Showing papers by "Leicester Royal Infirmary published in 1992"

Comparative study of calcipotriol (MC 903) ointment and betamethasone 17-valerate ointment in patients with psoriasis vulgaris.

Abstract: Background: Topical vitamin D analogues have been reported to be an effective treatment in patients with psoriasis. Comparative studies with existing treatments are required. Objective: Our purpose was to compare the effectiveness of calcipotriol (50 μg/gm) and betamethasone 17-valerate (1 mg/gm) ointments twice daily in the treatment of stable plaque psoriasis. Methods: This study was a randomized, double-blind comparison over 6 weeks in 409 patients. Efficacy, as measured by the Psoriasis Area and Severity Index (PASI), and safety were assessed at 2, 4, and 6 weeks. Results: Reduction of PASI was statistically significant at all time points for both treatments but there were no significant between-treatment differences. At the completion of 6 weeks of treatment, the mean PASI reduction was 5.50 for calcipotriol and 5.32 for betamethasone (95% confidence interval [CI] −0.40 to 0.78). Analysis of patient assessment at 6 weeks showed clearance or marked improvement in 61.2% of the calcipotriol patients and 50.5% with betamethasone (95% CI 1.4 to 20.8). Calcipotriol produced significantly more local side effects (19.5% compared with 3.9%, p Conclusion: Calcipotriol ointment was as effective as betamethasone 17-valerate ointment as measured by the PASI and superior as measured by self-assessment in patients with stable plaque psoriasis. Both treatments were well tolerated.

Regurgitation of gastric contents during general anaesthesia using the laryngeal mask airway

Abstract: We have investigated the incidence of regurgitation of gastric contents during general anaesthesia administered via a laryngeai mask airway (LMA) or face mask and Guedel airway in 56 patients with no risk factors for regurgitation. Patients swallowed a gelatine capsule containing methylene blue 10 min before induction of anaesthesia. Fibreoptic laryn–goscopy in the LMA group or conventional laryn-goscopy in the face mask group was performed at the end of surgery. Dye was observed within the laryngeai mask in seven of 28 patients (25%). No patients in the face mask-Guedel airway group regurgitated dye (P = 0.005). There was no evidence of aspiration of dye.

Current management of postoperative nausea and vomiting.

Abstract: Before specific antiemetic agents became available, various techniques, including olive oil [51] and insulin-glucose infusions [122], were reported to be effective in reducing the incidence of postoperative nausea and vomiting (PONV). Robert Ferguson [51] described the use of olive oil in 1912. The oil was administered «by mouth immediately after partial restoration of consciousness» and he postulated that oil in the stomach «absorbed any ether that might be there»

Cardiovascular responses to insertion of the laryngeal mask.

Abstract: We have compared, in 40 healthy patients, the cardiovascular responses induced by laryngoscopy and intubation with those produced by insertion of a laryngeal mask. Anaesthesia was induced with thiopentone and maintained with enflurane and nitrous oxide in oxygen; vecuronium was used for muscle relaxation. Arterial pressure was measured with a Finapres monitor. The mean maximum increase in systolic arterial pressure after laryngoscopy and tracheal intubation was 51.3% compared with 22.9% for laryngeal mask insertion (p less than 0.01). Increases in maximum heart rate were similar, (26.6% v 25.7%) although heart rate remained elevated for longer after tracheal intubation. We conclude that insertion of the laryngeal mask airway is accompanied by smaller cardiovascular responses than those after laryngoscopy and intubation and that its use may be indicated in those patients in whom a marked pressor response would be deleterious.

A multicentre, parallel-group comparison of calcipotriol ointment and short-contact dithranol therapy in chronic plaque psoriasis.

