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Biomedical subjects

R Savage

Publications and source records attributed to R Savage.

At least 37 records · Page 2Linked to original sources

The role of scaffolding errors in reading development: evidence from a longitudinal and a correlational study.

BACKGROUND: Identification of patterns of early reading behaviour that predict later reading success is clearly important. Reading errors of 6-year-olds represent a source of such early assessment information, but their significance as predictors of later reading is unknown. AIMS: The relationship between word reading errors at age 6 and accurate word reading at age 8 is investigated here. SAMPLES, METHODS, RESULTS: In study 1, 44 children completed word reading tests at 6 and 8 years. 'Scaffolding errors' preserving both initial and final phonemes (e.g., 'bark' misread as 'bank'); errors preserving either initial or final phonemes (e.g., 'bark' misread as 'bed' or 'like'); distant or unrelated errors (e.g., 'bark' misread as 'can' or 'men') and non-responses were measured at age 6. Scaffolding errors were the best predictors of word reading at age 8. Study 2 investigated the correlations between word and nonsense word reading, and scaffolding errors in 30 children aged 6 years. Scaffolding errors predicted unique variance in word reading after nonword reading was entered. CONCLUSIONS: Scaffolding errors represent a significant qualitative indicator of later word reading success. Implications of findings for early identification of reading difficulties, and facilitating reading interventions are discussed.

Child↗

Patients' satisfaction with osteopathic and GP management of low back pain in the same surgery.

Chronic low back patients reported their satisfaction with the treatment they received for back pain from GPs and osteopaths practising in the same surgery. Although levels of satisfaction were high for all treatments, patients reported significantly higher scores for satisfaction with the osteopathic treatment. The difference was stronger for aspects of care/communication and competence, and weaker for satisfaction with efficacy. These findings are discussed in reference to patients' expectations, novelty, time spent with patients, number of visits, and patients' age.

Adult↗

Changes in regional myocardial function after coronary artery bypass graft surgery are predicted by intraoperative low-dose dobutamine echocardiography.

BACKGROUND: Left ventricular dysfunction is often reversed after coronary artery bypass graft (CABG) surgery; however, this change is not easily predicted. The authors hypothesized that functional changes after a low dose of dobutamine (5 microgram. kg-1. min-1) intraoperatively would predict functional changes when complete revascularization was achieved. METHODS: The authors analyzed 560 segments in 40 patients scheduled for elective CABG surgery for regional wall motion (1-5 scoring system) at four stages: baseline (after induction and intubation), with administration of low-dose dobutamine before cardiopulmonary bypass, after separation from cardiopulmonary bypass (early), and after administration of protamine (late). Two independent observers scored the myocardial regions according to a 16-segment model in multiple imaging planes. For each segment, the response to dobutamine was dichotomized as improved or not improved from baseline and analyzed with logistic regression. The influence of covariates (ejection fraction, myocardial infarction, diabetes mellitus, and beta blockers) was also determined with logistic regression models. P < 0.05 was considered significant. RESULTS: Changes in myocardial function after low-dose dobutamine were highly predictive for early (P < 0.0001) and late (P < 0.0001) changes in myocardial function from baseline regional scores. The overall odds ratio for early and late improvement increased by 20.7 and 34.6, respectively, when improvement was observed after low-dose dobutamine was administered. The overall positive predictive value of improved regional wall motion after CABG did not vary with left ventricular ejection fraction, a history of myocardial infarction, or beta blocker use, and it varied little with diabetic status (range, 0.86-0.96) if regional wall motion improved with low-dose dobutamine before CABG. The overall negative predictive value was 0.70; however, the range varied with diabetic status (i.e., lowest in diabetic patients and highest in nondiabetic patients). CONCLUSION: Intraoperative low-dose dobutamine is a reliable method to predict myocardial functional reserve and to determine functional recovery expected after coronary revascularization.

Adult↗

Effect of an administrative intervention on rates of screening for domestic violence in an urban emergency department.

