Biomedical subjects
Publications and source records attributed to R Flynn.
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The high prevalence of thyroid dysfunction requires an efficient and effective means of monitoring and adjustment. We compared the current network of 12,524 patients with thyroid dysfunction with register data prior to 1991 to examine the precision of thyroxine replacement in patients with hypothyroidism and assess locally changing trends in treatment of hyperthyroidism. Since 1991, due to the associated adverse effects of a suppressed thyroid-stimulating hormone (TSH) (<0.03 mU/l), the network has facilitated a significant reduction in the proportion of thyroxine-treated patients with TSH suppression from 58.5% before 1991 to 9.2 +/- 3.8% thereafter. Since 1991, there has been an increased use of radioiodine by 14.3% [95% confidence interval (95% CI): 10.6-17.8] and a reduced use of thyroidectomy by 12.3% (95% CI: 8.8-15.8) to treat hyperthyroid patients compared with before 1991. Between the two treatments, there were no differences in subsequent rates of hypothyroidism or mean thyroxine dosage.
Addition of epinephrine to epidural anaesthetic solutions may enhance efficacy and duration of analgesia. We postulated that addition of epinephrine 5 microg.mL(-1) to epidural ropivacaine would improve efficacy, decrease systemic absorption and reduce neonatal effects. Twenty-one multiparous women were studied. An initial dose of ropivacaine 30 mg followed by an infusion of ropivacaine 10 mg.h(-1) was given via a lumbar epidural catheter. According to random allocation, epinephrine 5 microg.mL(-1) was added to ropivacaine. Ropivacaine concentrations were measured in maternal venous plasma after one hour of infusion and in both umbilical venous and maternal plasma at delivery. Neonatal neurologic and adaptive capacity score (NACS) tests were performed at 2 and 24 h postpartum. All women delivered vaginally. The groups had similar ropivacaine dose requirements, epidural-delivery intervals and satisfaction scores. Bromage scores for motor block were greater in the epinephrine group (2; range: 1-3) than controls (1; range: 0-2). Mean plasma ropivacaine concentrations (+/-SD) were less in the epinephrine group (0.17 +/- 0.05 mg.L(-1), n = 10) than controls (0.31 +/- 0.14 mg.L(-1), n = 11; P < 0.05) after one h of infusion but not at delivery. UV ropivacaine concentrations and NACS scores were similar in the two groups. The addition of epinephrine to ropivacaine decreases maternal plasma concentrations after one h of epidural infusion but also increases motor block.
This study was undertaken: (i) to quantify the effects of labour and epidural analgesia on plasma alpha1-acid glycoprotein concentration, (ii) to examine the effects of changes in plasma alpha1-acid glycoprotein concentration on plasma protein binding and placental transfer of ropivacaine, and (iii) to examine the association between umbilical venous ropivacaine concentration and neurobehavioural function in the neonate. Multiparous patients undergoing induction of labour received a continuous epidural infusion of 0.1% ropivacaine following an epidural bolus. A significant association was demonstrated between maternal plasma alpha1-acid glycoprotein concentration and 1/free fraction of ropivacaine 60 min after starting ropivacaine administration (r(2) = 0.77) but not at delivery. No significant correlation was demonstrable between maternal unbound ropivacaine concentration and either neonatal (cord) ropivacaine concentration or UV/MV (a measure of placental transfer). Thirty minutes after delivery, 9/10 neonates had neurological and adaptive capacity scores < 35, whereas only three infants had scores < 35 at 2 h. All scores exceeded 35 16 h after delivery. No association between mean (SD) umbilical venous ropivacaine concentration [0.09 (0.08) mg x l(-1)] and neurological and adaptive capacity scores was demonstrated.
This study investigated the contribution of psychological factors to disease progression among long-term HIV-1 infected gay men. Participants completed self-report measures including coping strategies, life events, social support, personality and psychological morbidity and were followed clinically for up to 30 months. Cox proportional hazards survival analyses were carried out to CD4<200 x 106/1 and AIDS-related complex (ARC) or AIDS diagnosis controlling for viral load, antiretroviral drug use and CD4 count. Only acceptance coping was a significant predictor of time to ARC or AIDS diagnosis: the risk of ARC or AIDS was almost 5 times greater for those scoring within the lowest tertile compared with those scoring in the highest tertile (HR=4.7, 95% CI 1.8-12.3).
