Nanocrystalline silver dressings as an efficient anti-MRSA barrier: not a new solution to an increasing problem?
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Bandages↗
Biomedical subjects
L Dunn
Publications and source records attributed to L Dunn.
Family practice-friendly guidelines. Anti-infective guidelines (1994-2005).
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Anti-Infective Agents↗
Assessment of different data representations and averaging methods on the Spiegelberg compliance device.
The Spiegelberg Compliance Device (Spiegelberg KG, Hamburg, Germany) has been available for the automated measurement and calculation of minute by minute intracranial compliance. Widespread practical use has been somewhat limited by the instability of values: especially at low intracranial pressures. We looked at two aspects of a methodology in an attempt to increase the value of the Spiegelberg device in the clinical setting. Firstly, we discussed the difference in representing measured values as elastance (dp/dv) instead of compliance (dv/dp); and secondly we proposed the use of an averaging algorithm called the Exponentially Weighted Moving Average (ewma), which could be applied as a flexible method to follow trends and rapid changes in the elastance (or compliance). Clinical data from sixteen patients were gathered and statistical analysis was focused on three particular aspects, the coefficient of variation which indicates the variability of data values, the correlation between the elastance (or compliance) time series and the underlying ICP signal and the percentage of outliers greater than 2.5 standard deviations from the mean. Our results showed that expressing elastance (dp/dv) instead of compliance (dv/dp) yielded fewer outliers and had a better correlation to ICP, and the ewma method had a better correlation to ICP than the Spiegelberg method.
Adult↗
Aciclovir or valaciclovir for Bell's palsy (idiopathic facial paralysis).
BACKGROUND: The most common disorder of the facial nerve is acute idiopathic facial paralysis or Bell's palsy and there may be significant morbidity or incomplete recovery associated with severe cases. OBJECTIVES: To assess the efficacy of aciclovir or similar agents for treating Bell's palsy. SEARCH STRATEGY: We searched the Cochrane Neuromuscular Disease Group register (searched April 2003), MEDLINE (from January 1966 to April 2003), EMBASE (from January 1980 to April 2003) and LILACS (from January 1982 to April 2003). We also contacted authors of identified trials. SELECTION CRITERIA: Randomised or quasi-randomised trials of aciclovir or valaciclovir therapy, alone or in combination with any other drug, in patients with Bell's palsy. DATA COLLECTION AND ANALYSIS: We identified six randomised trials. MAIN RESULTS: Three studies met our inclusion criteria, including 246 patients. One study evaluated aciclovir with corticosteroid versus corticosteroid alone, another study evaluated aciclovir alone versus corticosteroid and a further study evaluated valaciclovir with corticosteroid versus corticosteroid alone or versus placebo alone. Incomplete recovery after one year: data were not available. An analysis was performed on data reported at the end of the study period in each trial. The results from one study four months after the start of treatment significantly favoured the treatment group, whilst the results of the study three months after the start of treatment significantly favoured the control group. The results from the second study at four months showed no statistically significant difference between the three groups. Adverse events: relevant data were not reported in any of the three trials. Complete facial paralysis six months after start of treatment: only one patient had complete paralysis upon entering one of the studies. This patient was assigned to the control group and the level of recovery attained was not reported. Motor synkinesis or crocodile tears one year after start of treatment: data were available up to a maximum of four months after onset of paralysis. One study reported a significant difference between the treatment groups in favour of the aciclovir plus corticosteroid group over corticosteroid alone, another demonstrated an inconclusive result with no difference between the aciclovir and corticosteroid. The third study did not comment upon these sequelae. REVIEWERS' CONCLUSIONS: More data are needed from a large multicentre randomised controlled and blinded study with at least 12 months' follow up before a definitive recommendation can be made regarding the effect of aciclovir or valaciclovir on Bell's palsy.
Acyclovir↗
Social deprivation and adult head injury: a national study.
