Biomedical subjects
M J Clancy
Publications and source records attributed to M J Clancy.
Clearing the cervical spine of paediatric trauma patients.
OBJECTIVES: To review the evidence available for clearance of the cervical spine in children under 16 years of age after trauma, and to provide guidance to enable this to be practised safely. METHODS: A comprehensive literature review was carried out, and combined with a review of standard texts and liaison with experts. RESULTS: 241 papers were identified, of which 71 papers were thought possibly relevant. These were obtained and appraised. Children in whom there is concern about possible cervical spine injury may be divided into three groups. Alert, asymptomatic children with a normal examination may be clinically cleared without need for radiology. Children with cervical spine symptoms or signs require plain radiology in the first instance. Those areas that are poorly visualised or suspicious should be discussed with a paediatric radiologist and are likely to undergo computed tomography. Children with impaired conscious level require careful evaluation. Plain radiology, if normal, can be usefully complemented by early magnetic resonance imaging to exclude ligamentous and spinal cord damage. CONCLUSIONS: There is limited evidence to guide clinicians on how to clear the paediatric cervical spine. The approach suggested is similar to adult recommendations made elsewhere, and the differences are highlighted.
Laryngopharyngeal pH measurement.
OBJECTIVES: Most emergency department (ED) intubations are to prevent gastric contents aspiration. The incidence of aspiration is unknown and intubation has complications. Balancing these risks requires an idea of the incidence of aspiration. This study assessed one technique for investigating the aspiration risk in ED patients. Cricoid pressure is used to reduce this risk and the technique may also examine this manoeuvre. METHODS: Cohorts of unconscious adult ED and elective surgical patients were recruited. The posterior pharyngeal wall pH was measured immediately before and after intubation. Pharyngeal pH was used to indicate risk of aspiration, and pH change to assess the efficacy of cricoid pressure. RESULTS: Eight ED and 48 control patients were recruited. In the ED cohort, pH ranged from 6.0 to 8.0 before intubation and 4.7 to 8.0 after intubation: a mean decrease of 0.3 (95% CI 1.5 decrease to 0.9 increase). In the control cohort pH ranged from 5.8 to 8.0 before intubation and 6.0 to 8.0 after intubation: a mean increase of 0.4 (95% CI 0.1 to 0.6 increase). CONCLUSIONS: This is a simple, cheap, and repeatable technique for assessing aspiration risk in emergency intubations. A larger study is required to assess the efficacy of cricoid pressure.
What is the patient's best telephone number?
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A new way of demonstrating how close the evidence is to the question you asked.
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Tube migration causing gastric outlet obstruction: an unusual complication of percutaneous endoscopic gastrostomy.
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Bronchoscopic removal of an inhaled, sharp, foreign body: an unusual complication.
A case is reported in which an inhaled sewing needle, stuck fast in the trachea, became displaced through the tracheal wall during attempted removal via flexible bronchoscopy. The inherent risks and pitfalls of this procedure are highlighted.
Clearing the cervical spine of adult victims of trauma.
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Use of the Cochrane Library by emergency physicians.
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Should UK emergency physicians undertake diagnostic ultrasound examinations?
From the published evidence there is no doubt that emergency physicians in America can undertake focused ultrasound examinations and that, by extrapolation, this would also be the case for UK emergency physicians. If this skill is to become part of the diagnostic armamentarium of the emergency physician, however, it needs to be demonstrated to be cost effective compared with the alternatives already available to the hospital. Trials to test for this benefit should adopt a hospital and not an emergency department perspective if the results are to influence health policy and specialty training.
How to conduct an appraisal of a senior house officer.
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Point of care testing in the accident and emergency department: a cost analysis and exploration of financial incentives to use the technology within the hospital.
