent) used endosheaths, 26 units (24 percent) used a variety of inadequate cleaning methods, and 34 respondents (32 percent) were unsure how their scopes were cleaned. This survey has shown that not all ENT units have appropriately equipped out-of-hours facilities. There is a need for nationally agreed guidelines stating the minimum equipment and assistance required to provide a safe, adequate and suitable out-of-hours service. National guidelines on out-of-hours disinfection of flexible nasoendoscopes are also required.

After-Hours Care↗
PubMed2005

Upper neck spinal accessory nerve identification during neck dissection.

Iatrogenic injury to the spinal accessory nerve (SAN) during neck dissection may result in significant and avoidable morbidity in the form of 'shoulder syndrome'. The authors describe a simple method, based on the anatomy of the sternocleidomastoid muscle (SCM), which allows consistent and rapid identification of the SAN in the upper neck during dissection, thereby facilitating its preservation.

Accessory Nerve↗
PubMed2004

A model to estimate the lifetime health outcomes of patients with type 2 diabetes: the United Kingdom Prospective Diabetes Study (UKPDS) Outcomes Model (UKPDS no. 68).

AIMS/HYPOTHESIS: The aim of this study was to develop a simulation model for type 2 diabetes that can be used to estimate the likely occurrence of major diabetes-related complications over a lifetime, in order to calculate health economic outcomes such as quality-adjusted life expectancy. METHODS: Equations for forecasting the occurrence of seven diabetes-related complications and death were estimated using data on 3642 patients from the United Kingdom Prospective Diabetes Study (UKPDS). After examining the internal validity, the UKPDS Outcomes Model was used to simulate the mean difference in expected quality-adjusted life years between the UKPDS regimens of intensive and conventional blood glucose control. RESULTS: The model's forecasts fell within the 95% confidence interval for the occurrence of observed events during the UKPDS follow-up period. When the model was used to simulate event history over patients' lifetimes, those treated with a regimen of conventional glucose control could expect 16.35 undiscounted quality-adjusted life years, and those receiving treatment with intensive glucose control could expect 16.62 quality-adjusted life years, a difference of 0.27 (95% CI: -0.48 to 1.03). CONCLUSIONS/INTERPRETATIONS: The UKPDS Outcomes Model is able to simulate event histories that closely match observed outcomes in the UKPDS and that can be extrapolated over patients' lifetimes. Its validity in estimating outcomes in other groups of patients, however, remains to be evaluated. The model allows simulation of a range of long-term outcomes, which should assist in informing future economic evaluations of interventions in type 2 diabetes.

Amputation, Surgical↗
PubMed1999

The effect of the 30% private health insurance rebate on the purchasing behaviour and intentions of the Australian population.

This article examines the likely effect of the 30% private health insurance rebate on private health insurance coverage. It is based on a survey of the Australia population conducted in April-May 1999 which collected information on health insurance purchasing behaviour and intentions. These data are used to predict the subsidy's likely effect on hospital insurance coverage, with estimates ranging from 30.5% to 34.3% by May 2000. Ancillary insurance membership is forecast to increase to between 32.7% and 37.2% of the population over the same period. The 30% insurance rebate will probably produce, at best, a small increase in hospital insurance membership. The cost of the rebate is estimated at $1.4 billion in 1999-2000. Given the small increases in projected membership, the cost of the initiative is very high.

Age Factors↗
PubMed1998

Cost-benefit analysis and mammographic screening: a travel cost approach.

This study describes the methodology and presents preliminary results of an economic appraisal of a program to use mobile mammographic screening units in rural areas of Australia. The benefits of the project are measured using the travel cost method. Since mammograms are a 'binary good', conventional welfare analysis must be modified and discrete choice models used to estimate the demand for screening. The results suggest that the level of welfare benefits depends on the distance a town is from the nearest fixed screening unit. In the 10 towns studied, the economic benefits of mobile screening outweighed the economic costs if a rural town is situated 29 km or more from a fixed mammographic screening unit.

Aged↗
PubMed1998

A complication of peribulbar block in a patient with exophthalmos.

A patient with marked exophthalmos secondary to thyroid eye disease presented for tarsorrhaphy and removal of orbital fat. A single superolateral peribulbar injection was performed. After injection of 3.5 ml of local anaesthetic solution, the globe suddenly dislocated anteriorly. This complication has not been described previously. In patients with exophthalmos, general anaesthesia should be considered as the method of choice for ophthalmic procedures.

Anesthesia, Local↗