OBJECTIVES: To establish the association between measures of social deprivation, mechanisms of injury, patterns of care, and outcome following closed head injury. METHODS: All Scottish adult A&E attendees with closed head injury (AIS Head > or =3) between July 1996 and December 2000 were studied. RESULTS: Trauma was more common in individuals from more deprived areas. Within the trauma population head injury was relatively more common in patients from deprived areas; these individuals were more likely to sustain an isolated head injury as a result of an assault. Admission GCS was higher and normal physiology (as assessed by the RTS) was more common in individuals from more deprived areas. Recorded co-morbidity was similar between the two groups with the exception of a history of alcohol or substance abuse which was more common among patients from more deprived areas. Similar proportions of patients from more deprived and less deprived areas were transferred to the Regional Neurosurgical Centre. For patients who were transferred directly from A&E, time to neurosurgical theatre was similar for both groups. Length of hospital and ITU stay was less in patients from more deprived areas. After adjusting for known predictors of outcome using logistic regression analysis, there was no significant difference in mortality between patients from more deprived and less deprived areas. CONCLUSIONS: Residing in a more deprived area is not associated with increased mortality from head injury among adults in Scotland. It is associated with different patterns of injury and a different process of care following presentation to hospital.
Abbreviated Injury Scale↗
Multi-centre assessment of the Spiegelberg compliance monitor: interim results.
Analyses of a multi-centre database of 71 patients at risk of raised ICP showed that in head injured patients (n = 19) and tumour patients (n = 13) clear inverse relationships of ICP vs compliance exist. SAH patients (n = 5) appear to exhibit a biphasic relationship between ICP and compliance, however greater numbers of patients need to be recruited to this group. Patients with hydrocephalus (n = 34) show an initial decrease in compliance while ICP is less than 20 mmHg, thereafter compliance does not show a dependence upon ICP. A power analysis confirmed that sufficient numbers of patients have been recruited in the hydrocephalus group and a ROC analysis determined that a mean compliance value of 0.809 (lower and upper 95% CL = 0.725 & 0.894 resp.) was a critical threshold for raised ICP greater than 10 mmHg. Preliminary time-series analyses of the ICP and compliance data is revealing evidence that the cumulative time compliance is in a low compliance state (< 0.5 ml/mmHg), as a proportion of total monitoring time, increases more rapidly than the cumulative time ICP is greater than 25 mmHg. Before trials testing compliance thresholds can be designed, we need to consider not just the absolute threshold, but the duration of time spent below threshold. A survey may be required to identify a consensus of what is the minimum duration of raised ICP above 25 mmHg needed to instigate treatment.
Automation↗
"Normal pressure hydrocephalus": what's in a name?
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Humans↗
Tolerance or immunity to a tumor antigen expressed in somatic cells can be determined by systemic proinflammatory signals at the time of first antigen exposure.
Mice transgenic for the E7 tumor Ag of human papillomavirus type 16, driven from a keratin 14 promoter, express E7 in keratinocytes but not dendritic cells. Grafted E7-transgenic skin is not rejected by E7-immunized mice that reject E7-transduced transplantable tumors. Rejection of recently transplanted E7-transgenic skin grafts, but not of control nontransgenic grafts or of established E7-transgenic grafts, is induced by systemic administration of live or killed Listeria monocytogenes or of endotoxin. Graft recipients that reject an E7 graft reject a subsequent E7 graft more rapidly and without further L. monocytogenes exposure, whereas recipients of an E7 graft given without L. monocytogenes do not reject a second graft, even if given with L. monocytogenes. Thus, cross-presentation of E7 from keratinocytes to the adaptive immune system occurs with or without a proinflammatory stimulus, but proinflammatory stimuli at the time of first cross-presentation of Ag can determine the nature of the immune response to the Ag. Furthermore, immune effector mechanisms responsible for rejection of epithelium expressing a tumor Ag in keratinocytes are different from those that reject an E7-expressing transplantable tumor. These observations have implications for immunotherapy for epithelial cancers.
Animals↗
Aciclovir for Bell's palsy (idiopathic facial paralysis).