OBJECTIVES: To compare the costs of current arrangements for testing emergency blood samples from patients attending an accident and emergency (A&E) department in a large teaching hospital in England with point of care testing (POCT). METHODS: Estimates were made of the fixed and variable costs of two options: a supplemental option, in which POCT was introduced to A&E only; and a replacement option, in which POCT was introduced to A&E and the intensive therapy unit (ITU), thereby entirely replacing an existing process. RESULTS: For the supplemental option, current arrangements cost 68,466 Pounds in total per year; average costs per test were 5.53 Pounds (venous in the central laboratory) and 3.60 Pounds (arterial on the ITU). Introducing POCT would increase total hospital costs by 35,929 Pounds, and average costs per test would be 5.32 Pounds (venous) and 4.28 Pounds (arterial). For the replacement option, current arrangements cost 132,630 Pounds in total, and average cost per test (for all tests) was 4.06 Pounds. Introducing POCT would make hospital savings ranging from 8332 Pounds to 20,000 Pounds, and average cost per test would be 3.78 Pounds. CONCLUSIONS: Introducing POCT results in lower average costs per test. The supplemental option will result in significantly increased costs to the hospital. The replacement option can lead to significant savings. The internal cross-charging arrangements between departments that exist in this hospital may mean that supplemental implementation of POCT could be potentially 'profitable' for the A&E department, but would result in higher expenditure for the hospital as a whole.
Meiosis: step-by-step through sporulation.
A transcription factor, Ndt80p, has been identified that has a critical role in the pathway that controls meiosis--sporulation--in budding yeast. Ndt80p coordinately controls genes that mediate spore formation and progression through the two meiotic divisions; it may also be a target of a checkpoint control.
Research in accident and emergency medicine.
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The S. cerevisiae nitrogen starvation-induced Yvh1p and Ptp2p phosphatases play a role in control of sporulation.
Starvation for nitrogen in the absence of a fermentable carbon source causes diploid Saccharomyces cerevisiae cells to leave vegetative growth, enter meiosis, and sporulare; the former nutritional condition also induces expression of the YVH1 gene that encodes a protein phosphatase. This correlation prompted us to determine whether the Yvh1p phosphatase was a participant in the network that controls the onset of meiosis and sporulation. We found that expression of the IME2 gene, encoding a protein kinase homologue required for meiosis- and sporulation-specific gene expression, is decreased in a yvh1 disrupted strain. We also observed a decrease, albeit a smaller one, in the expression of IME1 which encodes an activator protein required for IME2 expression. Under identical experimental conditions, expression of the MCKI and IME4 genes (which promote sporulation but do not require Ime1p for expression) was not affected. These results demonstrate the specificity of the yvh1 disruption phenotype. They suggest that decreased steady-state levels of IME1 and IME2 mRNA were not merely the result of non-specific adverse affects on nucleic acid metabolism caused by the yvh1 disruption. Sporulation of a homozygous yvh1 disruption mutant was delayed and less efficient overall compared to an isogenic wild-type strain, a result which correlates with decreased IME1 and IME2 gene expression. We also observed that expression of the PTP2 tyrosine phosphatase gene (a negative regulator of the osmosensing MAP kinase cascade), but not the PTP1 gene (also encoding a tyrosine phosphatase) was induced by nitrogen-starvation. Although disruption of PTP2 alone did not demonstrably affect sporulation or IME2 gene expression, sporulation was decreased more in a yvh1, ptp2 double mutant than in a yvh1 single mutant; it was nearly abolished in the double mutant. These data suggest that the YVH1 and PTP2 encoded phosphatases likely participate in the control network regulating meiosis and sporulation. Expression of YVH1 and PTP2 was not affected by nitrogen source quality (asparagine compared to proline) suggesting that nitrogen starvation-induced YVH1 and PTP2 expression and sensitivity to nitrogen catabolite repression are on two different branches of the nitrogen regulatory network.
Volumetric flow estimation in vivo and in vitro using pulsed-Doppler ultrasound.
The measurement of volumetric blood flow in small vessels in vitro and in vivo poses a significant technological challenge. In this study, two pulsatile flow models were developed, one with a 3.2-mm lumen diameter and one with a 12.7-mm lumen diameter, to assess the accuracy of volumetric flow estimation of two pulsed-Doppler devices, a Crystal Biotech VF1 20-MHz system with either a cuff-mounted or a needle-mounted probe and an Advanced Technology Laboratories Ultramark 9 High Definition Imaging system with a 5-MHz linear array transducer. The VF1 volumetric flow error was measured in the 3.2-mm phantom over a variety of pulsatile and continuous waveforms. The accuracy of the VF1 was also tested in porcine femoral and renal arteries. VF1 volumetric flow error ranged from 4.8% to 54.3% in the in vivo studies. The ATL demonstrated similar volumetric flow errors in the porcine femoral artery (approximately 3.2 mm diameter), but these errors were reduced to < or = 17.4% in the 12.7-mm-diameter in vitro flow model.