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Biomedical subjects

G D Murray

Publications and source records attributed to G D Murray.

At least 73 records · Page 4Linked to original sources
PubMed1996

An audit of treated epilepsy in Glasgow. West of Scotland Epilepsy Research Group.

An audit of patients receiving antiepileptic drug therapy for epilepsy was carried out in 25 general practices in Glasgow. Patients were identified from computerized records of repeat prescriptions for antiepileptic drugs. Overall, 1052 (0.72%) of 145,609 screened patients had treated epilepsy. Only 5% were children, while 19% were over 65 years. Twenty-nine per cent were diagnosed by a neurologist, and in 24% no record was available of who had made the diagnosis. Fifty per cent had tonic-clonic seizures only. Partial seizures occurred in 39%, absences in 4%, and myoclonic jerks in 3%. In only 39% of case records was current seizure control documented. Seventy-four per cent and 41% of patients had surface electroencephalography and computerized tomographic brain scanning, respectively. In more than 80% of patients the presence or absence of birth injury, febrile convulsions in childhood, and a family history of epilepsy were not mentioned. Seventy-six per cent of patients were receiving anticonvulsant monotherapy. The most commonly prescribed drugs were carbamazepine (43%), phenytoin (34%), sodium valproate (22%) and phenobarbitone (15%). Eighty-four per cent had attended a hospital clinic with their epilepsy, and 19% had been admitted to hospital with seizures or complications. A standard record form for the assessment and follow-up of epileptic patients in general practice would help in providing optimal management and in facilitating the setting up of a shared-care programme.

Adolescent↗
PubMed1996

Low blood pressure in Down's syndrome, A link with Alzheimer's disease?

Low blood pressure is reported in Down's syndrome (DS). To assess this and determine whether low pressure results from the disease or from long-term residence in hospital, we measured blood pressure with a random-zero sphygmomanometer in three groups of patients: 52 DS inpatients, 62 DS outpatients, and 60 outpatients with other forms of mental handicap. Relative to normal reference populations, blood pressure was low in both DS inpatients (systolic, score -33 mm Hg, P < .0001) and DS outpatients (-25 mm Hg, P < .0001). It was normal in non-DS outpatients (-4.0 mm Hg, P = .3). Blood pressure rose normally with age in the non-DS group but not in the DS group. We conclude that blood pressure is low in DS and that this is a feature of the disease rather than of the protected environment in which patients live. A mechanism related to trisomy 21 is likely, and there may be a link with Alzheimer's disease (AD) because blood pressure is also low in Alzheimer's and a high proportion of Ds patients develop this disease. If, as is likely, blood pressure is lowered in Alzheimer's by the neuropathy, the same neuropathy developing early in DS may also reduce blood pressure.

Adult↗
PubMed1996

Comparison of neurological scales and scoring systems for acute stroke prognosis.

BACKGROUND AND PURPOSE: Clinical trials routinely use stroke scales to compare baseline characteristics of treatment groups. It is unclear which stroke scale provides the most prognostic information. This often leads to collection of multiple scales in clinical trials. We aimed to determine which of several commonly used scales best predicted outcome. METHODS: A single observer scored consecutive admissions to an acute stroke unit on the National Institutes of Health Stroke Scale (NIHSS), the Canadian Neurological Scale, and the Middle Cerebral Artery Neurological Score. Guy's prognostic score was determined from clinical data. Outcome at 2, 3, 6, and 12 months was categorized as good (alive at home) or poor (alive in care or dead). Predictive accuracy of the variables was compared by receiver operating characteristic curves and stepwise logistic regression. RESULTS: Of the 408 patients studied, 373 had confirmed acute stroke and completed follow-up. The three stroke rating scales each predicted 3-month outcome with an accuracy of .79 or greater. The NIHSS provided the most prognostic information: sensitivity to poor outcome, .71 (95% confidence interval [CI], .64 to .79); specificity, .90 (95% CI, .86 to .94); and overall accuracy, .83 (95% CI, .79 to .87). Logistic regression showed that the NIHSS added significantly to the predictive value of all other scores. No score added useful information to the NIHSS. A cut point of 13 on the NIHSS best predicted 3-month outcome. CONCLUSIONS: Baseline NIHSS best predicts 3-month outcome. The Canadian Neurological Scale and Middle Cerebral Artery Neurological Score also perform well. Baseline assessments in clinical trials only need to include a single stroke rating scale.