BACKGROUND: The most common disorder of the facial nerve is acute idiopathic facial paralysis or Bell's palsy and there may be significant morbidity or incomplete recovery associated with severe cases. Although the cause remains unknown, recent evidence suggests a possible association with Herpes simplex virus (HSV) infection. To test this hypothesis clinically four clinical trials have used aciclovir, an antiviral agent, either alone or in combination with corticosteroids to treat Bell's palsy. OBJECTIVES: To assess the efficacy of aciclovir for treating Bell's palsy and to evaluate any adverse effects of the drug treatment. SEARCH STRATEGY: Search of the Cochrane Neuromuscular Disease Group register, MEDLINE, EMBASE and LILACS databases for randomised trials. We also contacted authors of identified trials. SELECTION CRITERIA: Randomised or quasi-randomised trials of aciclovir therapy, alone or in combination with any other drug, in patients with Bell's palsy. DATA COLLECTION AND ANALYSIS: We identified four randomised trials. One author extracted the data and the other checked them. We wrote to all the authors of the trials identified. No additional data were obtained. MAIN RESULTS: Only two studies met our inclusion criteria and provided results from 200 patients. One study evaluated aciclovir with corticosteroid versus steroid alone and the other study evaluated aciclovir alone versus corticosteroid. PRIMARY OUTCOME Proportion of patients with incomplete recovery after one year: These data were not available. However an analysis was performed on data reported at the end of the study period, three (De Diego 1998) or four months (Adour 1996) after the start of treatment. The results from the Adour study significantly favoured the treatment group whilst the De Diego study significantly favoured the control group. Adverse events: This analysis was not performed as the data were not reported. Complete facial paralysis six months after start of treatment: Only one patient had complete paralysis upon entering only one of the studies (De Diego 1998). This patient was assigned to the control group and the level of recovery attained was not reported. Motor synkinesis/Crocodile tears one year after start of treatment: Data were available up to a maximum of four months after onset of paralysis. One study reported a significant difference between the treatment groups in favour of the aciclovir group and the other demonstrated an inconclusive result. REVIEWER'S CONCLUSIONS: More data are needed from a large multicentre randomised controlled and blinded study with at least 12 months' follow up before a definitive recommendation can be made regarding the routine use of aciclovir in Bell's palsy.
Acyclovir↗
A model of acute subdural hematoma in the mouse.
The availability of genetically modified mice has allowed the study of genetic influences on acute brain injury. An animal model of acute subdural hematoma (ASDH) has been previously described in the rat but not the mouse. We describe a method for producing ASDH in the mouse. Subdural injections of 50 and 30 microL of nonheparinized autologous blood were associated with excessive mortality. Injections of 10 and 20 microL were associated with mean percentage volumes of damage of 1.804% and 4.019%, respectively. Sham subdural injections of saline were associated with minimal hemisphere damage (0.152%). This mouse model provides a means of investigating the effects of genotype on the brain's response to ASDH.
Animals↗
The Camino intracranial pressure sensor: is it optimal technology? An internal audit with a review of current intracranial pressure monitoring technologies.
OBJECTIVE: To audit the reliability of the Camino intracranial pressure (ICP) sensor (Camino Laboratories, San Diego, CA) in our clinical practice as part of a continuing quality assurance program, and to assess its relative usefulness as compared with currently available ICP monitoring technologies that we reviewed. DESIGN: Prospective audit of ICP device reliability and function in 50 patients with head injuries. METHODS: Zero drift was recorded immediately after the ICP device was removed from the patient. Dynamic frequency response bench testing of each functioning catheter from 0 to 30 Hz and static calibration testing from 0 to 100 mmHg during environmental temperature variation from 22 to 40 degrees C were carried out. RESULTS: Zero drift (range, -13 to 22 mmHg; median, -1 mmHg) was recorded immediately after the devices were removed from patients. Seventeen (50%) of the devices tested for zero drift had absolute drifts of at least 3 mmHg. There was no correlation between recorded zero drift and duration of monitoring (r = 0.154, P = 0.207). Five sensors (10% of those tested) failed during patient monitoring and were replaced. Static and dynamic calibration tests of the functioning sensors were within the manufacturer's specifications. However, the sensitivity of the devices to environmental temperature remains a problem. CONCLUSION: The Camino ICP sensor remains one of the most popular ICP monitoring devices for use in patients with traumatic brain injuries. However, our recent in-house assessment demonstrated the robustness of the device to be less than adequate during routine practice. In this study, more than 50% exhibited zero drift greater than 3 mmHg, which is unacceptable in a catheter tip ICP monitoring device in which zero drift and calibration cannot be checked in vivo. A review of the literature revealed that other available ICP monitoring devices may prove to be more reliable and thus more appropriate for routine clinical measurement of ICP.