OBJECTIVES: This study measured the effects of an administrative intervention on health care provider compliance with universal domestic violence screening protocols. METHODS: We used a simple, interrupted-time-series design in a stratified random sample of female emergency department patients 18 years or older (n = 1638 preintervention, n = 1617 postintervention). The intervention was a 4-tiered hospital-approved disciplinary action, and the primary outcome was screening compliance. RESULTS: Preintervention and postintervention screening rates were 29.5% and 72.8%, respectively. Before the intervention, screening was worse on the night shift (odds ratio [OR] = 0.46, 95% confidence interval [CI] = 0.31, 0.68) and with psychiatric patients (OR = 0.34, 95% CI = 0.14, 0.85); after the intervention, no previous screening barriers remained significant. CONCLUSIONS: An administrative intervention significantly enhanced compliance with universal domestic violence screening.

Adult↗

Early pregnancy assessment; a role for the gynaecology nurse-practitioner.

Recent improvements in the investigation of bleeding and pain in early pregnancy has led to simplified clinical guidelines. These in turn have created the opportunity for nurse-led early pregnancy assessment. We arranged for a gynaecology nurse-practitioner with experience to undergo additional training in early pregnancy care. She then took over the daily running of the Early pregnancy assessment centre (EPAC). A review of 200 consecutive cases showed that the nurse followed the guidelines extremely closely in terms of categorisation of patients, referral to the medical team for further investigation and selection of women who required anti-Rh(D) immunoglobulin. In addition, in the first 6 months of the clinic no cases of ectopic pregnancy were overlooked by the nurse-practitioner. Sixty-one per cent of the women attending the clinic did not need to see a doctor.

Journal Article↗

Sublexical Inferences in Beginning Reading: Medial Vowel Digraphs as Functional Units of Transfer.

Two experiments evaluated young children's use of lexical inference. Experiment 1 compared transfer from shared rimes (e.g., "beak"-"peak"), or heads (e.g., "beak"-"bean"), under three conditions: (a) when both clue word pronunciation and orthography were present at transfer; (b) when only the pronunciation of the clue word was given; and (c) when the clue was pretaught. Equivalent transfer occurred in both conditions (a and b) where clue word pronunciations were provided at transfer, but no transfer was found when the clue word was pretaught (condition c). Experiment 2 investigated transfer from three pretaught clue words sharing rimes (e.g., "leak"-"peak"), or vowel digraphs (e.g., "leak"-"bean"). Children demonstrated lexical transfer under these conditions, but improvements were equivalent for vowel and rime analogous words. Results are interpreted in terms of models of vowel transfer. Copyright 1998 Academic Press.

Journal Article↗

The mechanical effectiveness of erect and "bent-hip, bent-knee" bipedal walking in Australopithecus afarensis.

It is universally accepted that the postcranial skeleton of the early hominid Australopithecus afarensis shows adaptations, or at least exaptations, towards bipedalism. However, there continues to be a debate concerning the likely form of terrestrial bipedality: whether gait was erect, like our own, or "bent-hip, bent-knee" like the bipedalism of living chimpanzees. In this study we use predictive dynamic modelling to assess the mechanical effectiveness of AL-288-1 under both hypotheses, on the basis of data on segment proportions from the literature. AL-288-1's proportions are incompatible with the kinematics of chimpanzee bipedalism, but compatible with the kinematics of either erect or "bent-hip, bent-knee" human gait. In the latter case, neither the ankle nor the knee joint would have contributed substantial mechanical work to propulsion of the body, and net energy absorption is predicted for these joints, which would have resulted in increased heat load. Such an ineffective gait is unlikely to have lead to selection for "bipedal" features in the postcranial skeleton.

Animals↗

A comparison of bone scintigraphy and MRI in the early diagnosis of the occult scaphoid waist fracture.

OBJECTIVE: To determine the accuracy of MRI in the assessment of the radiographically occult scaphoid fracture. DESIGN: This prospective study compared the sensitivity and specificity of MRI for detection of radiographically occult scaphoid fractures with bone scintigraphy (BS), the currently accepted imaging modality of choice. Consecutive patients with clinical signs of a scaphoid injury but no evidence of fracture on plain radiographs at presentation and after 7-10 days were evaluated by MRI and BS. All images were reported in masked fashion and the sensitivities and specificities of the imaging modalities determined. All patients with a scaphoid fracture demonstrated by MRI or BS were followed for at least a year after injury. PATIENTS: Forty-three subjects (aged 12-74 years) had both MRI and BS carried out on average 19 days from the injury date. RESULTS AND CONCLUSIONS: Six patients (14%) had scaphoid waist fractures. There were other bony injuries in a further six. In 40 patients there was agreement between the BS and MRI findings. In three cases there was discrepancy between the imaging modalities; in all three MRI was found to be the more sensitive and specific. MRI could become the investigation of choice for this injury.

