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Biomedical subjects

R Hart

Publications and source records attributed to R Hart.

At least 55 records · Page 3Linked to original sources
PubMed2000

Nonoperative management of dens fracture nonunion in elderly patients without myelopathy.

STUDY DESIGN: A retrospective review of elderly patients treated without surgery for chronic mobile nonunions of the odontoid process. Patients were observed on an annual basis with clinical examinations and flexion/extensions plain film radiographs. OBJECTIVES: To evaluate the clinical and radiographic results of elderly patients without myelopathy treated without surgery for dens fracture nonunion. SUMMARY OF BACKGROUND DATA: Because of the risk of progressive myelopathy or sudden neurologic injury, many surgeons recommend operative stabilization for patients with mobile dens nonunions who are able to withstand an operation. There is, however, a lack of information about the radiographic and neurologic progression of dens nonunions. Although a less aggressive surgical approach has been recommended by some authors for elderly or medically compromised patients with acute fractures, long-term follow-up evaluation of patients with resulting nonunions has not been reported. METHODS: A series of elderly patients with chronic, unstable, dens nonunions without myelopathy were treated with a nonoperative treatment protocol. Patients were informed of the nature of their lesion, including the risk of acute or chronic spinal cord injury and the options for operative treatment. Patients were evaluated yearly for clinical and radiographic progression. No intervention to slow progression of atlantoaxial instability was undertaken. RESULTS: None of the patients developed myelopathic symptoms during the follow-up period, and no patient experienced more than a 1 mm radiographic increase in atlantoaxial excursion. None of the reported patients had less than 14 mm available for the spinal cord in either flexion or extension at the start of clinical monitoring. CONCLUSIONS: Although further follow-up evaluation is needed, the authors believe on the basis of this review that this treatment protocol may be considered for patients who are poor candidates for surgical fusion.

Aged↗
PubMed2000

Topical treatments for fungal infections of the skin and nails of the foot.

OBJECTIVES: The objective of this review is to identify and evaluate the evidence of efficacy for topical treatments for fungal infections of the skin and nails of the human foot. To establish the effectiveness of topical treatments in achieving a cured condition and in preventing recurrence SEARCH STRATEGY: Randomised controlled trials were identified from the MEDLINE, EMBASE and CINHAL databases, from the beginning of these databases to December 1997. Also we screened the Cochrane Controlled Trials Register, the Science Citation Index BIOSIS, CAB - Health, Healthstar and Economic databases. References and unpublished studies were searched, podiatry journals handsearched and the pharmaceutical industry contacted. SELECTION CRITERIA: Only randomised controlled trials (RCTs) using participants who have mycologically diagnosed fungal infections of the skin and nails of the human foot are included in the analysis. DATA COLLECTION AND ANALYSIS: Two reviewers independently summarised the included trials and appraised their quality of reporting using a structured data extraction tool which assessed 12 quality criteria. MAIN RESULTS: Of 126 trials identified in 121 papers, 72 met the inclusion criteria. Placebo-controlled trials yielded the following pooled relative risks of failure to cure (RRFC) for skin infections: allylamines 0.30 (95% confidence interval 0.23 to 0.37); azoles 0.53 (0.42 to 0.68); undecenoic acid 0.28 (0.11 to 0.74); tolnaftate 0.46 (0.17 to 1.22). Though meta-analysis of 11 trials comparing allylamines and azoles showed an RRFC of 0.88 (0.78 to 0.99) in favour of allylamines, there was evidence of language bias. Seven English language reports favoured allylamines (RRFC = 0.79; 0.68 to 0.93) but four foreign language reports showed no difference between the two drugs (RRFC = 1.00; 0.90 to 1.12). The two trials of nail infections did not provide any evidence of benefit for topical treatments compared with placebo. REVIEWER'S CONCLUSIONS CONCLUSIONS: In placebo-controlled trials allylamines, azoles and undecenoic acid were efficacious. There are sufficient comparative trials to judge relative efficacy only between allylamines and azoles. Allylamines cure slightly more infections than azoles but are much more expensive. The most cost-effective strategy is first to treat with azoles or undecenoic acid and to use allylamines only if that fails.

