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Biomedical subjects

A M Kelly

Publications and source records attributed to A M Kelly.

At least 37 records · Page 2Linked to original sources
PubMed2001

Prevention of stroke in chronic and recurrent atrial fibrillation: role of the emergency department in identification of "at-risk" patients.

The objective was to determine the proportion of patients presenting to the Emergency Department (ED) in atrial fibrillation (AF) who are at high risk of thromboembolic stroke as defined by the American Heart Association and who might benefit from anticoagulation therapy. We enrolled all patients identified as having AF between 28th June 1999 and 26th March 2000. Data collected included demographic information, presenting complaint, discharge diagnosis, risk factors for thromboembolic stroke, contraindications to anticoagulation (as defined by the Stroke Prevention in AF Investigators), admission and discharge medications, and cardiac rhythm on presentation and at discharge. 193 patients were identified within the study period. Two patient histories were not available for review. 121 patients had a prior history of AF. Of these, 65 patients were at high risk for thromboembolic stroke and had no contraindication to anticoagulation therapy 43 (66%) were on Warfarin at presentation but 14 (22%) were on Aspirin and 8 (12%) were on neither. 34% of patients with chronic atrial fibrillation presenting to the ED, at high risk of thromboembolic stroke and without contra-indication to anticoagulation, were not anticoagulated on presentation. ED attendance provides an opportunity for intervention for the prevention of stroke in this group.

Aged↗
PubMed2001

"Point of entry" treatment gives best time to thrombolysis for acute myocardial infarction.

The aim was to compare time to thrombolysis for patients treated via three treatment pathways: thrombolysis in the emergency department (ED), thrombolysis following direct admission by ambulance officers to coronary care (CCU) and thrombolysis after transfer from ED to CCU. We used a retrospective study of time to thrombolysis for all patients receiving thrombolysis for acute myocardial infarction (AMI) at Western Hospital during 1999. The median time to thrombolysis in the ED group was 30 minutes (mean 40 minutes), compared with 60 minutes for the CCU group (mean 63 minutes) and 40 minutes (mean 43 minutes) for the direct CCU admission group. Eighty-five percent of patients treated in ED received thrombolysis in less than 60 minutes compared with 21% of those transferred from the ED for treatment in CCU and 52% of those directly admitted to CCU. We conclude that point of entry thrombolysis, be it in ED or in CCU after direct admission, gives shorter times to thrombolysis than processes that require transfer of patients between departments.

Emergency Service, Hospital↗
PubMed2001

The minimum clinically significant difference in visual analogue scale pain score does not differ with severity of pain.

OBJECTIVE: To determine whether minimum clinically significant difference in visual analogue scale (VAS) pain score varies according to the severity of pain reported. METHOD: Prospective descriptive study of adult patients in an urban emergency department (ED). On presentation to the ED, patients marked the level of their pain on a 100 mm, non-hatched VAS scale. At 20 minute intervals thereafter they were asked to give a verbal categorical rating of their pain as "a lot better", "a little better", "much the same", "a little worse" or "much worse" and to mark the level of pain on a VAS scale of the same type as used previously. It was pre-defined that patients with VAS pain scores of 30 mm or less would be categorised as having mild pain, those with scores of 70 mm or more were categorised as having severe pain and those from 31 mm to 69 mm, moderate pain. The minimal clinically significant difference (MCSD) in VAS pain score was defined as the mean difference between current and preceding scores when the subject reported "a little worse" or "a little better" pain. RESULTS: 156 patients were enrolled in the study, yielding 88 evaluable comparisons where pain was rated as "a little better" or "a little worse". The MCSD in VAS score in the group overall was 12 mm (95%CI 9 mm to 15 mm). MCSD in VAS score for the "mild pain" group was 11 mm (95%CI 4 mm to 18 mm), for the "moderate pain" group 14 mm (95%CI 10 mm to 18 mm) and for the severe pain group, 10 mm (95%CI 6 mm to 14 mm). There is no statistical difference between the MCSD in VAS score between the severity groups. CONCLUSIONS: The MCSD in VAS pain score does not differ with the severity of pain being experienced.

Adult↗
PubMed2001

Venous pH can safely replace arterial pH in the initial evaluation of patients in the emergency department.

OBJECTIVE: This study aims to determine the extent of correlation of arterial and venous pH with a view to identifying whether venous samples can be used as an alternative to arterial values in the clinical management of selected patients in the emergency department. METHODS: This prospective study of patients who were deemed by their treating doctor to require an arterial blood gas analysis to determine their ventilatory or acid-base status, compared pH on an arterial and a venous sample taken as close to simultaneously as possible. Data were analysed using Pearson correlation and bias (Bland-Altman) methods. RESULTS: Two hundred and forty six patients were entered into the study; 196 with acute respiratory disease and 50 with suspected metabolic derangement. The values of pH on arterial and venous samples were highly correlated (r=0.92) with an average difference between the samples of -0.4 units. There was also a high level of agreement between the methods with the 95% limits of agreement being -0.11 to +0.04 units. CONCLUSION: Venous pH estimation shows a high degree of correlation and agreement with the arterial value, with acceptably narrow 95% limits of agreement. Venous pH estimation is an acceptable substitute for arterial measurement and may reduce risks of complications both for patients and health care workers.