Abstract: Short-contact treatment with dithranol (anthralin) is a widely used treatment for chronic plaque psoriasis. Although effective, it causes staining and irritation, and is therefore inconvenient. Calcipotriol is a recently developed vitamin D analogue which is effective and easy to use. To evaluate the relative efficacy, safety and acceptability of these treatments a multicentre, open, randomized, parallel-group comparison was performed. Four hundred and seventy-eight patients with chronic plaque psoriasis were randomized to use one of the two treatments for 8 weeks. One group applied calcipotriol ointment (50 micrograms/g) twice daily. The other used a single application for 30 min each day of Dithrocream in the highest concentration tolerated. Severity of psoriasis was assessed by modified PASI score at baseline, and after 2, 4, and 8 weeks of treatment. A five-point scale was used by subjects and by investigators as an additional assessment of overall response, and a similar scale was used by subjects to grade acceptability. Total serum calcium was monitored at baseline and after 2 and 8 weeks on treatment. The mean PASI score fell from 9.1 to 4.7 after 8 weeks on dithranol (P < 0.001), and from 9.4 to 3.4 on calcipotriol (P < 0.001). The difference between the two treatments was significant in favour of calcipotriol at 2 weeks (P < 0.001), and remained so at subsequent assessments. At 8 weeks the difference between mean improvements in scores for the two groups was 1.6 (95% confidence interval 0.5-2.7). Efficacy grading by subjects and investigators, and acceptability grading by subjects, were all significantly better for calcipotriol.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiovascular and plasma catecholamine responses at tracheal extubation

Abstract: The haemodynamic responses to tracheal extub-ation at the end of surgery were compared with those occurring at tracheal intubation in 12 patients undergoing major elective surgery. Arterial can-nulation was performed and heart rate (HR), systolic arterial pressure (SAP) and diastolic arterial pressure (DAP) were measured before induction of anaesthesia, before tracheal intubation, at the end of surgery and 1. 3 and 5 min after tracheal extubation. Laryngoscopy was avoided at the end of surgery. At all but the first of these stages, venous blood was obtained for measurement of plasma concentrations of adrenaline and noradrenaline. Rate-pressure product (RPP) was derived from SAP x HR. After tracheal intubation there were significant (P

Anaesthetic Factors Contributing to Postoperative Nausea and Vomiting

Abstract: This article reviews the anaesthetic contribution to postoperative nausea and vomiting (PONV). It does not discuss the physiology or mechanisms of causation of PONV, the patient and surgical factors contributing to, or the treatment of PONV, which are dealt with elsewhere in this supplement

Social Intervention and the Elderly:A Randomized Controlled Trial

Abstract: A randomized controlled trial was set up in 1985 to test the effect of social intervention over 3 years among elderly people, aged 75 and above, living alone. The sampling frame was the age/sex register of a large group practice of 12 general practitioners serving the town of Melton Mowbray, Leicestershire, England, with a list size of approximately 32,000 patients. A total of 523 elderly people living alone in 1985 were identified, interviewed, and randomized into experimental and control groups. A lay worker offered the experimental group (n = 261) individual packages of support that aimed at enhanced social contacts. The outcome measures, approximately 3 years later in 1988, were mortality; changes in physical status; demand for medical, paramedical, social, and voluntary services; and changes in a number of subjective variables (morale, loneliness, and self-perceived health). No significant differences were found for any of the variables with the exception of self-perceived health status, where the experimental group showed significantly greater improvements than did the control group. More importantly, half the elderly in this sample declined several offers of help.

Alteration of stromal protein and integrin expression in breast--a marker of premalignant change?

Abstract: Interactions between epithelia and the extracellular matrix are important in the modulation of cellular growth, differentiation, and motility. To investigate the possible roles of these interactions in the neoplastic process, this study examines the expression of the integrin subunits a2, a6, beta 1, and beta 4 and the stromal protein tenascin in 53 breast carcinomas, non-involved breast tissue from 21 of these cases, and 32 normal/benign cases. Frozen tissue and an indirect immunoperoxidase technique were used throughout. Linear staining in relation to the basement membrane was seen for all integrins in the normal/benign cases. The carcinomas showed complete loss of reactivity in 65 per cent of cases for a2, 80 per cent for a6 and beta 4, and 90 per cent for beta 1. Those showing reactivity displayed a diffuse cytoplasmic type of staining. The non-involved breast tissue showed linear basement membrane type staining with a2 and beta 1, but for a6 and beta 4 66 per cent of cases displayed reactivity identical to that of the corresponding tumour. For tenascin, band-like staining around ducts was seen in normal/benign cases, with a diffuse coarse reactivity in all carcinomas. Most non-involved cases stained as for normal breast. The altered a6 beta 4 integrin staining in non-involved tissue in cancerous breast may be an early event in the neoplastic process, and as such, may be of use as a marker of pre-malignant change.