Equipment Design↗
How the media do drugs: quality control and the reporting of drug issues in the UK print media.
Exaggeration, distortion, inaccuracy, sensationalism; each of these labels has been consistently applied to the reporting of drug related issues in the print and other media over the last 40 years and beyond. This research sought to understand what quality control mechanisms are employed by the UK print media in relation to issues related to illicit drugs to ensure accurate, informed and appropriate reporting. It was found that the print media in the UK employ almost no quality control mechanisms to ensure that such reporting takes place and that they predominately rely on the demonstrably insufficient qualities of the 'good reporting' skills that journalists bring to their research and writing. What concerns did exist regarding accuracy related predominately to protecting the publication from being sued for libel and no specific journalistic expertise of drug issues was considered necessary. A discussion of these issues is undertaken followed by the recommendation for the production of a negotiated media guide.
Journal Article↗
Non-steroidal anti-inflammatory drugs for preventing heterotopic bone formation after hip arthroplasty.
BACKGROUND: Heterotopic bone formation (HBF) in the soft tissues surrounding the hip joint is a frequent complication of hip surgery. Non-steroidal anti-inflammatory drugs (NSAIDs) administered in the immediate perioperative period reduce the risk of HBF. However, the magnitude of the effect on HBF, and the effects on other associated outcomes are uncertain. OBJECTIVES: To determine the effects of perioperative NSAID therapy versus control on the risk of HBF and other outcomes in patients undergoing hip arthroplasty. SEARCH STRATEGY: Medline, Current Contents and Cochrane Controlled Trials Register, and reference lists of all relevant reports were searched. Principal investigators and the manufacturers of the study drugs of eligible trials were approached. The most recent search was conducted in July 1998. SELECTION CRITERIA: All trials which enrolled patients scheduled to undergo hip arthroplasty with random or quasi-random allocation to perioperative NSAID or control and that recorded post-operative radiographically determined HBF. The primary outcome was post-operative radiographic HBF. Secondary outcomes were pain, disability, gastro-intestinal and other bleeding complications, and other causes of major morbidity or mortality. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed methodological quality and extracted data. All analyses were conducted on dichotomised outcomes. MAIN RESULTS: Twelve randomised and two quasi-randomised trials involving a total of 4,377 patients were included. Overall, in 13 trials that examined the effects of medium to high doses of NSAIDs, there was a reduced risk of developing HBF after hip surgery (62% reduction, 95% confidence interval 56% to 67% reduction). In contrast, one large trial examining low-dose aspirin, demonstrated no effect on the risk of HBF (2% reduction, 95% confidence interval 15% reduction to 12% increase). There was strong evidence of differences in the size of the treatment effects observed between the trials examining medium to high doses of NSAIDs, but reasons were not clearly identified. There was a non-significant one third increased risk of gastro-intestinal side effects among patients assigned NSAIDs (29% increase, 95% confidence interval 5% reduction to 76% increase). Most of this increase was due to an increased risk of minor gastro-intestinal complications. Data on the late post-operative outcomes of pain, impaired physical function and range of joint movement were few and no formal overviews of the effects of NSAIDs on these outcomes were possible. REVIEWER'S CONCLUSIONS: Perioperative NSAIDs appear to produce between a one half and two thirds reduction in the risk of HBF. With routine use, such agents may be able to prevent 15-20 cases of HBF (3-4 severe) among every 100 total hip replacements performed. However, while medium to high doses of perioperative NSAIDs clearly produce a substantial reduction in the incidence of radiographic HBF, there remains some uncertainty about short-term side effects of treatment and substantial uncertainty about effects on long-term clinical outcomes such as chronic pain and impaired physical function. The net effect of routine HBF prophylaxis with NSAIDs requires formal assessment in a randomised trial designed to determine the balance of benefits and risks for all outcomes.
