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Biomedical subjects

J Slattery

Publications and source records attributed to J Slattery.

At least 55 records · Page 3Linked to original sources
PubMed1994

Measuring the burden of secondary insults in head-injured patients during intensive care.

Primary traumatic brain damage may be compounded by secondary pathophysiological insults that can occur soon after trauma, during transfer to hospital or subsequent treatment of the head-injured patient. The aim of this prospective study was to quantify the burden of a wide range of secondary insults occurring after head injury and to relate these to 12-month outcome. In 124 adult head-injured patients studied during intensive care using a computerized data collection system, < or = 14 clinically indicated physiological variables were measured minute-by-minute. Verified values falling outside threshold limits for > or = 5 min, as defined by the Edinburgh University Secondary Insult Grading scheme, were analysed by insult grade and duration. A greater incidence of secondary insults was detected than previous studies have indicated. Insults were found in 91% of patients and occurred in all severities of head trauma, at all ages, and at every level of Injury Severity Score (ISS). The cumulative durations were much greater than previously recorded although 85% of the total time was at the least severe grade. Short duration insults were common. In 71 patients, in whom 8 insults could be assessed (intracranial pressure, arterial hypo- and hypertension, cerebral perfusion pressure, hypoxemia, pyrexia, brady- and tachycardia), outcome at 12 months was analysed using logistic regression to determine the relative influence of age, admission Glasgow Coma Sumscore, ISS, pupil response on admission, and insult duration on both mortality and morbidity. The most significant predictors of mortality in this patient set were durations of hypotensive (p = .0064), pyrexic (p = .0137), and hypoxemic (p = .0244) insults. When good versus poor outcome was considered, hypotensive insults (p = .0118) and pupil response on admission (p = .0226) were significant.

Adult↗
PubMed1993

Antithrombotic therapy in acute ischaemic stroke: an overview of the completed randomised trials.

A formal statistical overview of all truly randomised trials was undertaken to determine whether antithrombotic therapy is effective and safe in the early treatment of patients with acute stroke. There were 15 completed randomised controlled trials of the value of early antithrombotic treatment in patients with acute stroke. The regimes tested in acute presumed or confirmed ischaemic stroke were: heparin, 10 trials with 1047 patients: oral anticoagulants, one trial with 51 patients: antiplatelet therapy, three trials with 103 patients. Heparin was tested in one trial with 46 patients with acute haemorrhagic stroke. Outcome measures were deep venous thrombosis (confirmed by I125 scanning or venography), pulmonary embolism, death from all causes, haemorrhagic transformation of cerebral infarction, level of disability in survivors. In patients with acute ischaemic stroke, allocation to heparin was associated with a highly significant 81% (SD 8, 2p < 0.00001) reduction in deep venous thrombosis detected by I125 fibrinogen scanning or venogram. Only three trials systematically identified pulmonary emboli, which occurred in 6/106 (5.7%) allocated control vs 3/132 (2.3%) allocated heparin, a non-significant 58% reduction (SD 45.7, 2p > 0.1). There were relatively few deaths in the trials in patients with presumed ischaemic stroke: 94/485 (19.4%) among patients allocated to the control group vs 79/497 (15.9%) among patients who were allocated heparin. The observed 18% (SD 16) reduction in the odds of death was not statistically significant. The least biased estimated of the effect of treatment on haemorrhagic transformation of the cerebral infarct (HTI) comes from trials where all patients were scanned at the end of treatment, irrespective of clinical deterioration; using this analysis, haemorrhagic transformation occurred in 7/102 (6.9%) control vs 8/106 (7.5%) treated, a non-significant 12% increase (SD 56, 2p > 0.1). These data cannot exclude the possibility that heparin substantially increases the risks of HTI. No data on disability in survivors could be obtained. Early heparin treatment might be associated with substantial reductions in deep venous thrombosis (and probably also pulmonary embolism) and possibly a one fifth reduction in mortality (equivalent to the avoidance of 20-40 early deaths per thousand patients treated.) However, the data were wholly inadequate on safety, particularly on the risk of haemorrhagic transformation of the infarct and on the hazards of heparin therapy in patients with known intracerebral haemorrhage. The trials of oral anticoagulants (15 deaths among 57 patients) and antiplatelet therapy (two deaths among 103 patients) were too small to be informative. Much larger randomized trials-comparing aspirin, heparin and the combination of both drugs against control-in patients with acute ischaemic stroke are justified (and several are now planned or underway).

Acute Disease↗
PubMed1993

Interobserver reliability of a clinical classification of acute cerebral infarction.