Acute Disease↗
PubMed1995

Presentation of comparative audit data.

The Royal College of Surgeons of England organizes a voluntary comparative audit service for its general surgical fellows. To date, the information from the audit has been presented purely descriptively, which does not take account of statistical variability and the effects of differences in case mix between the participants. A new approach to the presentation of these data, based on statistical modelling of the effects of case mix, is presented. The approach is illustrated in an application based on data relating to 136203 admissions reported by 110 surgeons. The result of adjusting for case mix is a substantial change in the relative performance of the participating surgeons, which demonstrates the folly of attempting to compare surgical performance on the basis of a measure as crude as the unadjusted mortality rate. Further development of the statistical modelling is required, but this new statistical approach appears to enhance greatly the credibility of the audit data, by quantifying its strengths and limitations.

Age Distribution↗
PubMed1995

Trends in burn admissions in Scotland during 1970-92.

This retrospective study involved analysis of the data of the inpatients discharged with a diagnosis of burns, from various hospitals in Scotland, during the period 1970-92. There were 51,350 such inpatients all over Scotland, with an average annual rate of 2233 cases. Overall burn incidence in actual numbers was 43.7 per cent in < 15 year olds, 41.2 per cent in 15-64 year olds and 15.1 per cent in > or = 65 year olds. Burn rates per 100,000 population were highest in < 15 year olds and lowest in 16-64 year olds. The pattern of burn admissions has changed. Since 1987 the highest numbers of burn inpatients were the 16-64 year olds, followed by children, then the elderly. There has been a gradual but sustained fall in burns admissions in all age categories. The downward trend was statistically significant (t = 8.48, 21 d.f., P < 0.001). Though the population of the elderly (> or = 65 year olds) increased by about 13 per cent, the burn admissions and all deaths due to burns did not reveal an upward trend. The population of the old (81+ year olds) increased by 60 per cent during the same period. The incidence of burns was above average when > 80 year olds were considered separately, approaching the levels found in children. However the rate and incidence of burns in the 65-80 year olds resembled that of the younger age group (16-64 year olds). The total number of deaths due to burns and/or smoke inhalation has declined in all age groups and the decline has been statistically significant (chi-squared = 19.62, 1 d.f., P < 0.001). Maximum number of deaths occurred in > or = 65 year olds (44 per cent), followed closely by 16-64 year olds (43.5 per cent), and 12.5 per cent of deaths in adolescents and children. The decline was due to improved management of burns and a decrease in the number of patients having large body surface area burns.

Age Distribution↗
PubMed1995

Angiotensin-converting enzyme inhibitors after myocardial infarction: indications and timing.

A number of major studies have examined the impact of angiotensin-converting enzyme inhibitors on mortality in patients with ischemic heart disease. However, in these studies, selection of patients, choice of agent and timing of treatment after myocardial infarction have differed. In the Second Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS II), all patients, unless hypotensive, were treated immediately after thrombolysis with placebo or intravenous enalaprilat followed by oral therapy. In contrast, in the Survival and Ventricular Enlargement (SAVE) study, patients were selected with a reduced radionuclide ejection fraction and without overt ongoing ischemia. Despite these different approaches, both studies were based on the rationale that angiotensin-converting enzyme inhibition would beneficially affect infarct expansion and subsequent remodeling. The SAVE study reported a significant reduction in mortality rate (19% risk reduction, 95% confidence interval [CI] 3% to 32%) over an average follow-up period of 42 months, but with no observable impact on mortality rate until almost 1 year into treatment. The CONSENSUS II trial closed prematurely, with no benefit (a 10% increase in risk, 95% CI 7% reduction to 29% increase) apparent from enalapril after 6 months of follow-up. The recently reported but unpublished findings of Gruppo Italiano per lo Studio della Sopravvivenza nell'Infarto Miocardico (GISSI-3) and the Fourth International Study of Infarct Survival (ISIS-4) indicate a small benefit from early (within 24 h) short-term (4 to 6 weeks) treatment of all patients, unless hypotensive, after a myocardial infarction.(ABSTRACT TRUNCATED AT 250 WORDS)