Anti-Inflammatory Agents, Non-Steroidal↗
Multi-centre assessment of the Spiegelberg compliance monitor: preliminary results.
Acute brain injury states (e.g. head injury, subarachnoid haemorrhage) show clear inverse relationships of ICP vs compliance, with ICP instability at times of lower compliance states. Variance in compliance values is large in hydrocephalus where ICP is relatively lower and compliance higher. Nonetheless, early experience shows that compliance data influence decisions on CSF diversion treatments. Future work will focus on the ability of intracranial compliance to predict ensuing ICP instability and methodological refinement for monitoring patients who have higher compliance states.
Brain↗
Assessment of the variation in cerebrovascular reactivity in head injured patients.
Several indices have been reported which correlate with autoregulatory function [2, 3]. However, before critical thresholds for targeting therapy can be defined, a better understanding of the inherent variability of cerebrovascular reactivity as measured by these indices is required. In this study, patients had BP, ICP and bilateral MCA TCD velocity monitored before, during and after BP and CO2 challenges, applied in a random order, with measurements taken within 48 hours of injury. Four indices of reactivity were calculated: the PRx, the CORRx and the FVreact & ICPreact. At 48 hours post-injury inter-patient variation in cerebrovascular reactivity, as measured by these indices, is large and injury specific factors remain important determinants of the variance. Within patient analysis has identified instances where the combined monitoring of the PRx and the CORRx may provide information about the function of pressure autoregulation and further study of the combined use of these two indices of reactivity is warranted.
Adolescent↗
A systematic survey of 13 randomized trials of non-steroidal anti-inflammatory drugs for the prevention of heterotopic bone formation after major hip surgery.
We performed a systematic survey of randomized trials to determine the effects of perioperative NSAIDs on the occurrence of heterotopic bone formation, gastrointestinal side-effects and long-term clinical outcomes after major hip surgery. 13 trials involving 4,129 individuals were identified. Overall, in 12 small trials of medium-to-high-dose regimens, there was a 57% reduction (95% confidence interval 51%-63%) in the risk of heterotopic bone formation. The results of one large trial of low-dose aspirin differed markedly (2% reduction (95% CI 12% reduction to 15% increase)). The NSAID regimens studied had no definite effect on gastrointestinal complications, and data about the effects of NSAIDs on pain and function were too few, and too incompletely reported, to draw conclusions about their effects on these outcomes. Routine prophylaxis against heterotopic bone formation with NSAIDs may be a useful adjuvant therapy for patients undergoing major hip surgery, but the overall balance of risks and benefits requires assessment in a large-scale randomized trial.
Anti-Inflammatory Agents, Non-Steroidal↗
Pilot study for appropriate anti-infective community therapy. Effect of a guideline-based strategy to optimize use of antibiotics.
OBJECTIVE: To determine whether a community-wide, multi-intervention educational strategy (CoMPLI model) could enhance adoption of clinical guidelines and improve the use of antibiotics. DESIGN: Before-after trial using baseline and study periods with a control group. SETTING: A small community in central Ontario. PARTICIPANTS: Health professionals, the general public, and the pharmaceutical industry. INTERVENTIONS: The educational strategy (CoMPLI), carried out during 6 winter months, consisted of continuing medical education sessions for health professionals and pharmaceutical representatives and a parallel public education campaign that included town hall meetings and pamphlets distributed by local pharmacists. The two main messages were: do not use antibiotics for viral respiratory infections, and use drugs recommended in the publication, Anti-infective Guidelines for Community-Acquired Infections. MAIN OUTCOME MEASURES: Total number of antibiotic claims and adjusted odds ratios (OR) were used to measure the likelihood of physicians prescribing first- or second-line agents compared with the previous year and compared with control physicians. RESULTS: Claims in the study community decreased by nearly 10% during the 6-month study period compared with the baseline period from the previous year. Study physicians were 29% less likely (OR-1 = 0.71, range 0.67 to 0.76) to prescribe second-line antibiotics during the study period than physicians in the rest of the province. CONCLUSIONS: Physicians participating in the pilot study were more likely to follow drug recommendations outlined in published guidelines.
Adult↗