Administration, Topical↗
PubMed2000

Antiplatelet therapy for preventing stroke in patients with non-valvular atrial fibrillation and no previous history of stroke or transient ischemic attacks.

BACKGROUND: Atrial fibrillation (AF) carries an increased risk of stroke; antiplatelet agents are proven effective for stroke prevention in other settings. OBJECTIVES: The objective of this review was to determine the efficacy and safety of antiplatelet therapy for prevention of stroke in patients with chronic non-valvular AF. SEARCH STRATEGY: We searched the Cochrane Stroke Group Specialised Register of Trials, MEDLINE database (June 1999), and the database of the Antithrombotic Trialists Collaboration, as well as reference lists of relevant articles. SELECTION CRITERIA: All randomized trials comparing antiplatelet therapies to placebo in patients with non-valvular AF and no history of transient ischemic attack (TIA) or stroke. DATA COLLECTION AND ANALYSIS: Trials for inclusion were independently selected by two reviewers who also extracted each outcome and double-checked the data. The Peto method was used for combining odds ratios. All analysis were, as far as possible, "intention-to-treat". Since the published results of two trials included 3-8% of participants with prior stroke or TIA, unpublished results excluding these participants were obtained from the Atrial Fibrillation Investigators. MAIN RESULTS: Among 1680 participants without prior stroke/TIA, randomized to aspirin (N = 838) or placebo in two trials, aspirin was associated with nonsignificantly lower risks of ischemic stroke (OR = 0.71, CI 95% 0. 46 - 1.10), all stroke (OR = 0.70, CI 95% 0.45 - 1.08) all disabling/fatal stroke (OR =0.88, CI 95% 0.48 - 1.58) and the constellation of stroke, MI or vascular death (OR = 0.76, CI 95% 0. 54 - 1.05 ). Considering all randomized participants including those with prior stroke or TIA, reductions in these events by aspirin were consistently smaller and marginally statistically significant: ischemic stroke (OR = 0.77, CI 95% 0.60-1.00), all stroke (OR = 0.76, CI 95% 0.61 - 0.93), all disabling/fatal stroke (OR = 0.87, CI 95% 0.64 - 1.19) and the combined outcome (OR = 0.79, CI 95% 0.64 - 0. 99). No increase in major hemorrhage was seen, but the number of hemorrhagic events was small. REVIEWER'S CONCLUSIONS: Considering all randomized data, aspirin modestly (by about 20%) reduces stroke and major vascular events in nonvalvular AF. For primary prevention among AF patients with an average stroke rate of 4.5%/year, about 10 strokes would be prevented yearly for every 1000 given aspirin.

Atrial Fibrillation↗
PubMed2000

Oral anticoagulants for preventing stroke in patients with non-valvular atrial fibrillation and no previous history of stroke or transient ischemic attacks.