Angiotensin-Converting Enzyme Inhibitors↗
PubMed1995

Randomised, prospective evaluation of a new pericardial heart valve: outcome after seven years.

Between 2 February 1987 and 20 March 1990, 170 patients were randomly allocated to receive a new pericardial heart valve (the Bioflo) or the Carpentier-Edwards supra-annular porcine bioprosthesis. Eighty-five patients (mean age 61 years, range 38-77) received 93 Bioflo valves, 46 having aortic valve replacement (AVR), 31 mitral valve replacement (MVR) and 8 aortic and mitral valve replacement (A+MVR); 85 patients (mean age 62.1 years, range 41-77) received 99 Carpentier-Edwards porcine valves (48 AVR, 23 MVR and 14 A+MVR). Cumulative follow-up totals 926 patient-years (mean 5.45 +/- 1.93, median 6.03, maximum 7.47 years). The overall operative mortality rate for the Bioflo group was 2.4%, and 5.9% for the Carpentier-Edwards group. At 7 years, there was no statistically significant difference in survival or in any prosthesis-related complication between the pericardial and porcine valve recipients overall, or when the data were analysed according to valve implant position. The actuarial survival rate at 7 years for the Bioflo group was 80.1 +/- 5.1% and 72.3 +/- 5.9% for the Carpentier-Edwards group. Freedom from structural valve deterioration (SVD) at 7 years for Bioflo patients was 98.5 +/- 1.5% and for Carpentier-Edwards patients 91.2 +/- 4.1%. No patient in the Bioflo group has required reoperation for SVD. The randomised prospective trial has proven practical and effective and has shown the pericardial valve to perform at least as well as the porcine valve up to 7 years when all of the standard outcome measures of valve performance are assessed.

Actuarial Analysis↗
PubMed1995

Comparison of manually constructed and stapled anastomoses in colorectal surgery. West of Scotland and Highland Anastomosis Study Group.

OBJECTIVE: The authors compared both the initial and the long-term outcomes of patients undergoing stapled and sutured colorectal anastomoses. SUMMARY BACKGROUND DATA: Sutured and stapled large bowel anastomoses are perceived to be equally safe, but concern has been raised about increased rates of tumor recurrence with the use of stapling instruments. METHODS: The outcome of patients with sutured and stapled colorectal anastomoses were compared in a prospective, multicenter, randomized study. Factors affecting long-term outcomes were assessed by both univariate and multivariate analysis. RESULTS: Seven hundred thirty-two patients were recruited. There was a significant increase in radiologic leakage in the sutured group (14.4% vs. 5.2%, p < 0.05), but there was no difference in clinical anastomotic leak rates, morbidity, or postoperative mortality. Tumor recurrence and cancer-specific mortality were higher in the sutured patients (7.5% and 6.7%, respectively) and in patients with anastomotic leaks. CONCLUSIONS: This study shows that suturing or stapling are equally safe in large bowel surgery. However, it also shows a long-term benefit of stapling in colorectal cancer patients.

Anastomosis, Surgical↗
PubMed1995

Case mix adjustment in comparative audit.