BACKGROUND AND PURPOSE: The Oxfordshire Community Stroke Project (OCSP) clinical classification of subtypes of cerebral infarction (total and partial anterior circulation infarction, lacunar infarction, and posterior circulation infarction) can be used to predict early mortality, functional outcome, and whether the infarct was likely due to large- or small-vessel occlusion. The OCSP classification was originally developed and tested by neurologists as part of a community-based study of first-ever stroke, in which some cases were seen after the acute phase. We examined the interobserver reliability of the classification when used in everyday clinical practice in patients seen during the acute phase of stroke shortly after admission to the hospital. METHODS: Two clinicians independently assessed consecutive patients admitted to the hospital with an acute stroke and recorded both the neurological features and their opinion of the subtype of infarct. RESULTS: Eighty-five patients were assessed. Interobserver agreement for the classification was moderate to good (kappa = 0.54; 95% confidence interval, 0.39 to 0.68). Differences in the assessment of the commonly elicited neurological signs explained many of the disagreements: interobserver agreement was good for some signs (hemiparesis [kappa = 0.77], dysphasia [kappa = 0.70]), moderate for some (hemianopia [kappa = 0.39]), and poor for others (sensory loss [kappa = 0.15]). CONCLUSIONS: The classification was simple and practicable (and could be widely used in routine clinical practice, randomized controlled trials, and audit), and interobserver reliability was satisfactory.

Acute Disease↗
PubMed1992

Atrial fibrillation and stroke: prevalence in different types of stroke and influence on early and long term prognosis (Oxfordshire community stroke project)

OBJECTIVE: To determine in patients with first ever stroke whether atrial fibrillation influences clinical features, the need to perform computed tomography, and prognosis. DESIGN: Observational cohort study with maximum follow up of 6.5 years. SETTING: Primary care, based on 10 general practices in urban and rural Oxfordshire. SUBJECTS: Consecutive series of 675 patients with first ever stroke registered in the Oxfordshire community stroke project. MAIN OUTCOME MEASURES: Prevalence of atrial fibrillation by type of stroke; effect of atrial fibrillation on case fatality rate and risk of recurrent stroke, vascular death, and death from all causes. RESULTS: Prevalence of atrial fibrillation was 17% (95% confidence interval 14% to 20%) for all stroke types (115/675), 18% (15% to 21%) for cerebral infarction (97/545), 11% (4% to 11%) for primary intercerebral haemorrhage (7/66), and 0% (0 to 11%) for subarachnoid haemorrhage (0/33). For patients with cerebral infarction the 30 day case fatality rate was significantly higher with atrial fibrillation (23%) than with sinus rhythm (8%); the risk of early recurrent stroke (within 30 days) was 1% with atrial fibrillation and 4% with sinus rhythm. In patients who survived at least 30 days the average annual risk of recurrent stroke was 8.2% (5.9% to 10.9%) with sinus rhythm and 11% (6.0% to 17.3%) with atrial fibrillation. CONCLUSIONS: After a first stroke atrial fibrillation was not associated with a definite excess risk of recurrent stroke, either within 30 days or within the first few years. Survivors with and without atrial fibrillation had a clinically important absolute risk of further serious vascular events.

Aged↗
PubMed1992

Diurnal variation in incidence of stroke: Oxfordshire community stroke project.

OBJECTIVE: To determine whether diurnal variation occurs in the onset of stroke. DESIGN: Community based study over four years. SETTING: Oxfordshire, United Kingdom. SUBJECTS: 105,000 people, of whom 675 had a first ever stroke. 545 had a cerebral infarction, 66 had primary intracerebral haemorrhage, 33 had subarachnoid haemorrhage, and in 31 the type of stroke was not known. MAIN OUTCOME MEASURES: Time of stroke and degree of activity at onset. RESULTS: In the 578 patients for whom it was known whether onset occurred while asleep or awake, the proportion with onset during sleep was 25% (135/545) for cerebral infarction, 17% (11/66) for primary intracerebral haemorrhage, and 0% (0/33) for subarachnoid haemorrhage. This difference persisted if patients in whom it was not known whether they were asleep or awake at onset were classed as asleep. For all stroke types together there was a significant (chi 2 = 218.7, p less than 0.001) diurnal variation with a morning peak between 0800 and 1000, which persisted even after allowing for strokes first noted on waking by redistributing the hour of onset through the preceding eight hours (chi 2 = 47, p less than 0.001). A significant diurnal variation was also found in the onset of cerebral infarction (peak 0800-1000, chi 2 = 208.4, p less than 0.001). Fewer patients had other forms of stroke and the diurnal variations for primary intracerebral haemorrhage (peak 1000-1200) and subarachnoid haemorrhage (peaks 0800-1000 and 1800-2000) were not significant. There seemed to be a second smaller peak for all types of stroke. CONCLUSIONS: All types of stroke are most likely to occur after waking in the morning. The cause of the circadian variation requires further study.