Adolescent↗

Identifying the cause of left ventricular systolic dysfunction after coronary artery bypass surgery: the role of myocardial contrast echocardiography.

OBJECTIVE: Intraoperative myocardial contrast echocardiography was used to determine whether the identification of regional myocardial flow patterns during revascularization could predict myocardial contractile function immediately after separation from cardiopulmonary bypass (CPB) and at 1 month after coronary artery bypass grafting (CABG) surgery. DESIGN: A prospective, open-labeled, longitudinal analysis. SETTING: Two independent university hospitals. PARTICIPANTS: Twenty patients, during and up to 1 month after CABG. INTERVENTIONS: The contrast agent Albunex (Mallenckrodt Medical, Inc, St Louis, MO) was injected into the aortic root during CPB. MEASUREMENTS AND MAIN RESULTS: Myocardial contrast echocardiography opacification of flow was graded from intraoperative transesophageal echocardiographic images of the left ventricle in the short-axis, midpapillary view. The same myocardial images were also evaluated for regional wall motion abnormalities at 15, 30, and 60 minutes, 24 hours, 5 to 8 days, and 1 month after CPB. Logistic regression analysis was used to analyze the flow scores and regional function data from identical segments. Regional flow represented by contrast enhancement was assessed in 70% of the myocardial regions (55 of 80 possible segments; 95% confidence interval [CI], 61 to 76). Flow was more easily evaluated in the posterior region (95%) than in the anterior (70%) or septal regions (60%), and least likely evaluated in the lateral regions (50%). Regional wall motion was scored in 84% of the myocardial regions (469 of 560 possible regions). Function (segmental wall motion) was assessed in all regions with equal success. Segmental function and flow scores were matched to the same regions 66% of the time (53 of 80 possible series; 95% CI, 55 to 76). Regional myocardial contrast flow patterns did not predict myocardial function at 15, 30, or 60 minutes after separation from CPB. However, contrast opacification of flow did predict regional myocardial function at 1 week (p < or = 0.05) and at 1 month (p < or = 0.01) after CABG surgery. The probability that myocardial function would be normal at 1 month was 0.62 when intraoperative flow opacification was abnormal and 0.98 when flow opacification was normal. For patients with normal flow, the estimated odds of having normal myocardial function were 3.33 times those of patients with abnormal flow at 1 week (odds ratio, 3.33; 95% CI, 1.09 to 10.19) and 18.5 times those of patients with abnormal flow at 1 month (95% CI, 2.44 to 140.48). CONCLUSION: Intraoperative application of myocardial contrast echocardiography to determine regional flow patterns after revascularization may help differentiate conditions of left ventricular systolic dysfunction immediately after separation from CPB for CABG surgery and appear to predict myocardial function at 1 month.

Adult↗

The influence of collateral flow on the antegrade and retrograde distribution of cardioplegia in patients with an occluded right coronary artery.

BACKGROUND: The predictive value of electrocardiography (ECG) and coronary angiography for cardioplegia distribution in patients with an occluded right coronary artery was evaluated. METHODS: Coronary angiograms and ECGs were evaluated in 15 patients with right coronary artery occlusion. Prediction of antegrade cardioplegia distribution was based on ECG evidence of infarction and coronary collateral flow determined from the angiogram. Antegrade and retrograde delivery of cardioplegia was directly assessed in all patients by myocardial contrast echocardiography. Intraoperative transesophageal echocardiographic images of the right ventricular free wall, the apex, and the intraventricular septum were recorded while 4 ml of Albunex (Mallinckrodt Medical, St. Louis, MO) was injected into antegrade and retrograde cardioplegic catheters during cardioplegia delivery. The observed (myocardial contrast echocardiography) cardioplegia distribution was compared to the predicted cardioplegia distribution. Sensitivity, specificity, positive predictive values, and negative predictive values were calculated. RESULTS: Eighty seven of 90 (97%) segments were analyzed. Angiography and ECG poorly predicted incomplete cardioplegia distribution. Electrocardiography was a better predictor of inadequate cardioplegia distribution to the right ventricle than was angiography. The negative predicted values of cardioplegia distribution ranged from 20 to 50% for the septum and right ventricle, respectively, with ECG criteria and from 0 to 33% for the septum and apex, respectively, with angiographic criteria. Antegrade cardioplegia delivery was distributed to the right ventricle in 31% of patients, despite 100% occlusion of the right coronary artery; whereas retrograde cardioplegia delivery to the right ventricle occurred 20% of the time. CONCLUSIONS: In the presence of 100% right coronary artery occlusion, retrograde cardioplegia delivery is not often observed and antegrade delivery of cardioplegia to the right ventricle is not easily predicted. The preoperative angiography and ECG are not predictive of coronary collateral circulation and therefore not predictive of cardioplegia distribution to the right ventricle.