Modern treatment of warts: cure rates at 3 and 6 months.

Abstract: Summary Four-hundred consecutive referrals with viral warts of the hands and/or feet were investigated to determine the cure rate from a combination of cryotherapy, keratolytic wart paint and paring. For treatment failures after 3 months, the value of continuing cryotherapy and of additional treatment with the immunomodulator inosine pranobex were assessed. Subjects were treated for 3 months with wart paint and cryotherapy and were randomized to receive, or not, paring in addition. Those who did not respond by 3 months were randomized to receive, or not, 3 months further cryotherapy, and to receive inosine pranobex 60 mg/kg/day for 1 week each month, or matching placebo. Fifty-two per cent of subjects were cured by 3 months. The chance of cure was inversely related both to the length of history and to the diameter of the largest wart. Paring improved the cure rate for plantar warts but not for hand warts. During the second 3 months the cure rate fell to 41%. Neither cryotherapy nor inosine pranobex significantly improved this response.

Efficacy of orally-administered ondansetron in the prevention of postoperative nausea and vomiting - a dose ranging study

Abstract: In a placebo-controlled, double-blind study, we have compared the efficacy of ondansetron 16 mg, 8 mg and 1 mg administered 8-hourly for prevention of postoperative nausea and vomiting. We studied 995 patients undergoing major gynaecological surgery; 982 were included in the analysis. Study medication was administered 1 h before induction of anaesthesia and second and third doses were given 8 and 16 h after the first. The treatment groups were similar for patient characteristics, surgical procedures, anaesthetics administered and opioids given. The frequency of nausea was 75%, 70%, 56% and 55% after placebo and ondansetron 1 mg, 8 mg and 16 mg, respectively; the corrresponding frequencies of vomiting were 60%, 55%, 37% and 37%. Ondansetron 8 mg was as effective as 16 mg and both resulted in significant reductions in nausea and vomiting compared with placebo and ondansetron 1 mg (P

Misclassification of Dementia by the Mini-Mental State Examination— Are Education and Social Class the only Factors?

Abstract: The 1988 Melton Mowbray Study of the Elderly comprised an initial screen with the Mini-Mental State Examination (MMSE) followed by a detailed clinical assessment using the Cambridge Mental Disorders of the Elderly Examination (CAMDEX) for all those scoring 21 and under on the MMSE, a one in two sample of those scoring 22 or 23 and a one in ten of the remainder. A total of 1579 subjects completed the initial screen with 438 subjects undergoing the CAMDEX assessment. Analysis of those subjects who were found to be free of dementia at the clinical assessment (n = 155) demonstrated that the very elderly, those from the manual social classes and subjects with visual impairments had an increased chance of being misclassified as demented by the MMSE. Low educational level and various measures of physical disability also showed a tendency to result in misclassification as falsely positive by the MMSE when viewed alone but these effects appeared to be due solely to their association with extreme age and/or manual social class.

A retrospective audit of the combined pituitary function test, using the insulin stress test, TRH and GnRH in a district laboratory.

Abstract: SUMMARY objective To assess the value of the combined insulin stress test (IST), thyrotrophin-releaslng hormone (TRH) and gonadotrophin hormone-releasing hormone (GnRH) tests design A retrospective audit of 232 such tests performed between 1980 and 1989 inclusive patients One hundred and ninety-seven patients with known or suspected pituitary disease measurements IST, TRH and GnRH responses were retrieved from laboratory records. Case notes were surveyed for clinical data and additional results results A basal serum cortisol level of > 100 nmol/l (or > 200 nmol/l in patients who had recently received glucocorticoid replacement therapy) accurately predicted a subnormal response to hypoglycaemla. All patients with a basal cortisol level of >400 nmol/l, except those who had recently received steroids, showed a normal cortisol response. In retrospect, by consideration of such basal values, 55% of ISTs could have been avoided if the only aim was to assess cortisol reserve. A deficient growth hormone (GH) response to hypoglycaemia was, however, common In patients with a normal cortisol response. Two-thirds of patients with GH deficiency would have been missed If an IST had been avoided on the basis either of basal cortisol levels alone, or of cortisol responses to an alternative test which did not test GH reserve. There was poor agreement between the pituitary response to TRH and GnRH and basal levels of thyroxlne and gonadotrophins respectively, suggesting that these releasing hormone tests are misleading. conclusions The IST provides information regarding pituitary function not provided by other tests of the hypothalamlc-pltuitary-adrenal axis, so that the choice between the IST and alternative tests must depend on a critical assessment of what Information is required. Routine TRH and GnRH testing appears to yield little Information of practical clinical value