Cerebral Hemorrhage↗
PubMed1992

A comparison of facial grading systems.

There have been several attempts at establishing a grading system to estimate the severity of a facial palsy. This study compares the validity and consistency of all the leading systems. The results indicate that the systems are comparable and overall none had the advantage over the others. Interobserver variation had a significant effect on the consistency of the systems used, but experience of the observer was not a significant factor. The simplest classification studied was the House-Brackman system which is recommended.

Facial Paralysis↗
PubMed1991

Facial weakness. A comparison of clinical and photographic methods of observation.

The search for an internationally acceptable facial grading system has resulted in an assessment of existing methods by several investigators. These studies were based on observations of video film taken of patients with varying degrees of facial malfunction. Although the grading systems were evaluated, the use of videotape has never been compared with clinical examination and its suitability for this type of work is, therefore, unknown. We used nine facial grading systems to compare the results of clinical observation with those of photographic methods of presentation. The latter included videotape, photographic slides, and a combination of the two. The correlation between clinical examination findings and findings of any of the photographic methods was poor, suggesting the need for a standard form of presentation when grading patients. The most consistent results were found with either clinical examination or photographic slides; videotape was the least reliable.

Data Interpretation, Statistical↗
PubMed1990

11 beta-hydroxysteroid dehydrogenase activity in the mammary gland.

Levels of 11 beta-hydroxysteroid dehydrogenase activity in mammary gland homogenates from pregnant and lactating Sprague-Dawley rats were determined by incubation with [3H]corticosterone under standard conditions, followed by thin-layer chromatography of incubated media. Enzyme activity was high in virgin and pregnant rats, but fell soon after parturition, suggesting a possible role for this enzyme in the co-ordinate regulation of glucocorticoid effects on milk protein synthesis.

11-beta-Hydroxysteroid Dehydrogenases↗
PubMed1990

A simple method to improve the accuracy of non-invasive ultrasound in selecting TIA patients for cerebral angiography.

A prospective study is reported of the ability of B mode ultrasound imaging and continuous wave Doppler flow studies to detect different degrees of stenosis of the extracranial internal carotid artery (ICA) in 186 arteries in 99 patients with transient ischaemic attacks (TIA) and minor ischaemic stroke. A simple mathematical equation has been developed which combines the image and flow data to provide a single predictor of the degree of angiographic stenosis which has advantages over either ultrasonic modality used alone. The sensitivity and specificity of the predictive model in the detection of stenosis greater than or equal to 25% was 73% and 98%, of stenosis greater than or equal to 50% was 90% and 93%, of stenosis greater than or equal to 75%, 65% and 99% and occlusion 100% and 94% respectively. The principal clinical value of ultrasound screening is to spare patients with "non-significant" stenosis the risk of unnecessary angiography. Thus a simple measure of the Duplex screening tests' performance is the proportion of all strokes occurring as a complication of angiography that are avoided by changing the investigation policy from "angiograms for all carotid TIA and minor ischaemic stroke patients" to "angiograms for all patients with abnormal ultrasound results". If Duplex scanning were used to select patients most likely to have a significant abnormality on angiography, depending on the degree of stenosis to be detected, 52-85% of angiographic strokes might be avoided. If the predictive equation were used 62-88% of angiographic strokes might be avoided.

Blood Flow Velocity↗
PubMed1989

Projecting the number of patients with first ever strokes and patients newly handicapped by stroke in England and Wales.

The common assumption that future increases in the number of elderly people will result in a parallel increase in the burden of care of long term disabled survivors of stroke was examined. The number of patients with first ever strokes and the net number of people handicapped after these strokes in England and Wales every five years until 2023 have been projected. Between the base year 1983 and the year 2023 an increase in population of about 5% will occur; first ever strokes are projected to increase by about 30% and deaths within six months of first ever strokes by about 40%. The net number of severely handicapped people six months after a first ever stroke is projected to increase by only about 8%, however, and the net number of people who are moderately or severely handicapped by only 4%. This paradox occurs because first ever stroke often kills people who have been handicapped by other causes, particularly if they are elderly. It is concluded that despite the limitations of these data they strongly suggest that the increased burden of health care of patients with first ever strokes in the next 40 years will be primarily that of caring for those in the acute stages of stroke and not with the management of chronic handicap after a stroke.