BACKGROUND: Non-valvular atrial fibrillation (AF) is associated with an increased risk of stroke. OBJECTIVES: The objective of this review was to characterize the efficacy and safety of oral anticoagulation (OAC) with vitamin K antagonists for the primary prevention of stroke in patients with chronic AF. SEARCH STRATEGY: We searched the Cochrane Stroke Group Specialised Register of Trials (June 1999), MEDLINE database, and the database of the Antithrombotic Trialists Collaboration, as well as reference lists of relevant articles. SELECTION CRITERIA: All randomized controlled trials comparing the value of OAC versus control in patients with non-valvular chronic atrial fibrillation and no history of transient ischemic attack (TIA) or stroke. DATA COLLECTION AND ANALYSIS: Trials for inclusion were independently selected by two reviewers who also extracted each outcome and double-checked the data. The Peto method was used for combining odds ratios. All analysis were, as far as possible, "intention-to-treat". Since the published results of four trials included 3-8% of participants with prior stroke or TIA, unpublished results excluding these participants were obtained from the Atrial Fibrillation Investigators. MAIN RESULTS: Of 2313 participants without prior cerebral ischemia from five trials, about half (n = 1154) were randomized to adjusted-dose OAC with an estimated mean INRs ranging between 2.0-2.6 during 1.5 years/participant average follow-up. Participant features and study quality were similar between trials. OAC was associated with large, highly statistically significant reductions in ischemic stroke (OR = 0.34, 95% CI 0.23 - 0.52), all stroke (OR = 0.39, 95% CI 0.26 - 0. 59), all disabling or fatal stroke (OR = 0.47, 95% CI 0.28 - 0.80), and the combined endpoint of all stroke, MI or vascular death (OR = 0.56, 95% CI 0.42 - 0.76). The observed rates of intracranial and extracranial hemorrhage not significantly increased by OAC therapy, but confidence intervals were wide. REVIEWER'S CONCLUSIONS: Adjusted-dose OAC (achieved INRs between 2-3) reduces stroke as well as disabling/fatal stroke for patients with nonvalvular AF, and these benefits were not substantially offset by increased bleeding among participants in randomized clinical trials. Limitations include relatively short follow-up and imprecise estimates of bleeding risks from these selected participants. For primary prevention in AF patients who have an average stroke rate of 4%/year, about 25 strokes and about 12 disabling fatal strokes would be prevented yearly for every 1000 given OAC.

Anticoagulants↗
PubMed2000

Health complaints related to pesticide stored at a public health clinic.

Employees at a health center in Georgia were concerned that symptoms experienced by some employees were related to pesticide exposure at the center. Malathion and DDT, used for mosquito control from 1969 to 1981, had been stored and handled at the center's first floor. We surveyed 117 (91%) of 129 employees to determine whether reported symptoms were associated with pesticide exposure. We performed environmental sampling for pesticides. We analyzed serum samples for 17 chlorinated pesticides, and urine samples for malathion. We found that 37% of the participants had reported a diagnosis of sinusitis and 24% of bronchitis since working at the health center. Frequently reported symptoms were eye irritation (44%) and headache (68%). DDT and malathion were found at levels of 2.4 and 11%, respectively, in bulk samples from the loading dock of the building. Multivariate analysis of responses to the questionnaire showed that the perception of odors, inadequate air flow, and length of employment were significantly associated with the employees' health complaints. Pesticide concentrations in employees' serum and urine samples were not associated with any health complaint. The health complaints reported by the employees at the health center were precipitated by both environmental and psychological factors. The epidemiology and laboratory components of this study highlight the importance of obtaining biological measurements in episodes of perceived environmental exposure.

Adult↗
PubMed2000

Blood flow velocity using transcranial Doppler velocimetry in the middle and anterior cerebral arteries: correlation with sample volume depth.

The baseline transcranial Doppler studies of the middle (MCA) and anterior cerebral (ACA) arteries of 135 patients were retrospectively reviewed. 3312 data points were classified according to gender, vessel, mean blood flow velocity (MBFV), systolic blood flow velocity (SBFV), diastolic blood flow velocity (DBFV) and sample volume depth (SVD). The flow velocities at each depth were averaged, and plotted against acquisition depth. The male MCA yielded a correlation coefficient (r), between MBFV and SVD of 0.999. For the female MCA, r = 0.986. For the ACA, male, r = 0.911, and female, r = 0.894. All other data showed r values >/= 0.563, with 11 of 12 r values >/= 0.808. These data suggest that BFV reduces with SVD in a highly predictable way for the MCA and ACA, from which expected BFV values may be estimated at any given SVD.

Adult↗
PubMed2000

Vertebral arteries and neck rotation: Doppler velocimeter interexaminer reliability.