Antidepressants may not assist recovery in practice: a naturalistic prospective survey

Abstract: A total of 130 people attending psychiatric hospitals within 6 months of onset or relapse of an episode of depressive disorder were interviewed about their symptoms and treatment at the time of their initial contact. After a mean 4-month interval, 119 were reassessed to test the hypothesis that patients treated with antidepressants would be significantly more likely to be clinically improved compared with those untreated. Severity and duration of the episode emerged as the only significant clinical predictors of clinical improvement. Patients on treatment with antidepressants at the start of the study showed a nonsignificant trend for a lesser degree of clinical improvement, even when clinical severity and compliance were taken into account. Those who were not commenced on treatment until later in the study also fared no better than those who were never prescribed antidepressants. The effect of low doses of antidepressants (almost always a tricyclic) appeared to be less beneficial than either higher doses or clinical management without antidepressant drugs. The need for further experimental and naturalistic studies conducted over various periods of time and the implications for clinical practice, medical audit and the appropriate use of health outcome indicators are discussed.

Peripartum changes in gastric emptying

Abstract: Summary Applied potential tomography was ilsed to measure changes in gastric emptying during the peripartum period. Gastric emptying was measured sequentially in each of 10 healthy patients at 37–40 weeks gestation, 2–3 days postpartum and after the 6-week postnatal assessment (control),‘Aean (SD) times to 50% emptying were 15 (6.05), 11 (5.9) and 15 (5.5) min, respectively. There was no statistically signijicant change in gastric emptying as a result of pregnancy in this group of women. Retrospective power analysis (assuming α= 0.05 and β= 0.20) shows the study design was adequate to detect a difference of 8 min.

Vitamin D analogues and psoriasis.

Abstract: Topical vitamin D analogues offer a new, effective, more convenient and generally well-tolerated option for the treatment of psoriasis. Only psoriasis vulgaris has been intensively studied, but other forms of the disease may also respond. Both calcitriol and calcipotriol have been shown to be effective in numerous clinical trials, and the latter has compared well with betamethasone valerate and short-contact dithranol in controlled studies. Their mechanism of action is not yet fully understood and may prove complex. The most important effect may be a direct regulation of keratinocyte proliferation and differentiation. However, these compounds also have potent immunological properties, and may act by inhibition of cytokine production by keratinocytes or lymphocytes. Topical application of vitamin D analogues appears generally to be remarkably safe, but hypercalcaemia and hypercalciuria may develop if large quantities are used.

Recombinant human granulocyte-macrophage colony-stimulating factor after autologous bone marrow transplantation for malignant lymphoma: a British National Lymphoma Investigation double-blind, placebo-controlled trial.

Abstract: Granulocyte-macrophage colony-stimulating factor (GM-CSF) is active in enhancing the production of mature myeloid cells in vitro and several phase 1/11 clinical trials have suggested that its administration may accelerate neutrophil recovery after autologous bone marrow transplantation (ABMT). We have conducted a multicentre randomized double-blind placebo controlled trial in patients with poor prognosis malignant lymphoma receiving an identical high-dose combination chemotherapy regimen with ABMT. 61 patients were entered and 29 in each arm of the trial were evaluated. Treatment with GM-CSF did not affect the period of severe neutropenia (absolute neutrophil count (ANC) of 37.5-degrees-C (median 8 v 6) or days on parenteral antibiotics (11 v 10). Patients receiving GM-CSF had a median period of hospitalization following BMT of 24 d (control 25). No significant major toxicity attributable to GM-CSF administration was detected. We have confirmed in a randomized trial that GM-CSF accelerates neutrophil but not platelet recovery following ABMT. We were unable to demonstrate any accompanying changes in clinical outcome and believe that further trials are necessary to assess the clinical value of GM-CSF in BMT.