There is increasing pressure to measure and publicize the quality of health care, with, for example, hospital 'league tables' appearing regularly in the lay press. Equally, there is increasing recognition that such simplistic presentations of data can be seriously misleading, as differences in case mix mean that they do not compare like with like. We discuss what is required of a statistical model if it si to be used to make comparisons of clinical performance which are adjusted for case mix. Outcome measures must be well defined and relevant, and the risk factors used in the model must reflect the patients' potential prognosis rather than aspects of his or her clinical care. In addition, the calibration of the statistical model is crucial. We review a number of established clinical scoring systems and demonstrate that they fail to meet all of the required criteria. Of particular concern is the fact that these scoring systems are susceptible to biases which could actually mask differences in performance. We highlight areas where further research is required, with the aim of stimulating progress in this field.

Bias↗
PubMed1995

Risk of feline infectious peritonitis in cats naturally infected with feline coronavirus.

A longitudinal survey of 820 cats in 73 households was conducted over a period of 6 years to establish the fate of pet cats that were seropositive after natural exposure to feline coronavirus (FCoV). In particular, their risk of developing feline infectious peritonitis (FIP) was determined. The seropositive cats were assigned to 1 of 3 groups: cats from households in which FIP had recently been diagnosed; cats from households in which FIP had not been diagnosed, but from which kittens had been relocated and subsequently died of FIP; and cats from households in which FIP had not been diagnosed. Cats in the first group were not at greater risk of developing FIP than were cats in the other 2 groups. Consequently, any household in which seropositive cats live must be considered a potential source of FCoV that can cause FIP. There was no evidence that the enhanced disease, which has been described after experimentally induced infection of seropositive cats, exists in nature. Thus, analysis of the survival of the seropositive cats over periods of up to 36 months indicated that their risk of developing FIP decreased with time, suggesting the development of immunity rather than increased susceptibility to disease. In addition, of 56 cats deemed to have been naturally reinfected because their anti-FCoV antibody titers decreased and subsequently increased, only 3 developed FIP.

Animal Feed↗
PubMed1995

Lack of association between angiotensin converting enzyme gene insertion/deletion polymorphism and stroke.

AIM: The human angiotensin converting enzyme (ACE) gene is a candidate genetic locus for stroke because of the importance of the renin-angiotensin system to the development of cardiovascular disease. In the present study, the association between ACE gene deletion/insertion (D/I) polymorphism and the presence or absence of ischaemic stroke was evaluated and possible associations between ACE gene polymorphism and certain subgroups of stroke were investigated. MATERIALS AND METHODS: DNA samples from 585 unselected suspected stroke patients admitted to the Acute Stroke Unit, Western Infirmary, Glasgow, and from 188 age- and sex-matched controls were genotyped by polymerase chain reaction. RESULTS: There was no evidence of any association between ACE gene polymorphism and the presence of ischaemic stroke except in the subgroup containing only hypertensive patients, where the odds ratio of a DD genotype for ischaemic stroke was just significantly greater than 1 (odds ratio 2.51, 95% confidence interval 1.06, 5.94). There was no significant association between ACE genotype and the stroke subgroups investigated. CONCLUSION: The DD genotype may not be a risk factor for stroke, particularly in the normotensive population. Further study in a strictly controlled population is required to test for the possibility of an increased risk of stroke in hypertensives with DD homozygotes.

Cerebrovascular Disorders↗
PubMed1994

Poor accuracy of stroke scoring systems for differential clinical diagnosis of intracranial haemorrhage and infarction.

The differentiation of cerebral infarction and cerebral haemorrhage is the most important first step in the management of acute stroke, because clinical management of the two disorders differs substantially. The Guy's Hospital and Siriraj stroke diagnostic scores were developed to aid clinicians in this decision. We have tested the performance of the two scores on a group of 1059 patients admitted to the acute stroke unit (ASU) at the Western Infirmary, Glasgow, with suspected stroke between May, 1990, and December, 1993. The diagnosis was confirmed as stroke by computed tomography (CT) scanning or necropsy (n = 10) in 991 patients. For each clinical score we subjectively identified the cut-off point that maximised sensitivity to cerebral haemorrhage with the smallest loss of specificity. At its optimum cut-off point the Guy's Hospital score had a sensitivity for the diagnosis of haemorrhage of 70% and specificity of 64%. The corresponding figures for the Siriraj score at its optimum cut-off point were 68% sensitivity and 64% specificity. The overall predictive accuracy of both scores was 64%. The greater complexity of the Guy's Hospital score (thirteen variables included) did not result in substantially superior performance to the Siriraj score (five variables). This validation study suggests that neither score is useful for exclusion of haemorrhage before anticoagulant treatment is initiated or as a diagnostic screening procedure for trials of low-risk treatments such as aspirin. Our findings emphasise the need for routine CT scanning in this setting, since this method remains the most accurate for differentiating between haemorrhage and infarction.