Acid-Base Imbalance↗
PubMed2001

Breath-holding spells associated with significant bradycardia: successful treatment with permanent pacemaker implantation.

OBJECTIVE: To determine whether children with pallid breath-holding spells associated with bradycardia can be treated safely and successfully with permanent pacemaker implantation. METHODS: The records of pediatric patients who had apparent breath-holding spells and associated bradycardia and were treated with permanent pacemaker implantation were reviewed. RESULTS: Ten pediatric patients with apparent breath-holding spells associated with bradycardia were treated with a permanent ventricular demand pacemaker at the Mayo Clinic between 1985 and 1995. Patients had onset of symptoms between ages 6 days and 12 months and presented for evaluation between ages 12 months and 5 years. Duration of spells was 15 seconds to 10 minutes. Medications to prevent spells were unsuccessful. Electrocardiograms documented asystolic pauses of 1.7 to 24 seconds (mean: 11.9 seconds). Permanent ventricular demand pacemakers were implanted at 10 months to 5 years of age (median: 14.5 months): 9 endocardial and 1 epicardial. Three patients required pacemaker revision. At follow-up of 38 to 170 months (median: 65.5), 5 patients had complete resolution of spells, 2 had only mild color change without loss of consciousness or seizure activity, and 3 continued to have minor brief spells. CONCLUSIONS: Permanent pacemaker therapy for children with pallid breath-holding spells associated with severe bradycardia is safe, efficacious, and warranted.

Apnea↗
PubMed2001

Comorbidity among individuals classified with attention disorders.

This study examined the frequency of comorbidity among ADHD and ADHD subtypes. Specific aspects of comorbidity were examined in the areas of learning disorders, disruptive behavior disorders, and affective disorders. Two analyses were performed. The first analysis compared the comorbid second and third diagnoses for 287 individuals with a primary diagnosis of ADHD (Predominately Inattentive Type or Predominately Hyperactive-Impulsive Type) with a comparison sample (n = 290) who did not have a primary diagnosis of ADHD. The second analysis examined the comorbidity with specific ADHD subtypes. This analysis compared the comorbid second and third diagnosis of individuals with a primary ADHD subtype diagnosis of Predominately Inattentive (n = 143) with individuals who have a primary ADHD subtype diagnosis of Predominately Hyperactive-Impulsive (n = 143). Results from the first analysis indicated significant overlap between the diagnosis of ADHD and the diagnosis of learning disorders and disruptive behavior disorders but not for affective disorders. Results from the second analysis indicated that only conduct disorders were comorbid with certain ADHD subtypes, with disruptive behavior disorders being more likely to be diagnosed with ADHD Hyperactive-Impulsive Type than with ADHD Inattentive Type.

Adolescent↗
PubMed2000

Impairment of STAT activation by IL-12 in a patient with atypical mycobacterial and staphylococcal infections.

IL-12 plays a pivotal role in the stimulation of immune responses against intracellular infections. This role is manifested in the increased susceptibility to atypical mycobacterial and salmonella infections among individuals whose lymphocytes lack expression of IL-12Rbeta1. Here, we report on a patient with Mycobacterium avium infection, recurrent Staphylococcus aureus sinusitis, and multiple adverse drug reactions whose T cells were unable to produce IFN-gamma or proliferate in response to IL-12 despite the expression of wild-type IL-12Rbeta1 and IL-12Rbeta2. The defect in these functional responses to IL-12 was selective, as cytolytic activity induced by IL-12 was intact, and lymphocytes were responsive to stimulation by IL-2. An examination of cytokine signaling revealed that STAT4 and extracellular regulated kinase 1 (ERK1) activation by IL-12 was intact, whereas the activation of STAT1, -3, and -5 by IL-12 was lost. This impairment of STAT activation was specific for IL-12, as STAT activation by IL-2, IL-15, and IFN-gamma was unaffected. These findings demonstrate that the activation of STAT4 alone is not sufficient for IL-12-induced IFN-gamma production and proliferation and suggest that other STATs play a role in these responses to IL-12. While the etiology of the impaired IL-12 signaling in this patient has not yet been elucidated, the absence of mutations in IL-12Rbeta1 or IL-12Rbeta2 and the preservation of STAT4 activation raise the possibility that there may be a mutation in an as yet undiscovered component of the IL-12 signaling complex that is normally required for the recruitment and activation of STAT1, -3, and -5.

