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Biomedical subjects

J Dunning

Publications and source records attributed to J Dunning.

At least 19 recordsLinked to original sources
PubMed2006

Diagnosis of pulmonary embolism with CT pulmonary angiography: a systematic review.

OBJECTIVE: To appraise the evidence on the diagnostic accuracy of CT pulmonary angiography and the prognostic value of a negative CT pulmonary angiogram in the diagnosis of pulmonary embolism. METHODS: Medline, EMBASE, and grey literature were systematically searched by two researchers. Any study which compared CT pulmonary angiography to an acceptable reference standard or prospectively followed up a cohort of patients with a normal CT pulmonary angiogram was included. Study methods were appraised independently by two researchers, and data were extracted independently by three researchers. RESULTS: Thirteen diagnostic and 11 follow up studies were identified. Studies varied in prevalence of pulmonary embolism (19-79%), patient groups, and method quality. Few studies recruited unselected emergency department patients. There was heterogeneity in the analysis of sensitivity (53 to 100%), specificity (79 to 100%), and false negative rate (1.0 to 10.7%). The pooled false negative rate of combined negative CT pulmonary angiography and negative deep vein thrombosis testing was 1.5% (95% CI 1.0 to 1.9%). CONCLUSION: Diagnostic studies give conflicting results for the diagnostic accuracy of CT pulmonary angiography. Follow up studies show that CT pulmonary angiography can be used in combination with investigation for deep vein thrombosis to exclude pulmonary embolism.

Angiography↗
PubMed2006

The use of recombinant activated factor VII for refractory bleeding post complex cardiothoracic surgery.

We reviewed the outcome following use of recombinant activated factor VII (rVIIa) in patients with major bleeding post cardiothoracic surgery in our unit between January 2002 and July 2004. The unit consists of 16 cardiothoracic intensive care beds in a public metropolitan teaching hospital which serves as a referral centre for heart and lung transplant surgery. Patients with refractory bleeding following cardiothoracic surgical procedures who were treated with rVIIa were identified. A total of 12 episodes of rVIIa use were recorded in ten patients, including three episodes with ventricular assist devices, and 5 heart and/or lung transplants. The median dose used was 85 microg/kg. Chest tube drainage decreased in all patients following administration of rVlIIa; median chest tube drainage decreased from 445 ml/h to 171 ml/h (P = 0.03). Despite cessation of bleeding, mortality was high when rVIIa was used after more than 24 hours. In six episodes, despite early rVIIa use (within six hours), continued bleeding necessitated return to theatre, where a surgical source of bleeding was found. In this small retrospective study, rVIIa significantly reduced bleeding that was refractory to standard blood product transfusion. In this series of patients, those that did not respond to rVIIa early in the postoperative phase were found to have a surgical source of bleeding.

Adult↗
PubMed2005

HIV and hepatitis C co-infection.

HIV/HCV co-infection is emerging as a major cause of morbidity and mortality in the 21st century. This editorial reviews the prevalence of co-infection, the factors involved in acquisition of HCV, and the influence of co-infection on disease progression. We examine the results of the major co-infection trials including APRICOT, ACTG 5071 and RIBAVIC. These trials, in association with emerging evidence for future therapies currently undergoing investigation, have led to increased hope of treatment success in co-infected individuals.

Anti-HIV Agents↗
PubMed2005

A maximally sensitive clinical decision rule to reduce the need for radiography in mandibular trauma.

INTRODUCTION: To identify clinical symptoms and signs that exclude the presence of mandibular fracture in patients presenting with mandibular trauma and thus devise a clinical decision rule that will rule out the need for radiography in some patients. PATIENTS AND METHODS: A prospective study was conducted of consecutive patients with a possible diagnosis of mandibular fracture who attended a city-centre emergency department between July 2000 and December 2001. Clinical symptoms and signs were recorded for each patient using a predesigned proforma. Radiographic evaluation of a suspected mandibular fracture consisted of lateral-oblique and postero-anterior mandibular views. The presence of a fracture was based on the interpretation of the X-rays by a radiologist who was blinded to the clinical probability of a fracture. Data were initially analysed using the chi-square test. Recursive partitioning was then performed to create a maximally sensitive decision tree. RESULTS: 280 patients were included in the study, 65 of whom had a mandibular fracture. A maximally sensitive decision rule was found that identified 5 parameters (malocclusion, trismus, broken teeth, pain with mouth closed, step deformity) whose absence excluded mandibular fracture. This rule has a sensitivity of 100% and specificity of 39% in identifying patients with mandibular fracture. If applied to our patient cohort, this rule would have saved 83 radiographs without missing any fractures. CONCLUSIONS: A simple decision rule is presented that can be used to exclude the need for radiography in a subset of patients with mandibular trauma.