Dorsal fracture subluxation of the proximal interphalangeal joints treated by extension block splintage.

Abstract: In a prospective study, 27 consecutive patients with dorsal fracture subluxation of the PIP joint were treated conservatively using an extension block splint, with good results in 70% The percentage surface involved with the fracture varied considerably (19–77%) the average being 55% Three patients intially managed with splintage proceeded to surgery because the splint failed to hold the joint in reduction These patients had a less favourable outcome We feel that all such fractures can be treated by splintage, provided that early reduction is maintained in the splint and checked by serial radiology

Meta-analysis of observational epidemiological studies: a review

Abstract: Meta-analyses (integration of findings by quantitative analyses of results of individual studies) are already widely used in the psychological and educational sciences and in the pooling of clinical trial results. Examples of the application of such techniques to the results of observational epidemiological studies are now proliferating. In this paper meta-analysis of the results of observational epidemiological studies is reviewed. Uncritical adoption of techniques used in pooled analyses of clinical trial results may be inappropriate. Some alternative approaches, including meta-regression techniques, are discussed, and illustrated with reference to examples of meta-analyses of studies of breast cancer risk following oral contraceptive use and of patterns of post-bereavement mortality. Although substantial difficulties beset the use of meta-analysis in epidemiology, many of these problems are also implicit in the execution of traditional, narrative reviews. Foremost among these difficulties are those associated with publication bias and with making due allowance for the quality of the studies being combined. Unlike traditional narrative reviews, meta-analyses require explicit statement of the criteria for the review and hence highlight these difficulties. Nonetheless, careful and critical application of appropriate meta-analytical techniques facilitates quantitative exploration of inhomogeneities in, and (where appropriate) synthesis of study results.

Intracellular Free-Magnesium Levels in Vascular Smooth Muscle and Striated Muscle Cells of the Spontaneously Hypertensive Rat

Abstract: In humans with essential hypertension and in spontaneously hypertensive rats (SHR), insulin resistance may be present even in lean individuals. As the basis for this abnormality is unknown, we have used a newly developed fluorophore to measure intracellular free-Mg2+ concentrations in cultured aortic vascular smooth muscle cells and striated muscle cells from SHR and normotensive Wistar Kyoto (WKY) rats. Intracellular free-Mg2+ levels were lower in both striated muscle cells (SHR, 0.423 +/- 0.077 mmol.L-1 v WKY, 0.559 +/- 0.068 mmol.L-1; P less than .001) and vascular smooth muscle cells (SHR, 0.406 +/- 0.067 mmol.L-1 v WKY, 0.625 +/- 0.077 mmol.L-1; P less than .001) from hypertensive animals. This widespread, intrinsic defect in the regulation of intracellular Mg2+ may explain the increased vascular resistance and reduced insulin sensitivity present in hypertension.

Intracellular pH and Na+/H+ antiport activity of cultured skin fibroblasts from diabetics.

Abstract: Intracellular pH and Na + /H + antiport activity of cultured skin fibroblasts from diabetics Increased leucocyte Na + /H + antiport activity has previously been demonstrated in both hypertensive subjects and Type 1 diabetic patients with nephropathy and may indicate a predisposition to hypertension in such diabetic patients We have studied intracellular pH and Na + /H + antiport activity in cultured skin fibroblasts from diabetic patients with and without nephropathy, together with nondiabetic controls to assess if such differences persisted in cultured cells Fibroblasts from diabetic patients with nephropathy were significantly more alkaline [median (range): 690 (682 to 707)] compared to both normoalbuminuric diabetic patients [681 (675 to 689)] or normal controls [682 (677 to 693)] (P + /H + antiport activity in cells from patients with nephropathy when intracellular pH (pH i ) was clamped to pH 65, without any differences in the maximal transport capacity of the antiport at pH i 62 Using both intracellular pH and Na + /H + antiport activity at pH i 65, patients with nephropathy were separated from uncomplicated subjects with a sensitivity of 92% and a specificity of 100% In conclusion, the raised Na + /H + antiport activity in cells from patients with diabetic nephropathy persists despite passaging in vitro, thus indicating a heritable component, and results mainly from an increased apparent affinity of the antiport for intracellular H +

Cost effectiveness of a fine needle aspiration clinic.