Child, Preschool↗
PubMed2000

Reducing premature death and renal failure in Australian aboriginals. A community-based cardiovascular and renal protective program.

OBJECTIVE: To describe results of a systematic treatment program to modify renal and cardiovascular disease in an Aboriginal community whose rates of renal failure and cardiovascular deaths are among the highest in Australia. DESIGN: Longitudinal survey of people during treatment, and comparison of rates of natural death and renal failure with those in a historical control group. SETTING: Tiwi Islands (population, about 1800), November 1995 to December 1998. PARTICIPANTS: All adults with blood pressure > or = 140/90, with diabetes and urinary albumin/creatinine ratio (ACR) > or = 3.4 g/mol (microalbuminuria threshold), or with progressive overt albuminuria (ACR > or = 34 g/mol) were eligible for treatment. The historical control group comprised 229 people who satisfied these criteria in the pretreatment period 1992-1995. INTERVENTIONS: Perindopril, combined with calcium-channel blockers and diuretics if needed to achieve blood pressure goals; attempts to improve control of blood glucose and lipid levels; health education. MAIN OUTCOME MEASURES: Blood pressure, ACR, serum creatinine level and glomerular filtration rate (GFR) over two years of treatment; rates of renal failure and natural death compared with control group (analysed on intention-to-treat basis). RESULTS: 258 people enrolled in the program, and 118 had complete data for two years of treatment. In these 118, blood pressures fell significantly, while ACR and GFR stabilised. Rates of the combined endpoints of renal failure and natural death per 100 person-years were 2.9 for the treatment group (95% CI, 1.7-4.6) and 4.8 for the control group (95% CI, 3.3-7.0). After adjustment for baseline ACR category, the relative risk of the treatment group versus the control group for these combined endpoints was 0.47 (95% CI, 0.25-0.86; P = 0.013). Treatment benefit was especially marked in people with overt albuminuria or hypertension and in non-diabetic people. The estimates of benefit were supported by a fall in community rates of death and renal failure. CONCLUSIONS: Aboriginal people can participate enthusiastically in chronic disease management, with rapid, dramatic improvement in clinical profiles and mortality. Similar programs should be introduced urgently into other Aboriginal communities nationwide.

Adult↗
PubMed2000

The induction of skeletal muscle hypertrophy by a ski transgene is promoter-dependent.

The chicken c-ski gene expresses at least three alternatively spliced messages. Transgenic mice expressing proteins from cDNA corresponding to two of these messages (FB27 and FB29) under the control of a murine sarcoma virus (MSV) long terminal repeat (LTR) express the transgene in skeletal muscle and develop a muscular phenotype. Both a biologically active form of c-ski and the MSV LTR are required for the development of the muscular phenotype. The normal c-ski gene linked to two other tissue-specific promoters failed to induce muscle growth in transgenic mice, as did an inactive mutant of c-ski expressed under the control of the MSV LTR.

Animals↗
PubMed2000

Patient satisfaction with pain management does not correlate with initial or discharge VAS pain score, verbal pain rating at discharge, or change in VAS score in the Emergency Department.

The aim of this study was to correlate patient satisfaction with pain management in the Emergency Department (ED) with initial and discharge visual analog scale (VAS) pain score, verbal pain rating at discharge, and change in VAS pain score between presentation and discharge. It was conducted as a prospective observational study of patients who presented to an urban, adult ED experiencing pain and who were later discharged. Fifty-four patients completed the study of whom 70% rated the management of their pain as 'good' or 'very good.' There was no correlation between patient satisfaction with pain management initial VAS pain score, discharge VAS pain score, verbal rating of pain at discharge, or change in VAS pain score between presentation and discharge. The study suggests that patient satisfaction with pain management does not correlate with initial or discharge VAS pain score, verbal rating of pain at discharge or change in pain score in the ED. Therefore, information about the quality of analgesia provided in an ED cannot be inferred from patient satisfaction surveys.

Acute Disease↗
PubMed2000

Factors influencing outcome following mild traumatic brain injury in adults.