The purpose of this study was to test the interexaminer reliability of Doppler ultrasound (US) velocimeter examination of vertebral arteries during contralateral cervical rotation. Vertebral arteries from 20 adults were insonated using a bidirectional Doppler velocimeter at the suboccipital portal (standard technique) and C2 transverse process level (new technique) during contralateral cervical rotation. The data obtained by two examiners, regarding persistence or major reduction in Doppler signals, were compared. There was 93% agreement between the data from the two examiners, and the kappa score was 0.78 at p = 0.05. These results provide evidence to support the interexaminer reliability of bidirectional Doppler velocimeter examination for the purpose of assessing the effects of contralateral rotation on vertebral artery blood flow.

Adolescent↗
PubMed1999

Systematic review of topical treatments for fungal infections of the skin and nails of the feet.

OBJECTIVE: To identify and synthesise the evidence for efficacy and cost effectiveness of topical treatments for superficial fungal infections of the skin and nails of the feet. DESIGN: Systematic review. INTERVENTIONS: Topical treatments for superficial fungal infections. MAIN OUTCOME MEASURES: Cure confirmed by culture and microscopy for skin and by culture for nails in patients with clinically diagnosed fungal infections. RESULTS: Of 126 trials identified in 121 papers, 72 (57.1%) met the inclusion criteria. Placebo controlled trials yielded pooled relative risks of failure to cure skin infections: allylamines (0.30, 95% confidence interval 0.24 to 0.38); azoles (0.54, 0.42 to 0.68); undecenoic acid (0.28, 0. 11 to 0.74); and tolnaftate (0.46, 0.17 to 1.22). Although meta-analysis of 11 trials comparing allylamines and azoles showed a relative risk of failure to cure of 0.88 (0.78 to 0.99) in favour of allylamines, there was evidence of language bias. Seven reports in English favoured allylamines (0.79, 0.69 to 0.91), but four reports in foreign languages showed no difference between the two drugs (1. 01, 0.90 to 1.13). Neither trial of nail infections showed significant differences between alternative topical treatments. CONCLUSIONS: Allylamines, azoles, and undecenoic acid were efficacious in placebo controlled trials. There are sufficient comparative trials to judge relative efficacy only between allylamines and azoles. Allylamines cure slightly more infections than azoles but are much more expensive than azoles. The most cost effective strategy is first to treat with azoles or undecenoic acid and to use allylamines only if that fails.

Administration, Topical↗
PubMed1999

The excision of uterine fibroids by vaginal myomectomy: a prospective study.

OBJECTIVE: To evaluate the clinical effectiveness and safety of the excision of uterine fibroids by vaginal myomectomy. DESIGN: Prospective study. SETTING: A gynecology department of a university teaching hospital. PATIENT(S): Women with menorrhagia, pelvic pain, symptoms of pressure, or subfertility attributable to moderate-sized uterine fibroids who otherwise would have required abdominal or laparoscopic myomectomy. INTERVENTION(S): Vaginal myomectomy. MAIN OUTCOME MEASURE(S): The feasibility of vaginal surgery, operative complications, postoperative recovery, and relief of symptoms. RESULT(S): Myomectomy was completed vaginally in 32 (91.4%) of 35 patients and none required hysterectomy. The overall operating time was 78 minutes, the estimated operative blood loss was 313 mL, and the mean postoperative hospital stay was 4 days. Pelvic hematomas developed in 4 patients, and one colpotomy required resuture. Seventy-four percent of the women reported relief of their symptoms at 3 months' follow-up. Three patients have had full-term pregnancies since the operation. CONCLUSION(S): Myomectomy can be performed by the vaginal route in selected cases with low morbidity and a good short-term success rate. Unlike open myomectomy, it requires no skin incision, and unlike laparoscopic myomectomy, it can be used in patients who have numerous, relatively large, and intramural fibroids.