Adolescent↗
PubMed2004

A meta-analysis of variables that predict significant intracranial injury in minor head trauma.

BACKGROUND: Previous studies have presented conflicting results regarding the predictive effect of various clinical symptoms, signs, and plain imaging for intracranial pathology in children with minor head injury. AIMS: To perform a meta-analysis of the literature in order to assess the significance of these factors and intracranial haemorrhage (ICH) in the paediatric population. METHODS: The literature was searched using Medline, Embase, Experts, and the grey literature. Reference lists of major guidelines were crosschecked. Control or nested case-control studies of children with head injury who had skull radiography, recording of common symptoms and signs, and head computed tomography (CT) were selected. OUTCOME VARIABLE: CT presence or absence of ICH. RESULTS: Sixteen papers were identified as satisfying criteria for inclusion in the meta-analysis, although not every paper contained data on every correlate. Available evidence gave pooled patient numbers from 1136 to 22 420. Skull fracture gave a relative risk ratio of 6.13 (95% CI 3.35 to 11.2), headache 1.02 (95% CI 0.62 to 1.69), vomiting 0.88 (95% CI 0.67 to 1.15), focal neurology 9.43 (2.89 to 30.8), seizures 2.82 (95% CI 0.89 to 9.00), LOC 2.23 (95% CI 1.20 to 4.16), and Glasgow Coma Scale (GCS) <15 of 5.51 (95% CI 1.59 to 19.0). CONCLUSIONS: There was a statistically significant correlation between intracranial haemorrhage and skull fracture, focal neurology, loss of consciousness, and GCS abnormality. Headache and vomiting were not found to be predictive and there was great variability in the predictive ability of seizures. More information is required about the current predictor variables so that more refined guidelines can be developed. Further research is currently underway by three large study groups.

Child↗
PubMed2004

The implications of NICE guidelines on the management of children presenting with head injury.

BACKGROUND: NICE guidelines for the management of head injury were published in June 2003. Their recommendations differ markedly from previous guidelines published by the Royal College of Surgeons (RCS). In place of skull radiography and admission, computed tomography (CT) is advocated. The impact of these guidelines on service provision in the UK is unknown. METHODS: Data on all clinical correlates of children presenting with any severity of head injury was collected in three hospitals in the northwest of England. The current skull radiograph (SXR), CT scan, and admission rates were determined. The rates of SXR, CT scan, and admission that should have occurred when following either the RCS or NICE guidelines were then determined. RESULTS: Data from 10 965 patients who attended three hospitals between February 2000 and August 2002 was studied. Twenty five per cent of patients received a SXR, 0.9% a CT scan, and 3.7% were admitted. Strict adherence to the RCS guidelines would have resulted in a 50% SXR rate, a 1.6% CT scan rate, and a 7.1% admission rate. Adherence to NICE guidelines would result in a 0.3% SXR rate, an 8.7% CT scan rate, and a 1.4% admission rate, although the CT rate would drop to 6.3% if vomiting three or more times in the under 12s was used instead of more than one vomit. CONCLUSIONS: The new NICE guidelines do not increase the workload caused by patients attending with head injury but they move their management from the observation ward to the radiology department.

Adolescent↗
PubMed2003

Pulmonary thromboendarterectomy in a case of hereditary stomatocytosis.