This study aimed to investigate outcome in adults with mild traumatic brain injury (TBI) at 1 week and 3 months postinjury and to identify factors associated with persisting problems. A total of 84 adults with mild TBI were compared with 53 adults with other minor injuries as controls in terms of postconcussional symptomatology, behavior, and cognitive performance at 1 week and 3 months postinjury. At 1 week postinjury, adults with mild TBI were reporting symptoms, particularly headaches, dizziness, fatigue, visual disturbance, and memory difficulties. They exhibited slowing of information processing on neuropsychological measures, namely the WAIS-R Digit Symbol subtest and the Speed of Comprehension Test. By 3 months postinjury, the symptoms reported at 1 week had largely resolved, and no impairments were evident on neuropsychological measures. However, there was a subgroup of 24% of participants who were still suffering many symptoms, who were highly distressed, and whose lives were still significantly disrupted. These individuals did not have longer posttraumatic amnesia (PTA) duration. They were more likely to have a history of previous head injury, neurological or psychiatric problems, to be students, females, and to have been injured in a motor vehicle accident. The majority were showing significant levels of psychopathology. A range of factors, other than those directly reflecting the severity of injury, appear to be associated with outcome following mild TBI.

Adolescent↗
PubMed2000

Nurse-managed analgesia for renal colic pain in the emergency department.

A retrospective chart review was conducted of patients with acute renal colic for the years 1993 and 1997, in order to compare analgesia ordering and administration practices before and after implementation of a nurse-managed, titrated intravenous (i.v.) narcotic policy. The study demonstrated a significant and sustained change in analgesia administration practices away from the intramuscular (i.m.) route in favour of the i.v. route. For renal colic, in 1993, 76% of patients received i.m. narcotic analgesia compared to 3% in 1997. In contrast, i.v. narcotic (with or without adjuvant (NSAID) was used in 3% of the patients in 1993 compared to 95% in 1997.

Analgesics↗
PubMed2000

Does high dose ipratropium bromide added to salbutamol improve pulmonary function for patients with chronic obstructive airways disease in the emergency department?

BACKGROUND: To determine the effect of high dose ipratropium bromide, both alone or in combination with standard dose salbutamol, on pulmonary function in patients presenting to the Emergency Department (ED) with acute exacerbation of chronic obstructive airways disease (COAD). METHOD: The trial was a prospective, randomised, double blind trial of adult patients with COAD. All patients received nebulised salbutamol 5 mg and 500 microg ipratropium and hydrocortisone 250 mg i.v. at time=0, then were randomised to receive further nebulisers at time=15 minutes and time=30 minutes of salbutamol 5 mg combined with ipratropium 500 microg or salbutamol 5 mg alone or ipratropium 500 microg alone. Pulmonary function tests were conducted at time=0 and time=90 minutes. The primary endpoints were absolute and percent change in FEV1. RESULTS: The group randomised to receive 5 mg salbutamol and 500 microg ipratropium (n=18) showed a mean percentage change of FEV1 of 6.4% with a mean absolute change of 0.06 L (SD 0.18 L). Those who received 5 mg salbutamol (n=16) had a mean percentage change of 18.6% with a mean absolute change of 0.13 L (SD of 0.21 L). Those who received 500 microg ipratropium (n=16) had a mean percentage change of 4.8% with a mean absolute change of 0.023 L (SD of 0.07 L). There was no significant difference between the groups in FEV1 (p=0.56 for percentage change; p=0.36 for absolute change). CONCLUSION: The addition of 500 microg ipratropium to 5 mg salbutamol in subsequent nebulisers adds no benefit to pulmonary function after the initial nebuliser of both bronchodilators in the treatment of COAD in the ED.

Adrenergic beta-Agonists↗
PubMed2000

A process approach to improving pain management in the emergency department: development and evaluation.

AIM: (1) To describe a process approach to the improvement of pain management in emergency departments. (2) To compare analgesia ordering and administration practices for patients with acute fractures before and after implementation of a nurse managed, titrated intravenous narcotic policy. METHOD: Retrospective chart review of patients with long bone fractures for the years 1993 and 1997. RESULTS: There was a dramatic change in analgesia administration practices away from the intramuscular route in favour of the intravenous route (p<0.001). For long bone fractures, in 1993, 53% of patients received intramuscular narcotic analgesia compared with 5% in 1997. In contrast, in 1993, 6% of the patients received intravenous narcotic analgesia compared with 54% in 1997. CONCLUSION: This study demonstrates that a process approach to improving pain management that resulted in both changes in drug administration and pain assessment and management processes made a significant and sustained change to analgesia ordering and administration practices for patients with long bone fractures in an emergency department.

Analgesics↗
PubMed2000

Migraine: pharmacotherapy in the emergency department.

Migraine can be a disabling condition for the sufferer. For the small number of patients who fail home therapy and seek treatment in an emergency department, there are a number of therapeutic options. This paper reviews the evidence regarding the effectiveness and safety of the following therapies: the phenothiazines, lignocaine (lidocaine), ketorolac, the ergot alkaloids, metoclopramide, the "triptans", haloperidol, pethidine and magnesium. Based on available evidence, the most effective agents seem to be prochlorperazine, chlorpromazine and sumatriptan, each of which have achieved greater then 70% efficacy in a number of studies.

Analgesics, Opioid↗