Adult↗
PubMed1999

The alternatives to hysterectomy.

Hysterectomy is one of the commonest major operations, with 72,362 procedures performed in England in 1993. However, for women with dysfunctional uterine bleeding other less invasive surgical options have been developed. In particular, hysteroscopic endometrial ablation has been shown to be an effective therapy. Prospective randomized trials have shown that hysteroscopic surgery is associated with a shorter operating time, fewer complications, less analgesic requirement, a faster resumption of normal activities and work and savings in treatment costs. Psychological and social functioning also improves with no significant differences compared to hysterectomy. There is, however, a tendency for women randomized to hysterectomy to report higher rates of satisfaction. Several non-hysteroscopic ablative techniques are currently being developed and tested. While attractive, as they do not require significant hysteroscopic skills and will probably prove to have fewer operative risks than hysteroscopic procedures, the results of these procedures are still in the evaluation phase.

Electrocoagulation↗
PubMed1999

Endometrial cell dissemination at diagnostic hysteroscopy: a prospective randomized cross-over comparison of normal saline and carbon dioxide uterine distension.

The incidence of pelvic spreading of endometrial cells at diagnostic hysteroscopy was studied comparing the two distension media carbon dioxide (CO(2)) and normal saline (N/Saline). Thirty patients requiring laparoscopy and hysteroscopy were included in this study, the main indication for surgery being subfertility. Hysteroscopy was performed using both CO(2) and N/Saline distension on each patient, the order of the distension media being randomly allocated. Samples of peritoneal fluid were aspirated from the pouch of Douglas before and after hysteroscopy with each distension medium, and the specimens were investigated cytologically for the presence of endometrial cells. Endometrium was present in 2/30 (6.7%) peritoneal aspirates before and in 15/60 (25%) collected after the hysteroscopies. There was no major difference between liquid or gaseous distension, transtubal reflux of endometrial cells occurring in 7/30 (23.3%) and in 8/30 (26.7%) hysteroscopies respectively. Positive peritoneal cytology was observed significantly more often in patients who were in the proliferative phase of the menstrual cycle [9/14 (64.3%) versus 0/11, P < 0.004]. In conclusion, transtubal dissemination of endometrium occurs in about one quarter of patients, irrespective whether N/Saline or CO(2) is used for uterine distension; there is no advantage to using gaseous distension for hysteroscopy when investigating high-risk cases for endometrial malignancy.

Carbon Dioxide↗
PubMed1999

Long term follow up of hysteroscopic myomectomy assessed by survival analysis.

OBJECTIVE: To identify patient characteristics which affect outcome after hysteroscopic myomectomy for submucous fibroids. DESIGN: Prospective observational study. SETTING: A university teaching hospital. SAMPLE: One hundred and twenty-two consecutive patients treated by hysteroscopic myomectomy for submucous leiomyoma over a period of almost eight years. METHODS: Hysteroscopic electroresection of the leiomyoama using a continuous flow resectoscope. MAIN OUTCOME MEASURES: The avoidance of further surgery and patient satisfaction. RESULTS: The average age of the patients at the time of their surgery was 42.8 years. A total of 194 fibroids were removed. The mean follow up period was 2.3 years (range 1-7.6). Of those asked, 71.4% were satisfied with the results of surgery. Sixteen women required further surgery for fibroids, and six ultimately underwent hysterectomy. Survival analysis showed that the risk of further surgery was 21% at four years after the myomectomy, and 0% thereafter. Univariate regression analysis suggested that outcome was significantly better in older women, and in cases where the uterus was equivalent in size to < or = 6 weeks of gestation, the fibroid was < or = 3 cm in diameter and mainly intra-cavitary, and the procedure time was < or = 20 minutes. The influence of hormonal pre-treatment and the number of fibroids excised was not statistically significant. After multivariate regression analysis, only overall uterine size and the position of the fibroid being removed were found to significantly influence the success of surgery. CONCLUSIONS: Hysteroscopic myomectomy is an effective way to manage patients with symptomatic submucous leiomyomata, particularly when the uterus is not grossly enlarged and the fibroid(s) are mainly inside the uterine cavity.