Acute Disease↗
PubMed1994

Effect of the surgeon's specialty interest on the type of resection performed for colorectal cancer.

PURPOSE: The aim of this study was to examine the type of resection performed for colorectal cancer by surgeons with a colorectal interest and compare this with the type of resection performed by surgeons with other specialty interests. METHODS: One hundred sixteen patients had curative surgery performed for primary colorectal cancer over a one-year period by ten surgeons with four different specialty interests. RESULTS: Surgeons with an interest in colorectal cancer resected twice as much colon (280 mm vs. 130 mm; P > 0.0001, Mann-Whitney U test) and were more likely to remove adjacent clinically involved organs (15 percent vs. 0 percent) for left-sided colon and rectal cancers compared with surgeons with vascular or transplant interests. Surgeons with an interest in gastroenterology performed a resection that was intermediate between the colorectal and other specialty groups for left-sided cancers. Distal resection margins were significantly greater (55 mm vs. 20 mm; P > 0.001) for sigmoid cancers in the colorectal group, but were similar in all groups for rectal cancer. Resection lengths and margins for right-sided cancers were similar in all groups, although the number of lymph nodes retrieved from the mesentery was greater in the colorectal group (13 vs. 7.5; P = 0.08). CONCLUSION: This study shows a wide variability in the type of resection performed for colorectal cancer and illustrates the need for clinical trials to evaluate the effect of such variability on patient outcome.

Aged↗
PubMed1994

Evaluation of staples and prostheses for use in laparoscopic inguinal hernia repair.

With the increasing popularity of laparoscopic prosthetic inguinal hernia repair, it was decided to compare the various staples and prostheses currently in use. A twofold increase in breaking or opening strength was required to disrupt the Endoscopic Multifeed Staple (31.2 Newtons vs 15.6 Newtons) compared with the Multifire Endo Hernia Staple. A linear relationship existed between the number of staples used and the maximum load tolerated. No significant difference was found between the breaking strength of the prostheses evaluated. Further research into the biomechanics of laparoscopic inguinal hernia repair is necessary to determine how important staple and prosthesis strength is for the success of the repair.

Hernia, Inguinal↗
PubMed1994

ACE inhibition, atherosclerosis and myocardial infarction--the AIRE Study in practice. Acute Infarction Ramipril Efficacy Study.

Unlike most cell-types in the body, cardiomyocytes do not replicate in adult life. Consequently myocardial infarction produces irreparable damage to the heart which in turn increases the likelihood of premature death. Recent trials indicate that immediate aspirin and thrombolytic therapy beneficially modify the natural history of myocardial infarction, reducing both short- and long-term mortality rates. However, the occurrence of early heart failure in as many as one third of patients continues to carry with it a particularly poor prognosis. Recent trials with ACE inhibitors indicate that delayed initiation (beyond 24 h) and long-term maintenance treatment of patients selected on the basis of either heart failure (AIRE Study) or an ejection fraction of less than 40% (SAVE Study) result in large reductions in all-cause mortality. Although the exact mechanism of this benefit remains uncertain the reduction of further myocyte death due to reinfarction or gradual toxic attrition has been suggested. The currently unreported ISIS-4 and GISSI-3 should provide additional information as to whether the clinical indications for ACE-inhibitor therapy should be extended to other patient groups.

Coronary Artery Disease↗