Abstract: The resource implications of a Fine Needle Aspiration (FNA) Clinic at Northampton General Hospital have been evaluated over a 12 month period using a patient management questionnaire. A total of 490 cases from which fine needle aspirates were taken from superficial sites have been assessed (breast 381, thyroid 46, lymph node 44, salivary gland 9, soft tissue 10). Total resource savings (135,544 pounds) exceeded the expenses of the FNA clinic (27,290 pounds). Potential cost savings per case were the greatest for thyroid aspirates. The FNA clinic where the pathologist takes, stains and reports optimally prepared specimens, provides a high quality and accurate service on which clinicians can confidently base clinical management decisions. Unnecessary investigations and operations are avoided, allowing scant resources to be released for other procedures.

Gaviscon and Carobel compared with cisapride in gastro-oesophageal reflux.

Abstract: We compared the efficacy of the prokinetic agent cisapride with that of Gaviscon (an alginate/alkaline compound) plus Carobel (carob seed flour) in the treatment of gastrooesophageal reflux (GOR). Fifty infants with confirmed GOR received either oral cisapride (0.8 mg/kg/day) or Gaviscon plus Carobel for one month in a randomised, parallel group study. Parental evaluations, diary scores, and 24 hour lower oesophageal pH recordings before and at the end of each treatment were compared. In the cisapride group 14/26 (53%) were considered better by their parents compared with 19/24 (79%) of those who received Gaviscon plus Carobel. Diary scores, range (0.00-1.00), improved in both groups with the median change being greater in the Gaviscon plus Carobel group (-0.21) than the cisapride group (-0.15). Five of 17 pH variables had significantly improved from baseline in infants who had received cisapride compared with 11/17 in those receiving Gaviscon plus Carobel. However, unpaired analysis of diary and pH data showed no significant differences between the two groups. We conclude that first line treatment of GOR with cisapride is no more effective than conventional treatment with Gaviscon plus Carobel.

Epidermal cytokeratin and immunocyte responses during treatment of psoriasis with calcipotriol and betamethasone valerate.

Abstract: Changes in epidermal immunocytes and cytokeratins were investigated during treatment of psoriasis with calcipotriol and betamethasone valerate. Skin biopsies were obtained from 10 subjects on each treatment from lesional and non-lesional skin at baseline, and from treated lesions after 4 weeks. In each subject, changes in expression of cytokeratins K5, K10 and K16, and changes in epidermal immunocyte counts were assessed. Responses were compared with a separate histological parameter of improvement, epidermal thickness. Both treatments produced a marked normalization of cytokeratins. The reduction of K16 expression was similar on each treatment and correlated significantly with reduction in epidermal thickness. Expression of both K5 and K10 improved less than thickness with betamethasone valerate but more than thickness with calcipotriol, although these differences did not reach statistical significance. With calcipotriol there was an increase in K5 and K10 responses with increasing response of epidermal thickness, which was not seen with betamethasone valerate. T6+ cells, HLA-DR+ dendritic cells and T lymphocytes were all reduced by betamethasone valerate. There was a remarkable similarity in the level of normalization between cell types and also between cellular response and reduction in thickness. Calcipotriol produced a similar consistent reduction in cell numbers and in thickness, with the exception of T6+ cells which increased in some subjects during treatment. Only in subjects in whom thickness had virtually returned to normal was there a marked decrease in T6+ cells.

Follicle mites and their role in disease.

Abstract: Demodex folliculorum (Simon), the follicle mite, is an obligate parasite ofthe human pilosebaceous follicle. It was first discovered in cerumen by the anatomist Jakob Henle in 1841, but it was the dermatologist Gustav Simon who in 1842, gave the first complete description of the parasite, under the name Acarus folliculorum.^-^ The generic name Demodex was created for it in 1843 by the zoologist Richard Owen.