Adult↗
PubMed1999

Stulberg classification system for evaluation of Legg-Calvé-Perthes disease: intra-rater and inter-rater reliability.

BACKGROUND: Researchers and clinicians commonly use the classification system of Stulberg et al. as a basis for treatment decisions during the active phase of Legg-Calvé-Perthes disease because of its putative utility as a predictor of long-term outcome. It is generally assumed that this system has an acceptable degree of reliability. This assumption, however, is not convincingly supported by the literature. METHODS: The purpose of the present study was to assess the inter-rater and intra-rater reliability of the classification system of Stulberg et al. with use of a pre-test, post-test design. During the pre-test phase, nine raters independently used the system to evaluate the radiographs of skeletally mature patients who had been managed for Legg-Calvé-Perthes disease. The intervention between the pre-test and post-test phases consisted of a consensus-building session during which all raters jointly arrived at standardized definitions of the various joint structures that are assessed with use of the classification system. The effect of these definitions on reliability then was assessed by reevaluating the radiographs during the post-test phase. RESULTS: The pre-test intra-rater reliability coefficients ranged from 0.709 to 0.915, and the post-test coefficients ranged from 0.568 to 0.874. The pre-test inter-rater reliability coefficients ranged from 0.603 to 0.732, and the post-test coefficients ranged from 0.648 to 0.744. Contributing to the variance was a lack of agreement concerning the assessment of joint structures and the way in which the raters translated these evaluations into a classification according to the system of Stulberg et al. CONCLUSIONS: Although intra-rater reliability was marginally acceptable, the degree of variability between the classifications assigned by different raters even after the intervention - calls into question the reliability of the system of Stulberg et al.; consequently, the validity of any treatment decisions, outcome evaluations, or epidemiological studies based on this system is also in question.

Acetabulum↗
PubMed1999

Prevalence of asthma and other childhood allergies in Brazilian schoolchildren.

We determined the prevalence of asthma, rhinitis, and eczema among Brazilian children using the standardized protocol of the International Study on Asthma and Allergies in Childhood (ISAAC) to facilitate the comparison of our results with other studies using the ISAAC methodology. We conducted a cross-sectional study from June to October 1994 to determine the prevalence of asthma, rhinitis, and eczema in 5182 school children aged 7-8 years and 13-14 years residing in the Brazilian towns of Santa Maria and Itabira (iron-mining cities located in Minas Gerais). Parents completed questionnaires at their child's school in the presence of trained interviewers. The cumulative prevalence of doctor-diagnosed asthma was 4.6% for all ages with no significant difference between the age groups. In general, there was a higher prevalence of symptoms in the younger age group than the older. The prevalence of wheezing in the previous 12 months was 14.3% (7-8 years old) and 9.3% (13-14 years old) (p < 0.01), of chronic cough in the previous 12 months was 25.6% (7-8 years old) and 22.1% (13-14 years old) (p < 0.01), and of nighttime cough in the previous 12 months was 22.3% (7-8 years old) and 19.4% (13-14 years old) (p < 0.05). Overall the prevalences of asthma and wheezing symptoms in the previous 12 months were higher for boys than girls (5.2% vs. 3.9% for asthma, p < 0.01, and 13.2% vs. 10.6% for wheezing, p < 0.01, respectively). These results suggest that asthma-related respiratory illnesses affect a substantial part of the childhood population in Itabira and Santa Maria, Minas Gerais. Some factors such as male gender and younger age may be associated with an increase risk for chronic respiratory symptoms. Prevalences of asthma and allergic diseases in these Brazilian cities on the basis of self-reporting of symptoms and of one's medical history may more accurately portray the true prevalence of asthma than the use of medical records.

Adolescent↗