We present a case of pulmonary thromboendarterectomy performed successfully in a patient with stomatocytosis. Stomatocytosis is a rare condition of abnormal erythrocyte morphology in which haemolysis and hyperkalaemia occur at cooler temperatures. A 35-yr-old male with stomatocytosis was referred for pulmonary thromboendarterectomy in the context of chronic thromboembolic pulmonary hypertension. He had undergone splenectomy as a child, which rendered him hypercoagulable as the spleen normally removes the haemolysed red cell fragments from blood. By constantly monitoring urine for macroscopic haematuria, arterial and mixed venous blood gas analysis perioperatively and by limiting the period of deep hypothermic circulatory arrest that is normally required for this operation, we were able to perform the operation successfully.

Adult↗
PubMed2001

Pulmonary vein augmentation for single lung transplantation.

We describe a simple method of augmenting pulmonary veins using the donor pericardium in lung grafts which have been procured without an adequate donor left atrial cuff. The method allows making use of lungs procured with suboptimal surgical technique, such as those with short atrial cuffs or completely separated superior and inferior pulmonary veins. We also have applied it equally successfully on the right lung.

Humans↗
PubMed2001

Two-decade analysis of cardiac storage for transplantation.

OBJECTIVE: Cardiac storage solutions and methods remain unstandardized. We have surveyed the literature to establish how the subject has progressed, addressing models of preservation and measures of outcome. Since a lot of the literature on cardiac storage is generated in the laboratory, we were particularly interested to evaluate to what extent bench work finds its way into and clinical practice. The discussion focuses in addition to new areas of research and introduces the concept of integrated organ preservation. METHODS: Five representative journals (J Thorac Cardiovasc Surg, Circulation, J Heart Lung Transplant, Eur J Cardio-thorac Surg and Ann Thorac Surg) were searched by hand for papers published between 1980-1999. All laboratory, animal experimental and clinical studies focused on prolonged cardiac preservation and storage were selected. RESULTS: Two hundred and forty-nine publications were identified using preset criteria. Of these, 196 (79%) were studies performed in animal models and 10 (4%) were experiments carried out on animal tissue. One hundred and five experiments (42% of all studies) were performed in small animals. The most common animal model was of ischemia followed by ex vivo reperfusion (121 studies, 49% of publications). The measures of outcome were classified as biochemical, functional, morphologic and endothelial; the majority of studies had one (48%) or two (40%) end-points. Twenty-five studies (10%) had endothelial measures of outcome, alone or in combination with other types of outcomes. Human clinical work was represented by 34 (14%) studies of clinical transplantation and nine (4%) experiments on human tissue only. There were five randomized clinical trials, representing 2% of all papers and 15% of all clinical research. CONCLUSION: In conclusion, most of the surgical publications on prolonged cardiac preservation result from animal research. Small animal models of ex vivo ischemia and reperfusion are predominant.

Animals↗
PubMed2001

Pulmonary thromboendarterectomy.

Pulmonary thromboendarterectomy (PTE) provides a curative alternative to the otherwise fatal condition of chronic thromboembolic pulmonary hypertension (CTEPH). However, the condition is under-diagnosed due to a lack of awareness. An acceptable operative mortality of around 10% and long-term survival exceeding medical therapy or transplantation makes PTE a favourable choice for the treatment of CTEPH. Outcome is further optimised if the disease is diagnosed early and patients referred to specialised centres. An increase in the number of surgical procedures will also contribute to lower the mortality associated with this condition.

Chronic Disease↗
PubMed2000

An oral vaccine against NMDAR1 with efficacy in experimental stroke and epilepsy.

The brain is generally considered immunoprivileged, although increasing examples of immunological responses to brain antigens, neuronal expression of major histocompatibility class I genes, and neurological autoimmunity have been recognized. An adeno-associated virus (AAV) vaccine generated autoantibodies that targeted a specific brain protein, the NR1 subunit of the N-methyl-D-aspartate (NMDA) receptor. After peroral administration of the AAV vaccine, transgene expression persisted for at least 5 months and was associated with a robust humoral response in the absence of a significant cell-mediated response. This single-dose vaccine was associated with strong anti-epileptic and neuroprotective activity in rats for both a kainate-induced seizure model and also a middle cerebral artery occlusion stroke model at 1 to 5 months following vaccination. Thus, a vaccination strategy targeting brain proteins is feasible and may have therapeutic potential for neurological disorders.

Administration, Oral↗