Arterial Occlusive Diseases↗

The mechanics of food reduction in Tarsius bancanus. Hard-object feeder, soft-object feeder or both?

The high-cusped, almost tritubercular teeth of Bornean tarsiers are used to reduce a wide variety of animal food. Prey is characteristically consumed entire, no parts being discarded. This paper attempts to identify the dental characteristics which permit tarsiers to reduce food substrates with widely varying mechanical properties and to assess whether reduction of some substrates incurs greater costs for tarsiers. Finite elements stress analysis (FESA) modelling is used to compare the effectiveness of tarsier and human teeth in reducing three types of food substrate habitually reduced by both species. Bone is taken as the exemplar of strong, stiff substrates, skin as the exemplar of substrates low in both stiffness and strength, and tendon as the exemplar of low-stiffness but strong substrates. The parameters used to measure performance are the work that must be done to bring tensile stresses to the point where tensile failure will be initiated and the bite-force required to do so. Human molars perform best in reducing bone, and tarsier molars in reducing skin. Neither perform as well in reducing tendon. Blunt, bunodont human molars perform slightly better than the high-cusped molars of tarsiers in reducing bone, but tarsier molars perform much better than human molars in inducing failure in skin and are also considerably better in reducing tendon. While the reduction effectiveness of human molars is greatly affected by substrate properties, the high cusps of tarsier teeth enable them to reduce foodstuffs of widely differing properties reasonably well. Scaling factors undoubtedly influence selection for cusp height, since high cusps are a prerequisite of effective crack propagation in food substrates by small animals. Microwear features do not show a consistent pattern where striations are associated with surface-parallel loads but pitting with surface-normal loads (at least as modelled by FESA). However, FESA modelling of the magnitude of applied forces and relative food/tooth displacement during occlusion suggest that the type of wear found in different regions is governed by the combined influences of relative tooth/food displacement and food/tooth reaction force. Pitting is associated with low levels of food/tooth displacement but high levels of reaction force, striation with high levels of displacement but low levels of force, and stripping or gouging of enamel with high values of both displacement and reaction force.

Animals↗

How does cystitis affect a comparative risk profile of tiaprofenic acid with other non-steroidal antiinflammatory drugs? An international study based on spontaneous reports and drug usage data. ADR Signals Analysis Project (ASAP) Team.

Series of well-documented case reports strongly suggest a causal association between tiaprofenic acid and a form of aseptic cystitis, which can cause serious and long-term morbidity if the drug is not withdrawn promptly. These findings are supported in the Australian and UK spontaneous reporting data-bases. Using sales data as the denominator, a comparison of NSAIDs in the WHO drug monitoring data-base indicates that the reaction is specific to tiaprofenic acid and cannot be accounted for by changes in reporting patterns in certain countries or years. Delayed recognition is an important feature of this reaction and possible reasons for this are discussed. Comparison of the risk profiles of seven NSAIDs indicated that tiaprofenic acid had the poorest risk profile, compared with NSAIDs of similar efficacy, when cystitis reports were included. The results suggest that combining spontaneous reports, classified according to severity, with sales data may enhance the ability of drug monitoring data-bases to contribute to risk benefit appraisals.

Anti-Inflammatory Agents, Non-Steroidal↗

Training for excellence in the inner city: an interview with Richard Savage and Clare Vaughan. Interview by Douglas Carnall.