Age Factors↗
PubMed1988

Increased mortality rates in late-life depression.

Physical illness at referral and subsequent mortality were studied in a group of elderly patients with depression, and compared with age/sex-matched controls. The depressed group was significantly less well at first interview, and had a significantly higher 4-year mortality. When the effect of physical illness was controlled, the depressed patients (particularly the men) still had a significantly higher 4-year mortality, suggesting that the greater mortality in the depressed group was not due to differences in physical health alone.

Aged↗
PubMed1985

Segmental flexibility of receptor-bound immunoglobulin E.

The segmental flexibility of mouse immunoglobulin E (IgE) bound to its high-affinity receptor on membrane vesicles from rat basophilic leukemia cells was compared to that of IgE in solution by measuring the steady-state anisotropy as a function of temperature and viscosity. A monoclonal IgE was used to bind the fluorescent probe N-[5-(dimethylamino)naphthalene-1-sulfonyl]-L-lysine (DNS-Lys) rigidly and specifically in the antigen combining site at the tip of the Fab region. The average rotational correlation time, phi, of 74-89 ns for the receptor-bound IgE is only slightly longer than that for IgE in solution where phi = 54 ns. Another mouse monoclonal IgE was covalently labeled in the Fab region with N-(1-pyrenyl)maleimide. Anisotropy measurements with this derivative yielded results that are very similar to those found with anti-DNS IgE and DNS-Lys. These findings are strikingly different from that expected for a rigid IgE bound to its receptor since in this case phi is likely to be very much larger. Evidently, the segmental flexibility of IgE is not greatly altered upon binding to its receptor.

Animals↗
PubMedDate not supplied

The miracle of DICE therapy for acute stroke: fact or fictional product of subgroup analysis?

OBJECTIVE: To determine whether inappropriate subgroup analysis together with chance could change the conclusion of a systematic review of several randomised trials of an ineffective treatment. DESIGN: 44 randomised controlled trials of DICE therapy for stroke were performed (simulated by rolling different coloured dice; two trials per investigator). Each roll of the dice yielded the outcome (death or survival) for that "patient." Publication bias was also simulated. The results were combined in a systematic review. SETTING: Edinburgh. MAIN OUTCOME MEASURE: Mortality. RESULTS: The "hypothesis generating" trial suggested that DICE therapy provided complete protection against death from acute stroke. However, analysis of all the trials suggested a reduction of only 11% (SD 11) in the odds of death. A predefined subgroup analysis by colour of dice suggested that red dice therapy increased the odds by 9% (22). If the analysis excluded red dice trials and those of poor methodological quality the odds decreased by 22% (13, 2P = 0.09). Analysis of "published" trials showed a decrease of 23% (13, 2P = 0.07) while analysis of only those in which the trialist had become familiar with the intervention showed a decrease of 39% (17, 2P = 0.02). CONCLUSION: The early benefits of DICE therapy were not confirmed by subsequent trials. A plausible (but inappropriate) subset analysis of the effects of treatment led to the qualitatively different conclusion that DICE therapy reduced mortality, whereas in truth it was ineffective. Chance influences the outcome of clinical trials and systematic reviews of trials much more than many investigators realise, and its effects may lead to incorrect conclusions about the benefits of treatment.

Bias↗
PubMedDate not supplied

Glasgow Outcome Scale: an inter-rater reliability study.

This study was set up to test the reliability of the Glasgow Outcome Scale (GOS) when information was obtained from different sources. Eighty assessments were carried out on a group of 58 patients at three different time intervals up to 24 months post-injury. Each assessment consisted of three independently obtained GOS scores for each patient; (i) a score by a research psychologist after interview and neuropsychological testing of the patient; (ii) a score, obtained by post, by the patient's general practitioner (GP), and (iii) a score made by a research worker based on questionnaire information obtained from relatives by post. The agreement between the psychologist's score and that based on the relatives' information was high (r = 0.79 p = 0.001) whereas the correlation between the psychologist's score and that of the GP was low (r = 0.49 p = 0.001). The GPs tended to make overoptimistic assessments and this was most notable at 6 months post-injury when only 50% of the GPs' assessments agreed with those of the psychologist. We have shown that reliability of the GOS varies with the method of obtaining data. Ideally patients should be interviewed and tested by staff who have not been involved in the acute care of the patient. Failing this, information should be obtained from relatives of the patient and used by staff, trained in the use of the GOS, to assign a GOS score.

Adolescent↗