PURPOSE: We assessed the urodynamic changes after pubovaginal sling procedure for stress incontinence, particularly in regard to the associated symptoms of urgency, frequency, nocturia and urge incontinence, known as the urge syndrome. MATERIALS AND METHODS: A total of 85 women with proved stress incontinence underwent a pubovaginal sling procedure using rectus fascia between 1992 and August 1996. Of the women 41 (48%) had undergone previous anti-incontinence surgery and 59 (69%) had the associated urge syndrome. There was at least some degree of hypermobility in 51 cases and type III stress incontinence was diagnosed in 34. Patients were assessed with a questionnaire and video urodynamics preoperatively and 3 months postoperatively. Preoperative and postoperative ambulatory studies were performed in 25 cases. RESULTS: Of the 85 patients 83 (97%) were symptomatically cured of stress incontinence. The urge syndrome resolved in 32 patients (69%), almost all of whom had a closed bladder neck at rest. Overall bladder neck incompetence at rest decreased from 57 to 18% (p<0.001). Of 27 patients with the persistent urge syndrome postoperatively 9 (41%) had an open bladder neck at rest compared to 4 of 50 (8%) without urge incontinence (p<0.01). Despite symptomatic control of stress incontinence in 83 patients (97%), only 66 were satisfied with the surgical result, mainly because of the persistent urge syndrome in 27. Despite care to avoid obstruction overall, there were statistically significant obstructive changes in detrusor pressure at maximum flow rate, maximum flow rate and residual urine volumes. CONCLUSIONS: The pubovaginal sling is effective in curing genuine stress incontinence and, when correctly placed at the right tension, the associated urge syndrome also can be managed, usually by achieving bladder neck closure at rest. However, despite careful maneuvers, obstruction occasionally persists.
The expansion of GP fundholding (GPFH) is central to the British government's attempt to maintain the revolution under way in the National Health Service (NHS). Evaluations of the NHS reforms have portrayed GPFH as an important mechanism for competition, and GPFH's bargaining power is reported to have secured significant changes in health service provision. However, these developments have been acknowledged to be less applicable in relation to community health services (CHS) than acute hospital services. On the basis of case studies of the process of contracting for CHS, GPFHs are shown to display ambivalent and sometimes contradictory views which have to be related to broader policy developments in general practice and primary care. Although this paper focuses on the British situation, many of the issues raised by reforms in primary and community health services have implications for developments in other Western health care systems.
Identification of the reasons for long-term survival in HIV infection is an area of current intense research. The objective of this study was to determine the perceptions among patients with different rates of disease progression as to the reasons for a good outcome with HIV. In a case-control study of 134 long-term (> or = 8 years) HIV-infected participants, 62 were defined as non-progressors; current CD4 cell count > or = 500 x 10(6)/L and asymptomatic or only mildly symptomatic. Two groups of control patients were identified: intermediate progressors who also had been HIV-infected for > or = 8 years, but whose current CD4 cell count was < 500 x 10(6)/L (n = 61), and a group of rapid progressors who had developed AIDS within 5 years of HIV infection (n = 11). Non-progressors were asked 'what do you feel are the reasons for your good outcome with HIV-infection?' and intermediate and rapid progressors were asked 'what do you feel are the reasons for a good outcome with HIV infection?'. Mental attitude, and in particular a positive outlook was the reason most frequently given for a good outcome among both non-progressors (NP) 42%, and progressors (P) 40%, followed by lifestyle measures and personal action (NP 31%, P 35%). Medical treatments such as anti-retroviral drugs were rarely suggested (< 3%). No significant differences were observed in the frequency of the different reasons given by non-progressors and progressors. The belief among our long-term HIV-infected individuals, that a positive outlook, lifestyle and personal action are important determinants of a good prognosis, is in sharp contrast to the biomedical model of disease progression that prevails among the medical and scientific research community.