Recruitment to general practice is at its lowest level for 30 years, and many vocational training schemes report difficulty in attracting new trainees. Spurred on by the aging population of south London, and with the advantage of pounds 1.3m of development money resulting from the Tomlinson report, the south London organisation of vocational training schemes (SLOVTS) has perhaps been able to cope better than most. Its chair, Richard Savage, a general practitioner and course organiser, and Clare Vaughan, an assistant adviser, have devised and implemented many innovative training posts for general practice over the past two years, and their approach seems to be bearing fruit: most of the doctors who have finished the training scheme are now entering practice in south London. They talked to Douglas Carnall about the causes of the crisis and the measures they have implemented to counter it. Clare Vaughan died in the week following the interview (see obituary, p 555).

Education, Medical, Continuing↗

Variability in risk of gastrointestinal complications with individual non-steroidal anti-inflammatory drugs: results of a collaborative meta-analysis.

OBJECTIVE: To compare the relative risks of serious gastrointestinal complications reported with individual non-steroidal anti-inflammatory drugs. DESIGN: Systematic review of controlled epidemiological studies that found a relation between use of the drugs and admission to hospital for haemorrhage or perforation. SETTING: Hospital and community based case-control and cohort studies. MAIN OUTCOME MEASURES: (a) Estimated relative risks of gastrointestinal complications with use of individual drugs, exposure to ibuprofen being used as reference; (b) a ranking that best summarised the sequence of relative risks observed in the studies. RESULTS: 12 studies met the inclusion criteria. 11 provided comparative data on ibuprofen and other drugs. Ibuprofen ranked lowest or equal lowest for risk in 10 of the 11 studies. Pooled relative risks calculated with exposure to ibuprofen used as reference were all significantly greater than 1.0 (interval of point estimates 1.6 to 9.2). Overall, ibuprofen was associated with the lowest relative risk, followed by diclofenac. Azapropazone, tolmetin, ketoprofen, and piroxicam ranked highest for risk and indomethacin, naproxen, sulindac, and aspirin occupied intermediate positions. Higher doses of ibuprofen were associated with relative risks similar to those with naproxen and indomethacin. CONCLUSIONS: The low risk of serious gastrointestinal complications with ibuprofen seems to be attributable mainly to the low doses of the drug used in clinical practice. In higher doses ibuprofen is associated with a similar risk to other non-steroidal anti-inflammatory drugs. Use of low risk drugs in low dosage as first line treatment would substantially reduce the morbidity and mortality due to serious gastrointestinal toxicity from these drugs.

Anti-Inflammatory Agents, Non-Steroidal↗

Assessing myocardial perfusion with Albunex during coronary artery bypass surgery: technical considerations and safety of aortic root injections.

OBJECTIVE: To test the safety and report on limiting technical considerations, including optimal dosing of Albunex (Molecular Biosystems, Inc, Mallinckrodt Medical, St. Louis, MO) for myocardial opacification after intra-aortic root injections during cardiac surgery. DESIGN: This was a prospective randomized study with a control group who did not receive Albunex and a group who received intra-aortic root injections of Albunex. SETTING: Multicenter (two) independent university hospitals. PARTICIPANTS: 32 patients scheduled for elective coronary artery bypass surgery were evaluated after individual informed consent was obtained. INTERVENTIONS: 2 to 8 mL of Albunex were injected before and after coronary revascularization. MEASUREMENTS AND MAIN RESULTS: Quality of enhancement in each of four regions of the left ventricle was assessed from a short-axis mid-papillary ultrasound image by three experienced observers blinded to dose. Electrocardiogram (ECG), creatine phosphokinase (CPK) (MB fraction), and hemodynamics were evaluated at baseline and throughout the study period for up to 72 hours. No differences were noted between groups with respect to preoperative and postoperative CPK enzymes (CPK-MB fraction), ECG changes, hemodynamics, requirements for separation from CPB, need for postoperative inotropes, time to extubation, and time to discharge from the intensive care unit. The average total dose of Albunex injected was 19 mL +/- 4 (0.25 mL/kg). A single dose of 4.2 +/- 1.2 mL (0.05 mL/kg) appeared to offer optimal enhancement of contrast effect for myocardial perfusion assessment. CONCLUSION: Albunex is safe and easy to use for myocardial opacification when administered via an antegrade cardioplegia catheter into the aortic root during CPB.

Aged↗