OBJECTIVES: To assess, in men who were infected with the human immunodeficiency virus (HIV) and who identified themselves as having had sex with men; the nasopharyngeal prevalence of Neisseria gonorrhoeae, N meningitidis, Corynebacterium diphtheriae, and candida species; oral sexual behaviour; the relation between oral flora and oral sexual behavior. METHOD: Nasopharyngeal swabs were taken from HIV seropositive men for culture. The men were also asked to complete a self administered questionnaire. RESULTS: 390 men were recruited; 286 (73.3%) provided nasopharyngeal samples and questionnaires; 41 (10.5%) provided nasopharyngeal samples only; 63 (16.2%) provided questionnaires only. From the 327 nasopharyngeal samples N meningitidis was cultured in 49 (15%) and candida species in 165 (50.5%). Cultures for N gonorrhoeae and C diphtheriae were all negative. Data from the 349 completed questionnaires indicated that 285 men were practising oro-penile sex, over 90% did not consistently use condoms; 150 men were practising oro-anal sex, one used dental dams. In those providing both nasopharyngeal samples and sexual behaviour data meningococcal carriage was identified in 40 (17.5%) of the 228 men practising receptive oro-penile sex, compared with one (2.3%) of the 43 non-practisers (p < 0.025); in 21 (20%) of the 105 men practising insertive oro-anal sex, compared with 17 (12.5%) of the 136 non-practisers (p = 0.12). No correlation was identified between yeast carriage and oro-genital sex. CONCLUSION: Oro-genital sex, usually without barrier protection, is common among HIV infected men who have sex with men. It appears to be associated with increased meningococcal carriage but is autonomous to candida species isolation. Routine screening for nasopharyngeal N gonorrhoeae is not deemed necessary.
Acute gastric stress ulceration occurs frequently in severely ill patients. Mucosal ischemia is central to the etiology of stress ulceration. The ability of the mucosa to restore continuity when damaged is one of the most important of the local defence mechanisms against injury. The aims of this study were to investigate this restitutive process during stress ulcer formation and to determine the effect of prophylaxis against stress ulceration on gastric mucosal cell kinetics. Nuclear DNA was radiolabeled in vivo with tritiated thymidine, and after autoradiography the position and number of labeled cells along the gastric mucosal gland were determined. Wistar rats were studied immediately and 48 hr after cold restraint stress. The labeling index in the proliferative zone of the gastric mucosa was significantly suppressed immediately after stress (12.58% vs 16.81% for unstressed controls, P < 0.001). This effect persisted for 48 hr after stress (9.89% vs 16.35% for unstressed controls, P < 0.001). Prophylaxis against stress ulceration with cimetidine or allopurinol prevented this suppression of gastric mucosal cell kinetics and promoted early migration of labeled cells towards the surface of the mucosal gland. Allopurinol prophylaxis was associated with migration of mucosal cells immediately following stress greater than that following cimetidine prophylaxis (14.0% vs 9.3% surface layer labeling index, P < 0.01). Allopurinol, a xanthine oxidase inhibitor, reduces oxygen free radical production during ischemia reperfusion injury. These results emphasise the importance of the gastric mucosal defence mechanisms in protection against injury and indicate the role of ischemia in the aetiology of acute gastric stress ulceration.
An experiment was carried out to examine the effects of coffee on performance and alertness in the day and at night. The results showed that caffeinated coffee had a beneficial effect on alertness and improved performance on a variety of tasks in both day and night sessions. The effects were often very large. For example, at night, consumption of caffeinated coffee produced comparable alertness ratings to the day-time ratings given when juice was drunk. In contrast to the effects of caffeinated coffee, the difference between the decaffeinated coffee and juice were small and variable. Overall, these results clearly demonstrate the beneficial effects of consuming caffeinated coffee, and show that this effect is comparable in the day and night.
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The clinical effects and plasma levels associated with the use of 0.5% bupivacaine with and without the addition of 1:200,000 adrenaline (5 micrograms/ml) were studied in 30 patients who underwent extradural anaesthesia for elective Caesarean section. The addition of adrenaline to bupivacaine prolongs analgesia, reduces the degree of hypotension and delays its onset. Plasma bupivacaine levels were consistently lower when adrenaline was added, but this difference was significant only at 10 minutes after the initial dose. Prolonging the interval between increments seems to be a more reliable way to reduce plasma concentration than the addition of the catecholamine.
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Severe acute meningitis developed after the use of metrizamide for lumbar myelography; cerebrospinal fluid findings included a white blood cell count of 2300, mostly polymorphonuclear cells, glucose level of 8 mg% and protein level of 253%. This apparent chemical meningitis could not be distinguished, either clinically or by cerebrospinal fluid examination, from acute bacterial meningitis. This case emphasizes that severe acute meningeal reactions, while very rare, can occur after the use of metrizamide for myelography. Such patients must be evaluated promptly to rule out bacterial meningitis and should be followed carefully for possible later sequelae.
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