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Pearson G.A.,Royal Devon and Exeter NHS Foundation Trust | MacKenzie I.Z.,University of Oxford
European Journal of Obstetrics Gynecology and Reproductive Biology | Year: 2013

Objective To determine the range of, and influences on, the incision-delivery interval (IDI) and the impact on neonatal condition at delivery. Study design Analysis of prospectively collected cohort data from all women delivered by caesarean section over 12 months in an obstetric unit delivering 6000 women per year. Prospective data were collected from clinical records, with factors that influence IDI and relationship to neonatal condition at birth as the main outcome measures. Results IDI was recorded for 1379 (93%) caesarean sections and ranged between 1 and 37 min; median (IQR) was 6 (5-8) min, and for 3% the interval was longer than 15 min. Category 1 and 2 caesarean sections had shorter IDI than categories 3 and 4 and intrapartum operations had significantly shorter IDI at 5 (3-8) min than antepartum at 7 (5-9) min (P < 0.0001). Factors associated with longer IDI included previous delivery by caesarean section, increased maternal body mass index (BMI), regional anaesthesia, larger neonatal birthweight and technical problems including intraperitoneal adhesions, but did not include fetal malpresentation, multiple pregnancy, grade of surgeon or stage of labour. IDI had no impact on neonatal condition at birth. Conclusions Prolonged IDI does not adversely affect neonatal outcome, but factors associated with prolonged IDI should be acknowledged when assessing decision-to-delivery interval target times. © 2013 Elsevier Ireland Ltd. All rights reserved.

Morgan M.S.,Royal Devon and Exeter NHS Foundation Trust
Journal of Hospital Infection | Year: 2010

Necrotising fasciitis (NF) is situated with myositis and myonecrosis at the severe end of a spectrum of skin and soft tissue infections but is far removed from erisepelas, impetigo and cellulitis. Inexperienced clinicians are easily misled by the protean manifestations of infection, especially exotoxin or superantigen mediated consequences from streptococcal NF. Early clinical suspicion and surgery are key to improving survival, and patients with NF need integrated multidisciplinary management, adjusted to the infecting organism(s), the site of infection, and the effects from any toxins produced. A multiparametric approach, incorporating various clinical and laboratory parameters, can aid aggressive management. This review describes the diagnosis and management of the major types of NF, emphasising important aetiological clues from the history and the appropriate usage of diagnostic investigations. The potential benefits of controversial therapeutic approaches, including hyperbaric oxygen and intravenous immunoglobulin, are discussed. © 2010 The Hospital Infection Society.

Morgan M.,Royal Devon and Exeter NHS Foundation Trust
Injury | Year: 2011

MRSA is becoming increasingly common worldwide. With the emergence of new highly spreadable strains (community associated or CA-MRSA) novel presentation skin and soft tissue infections (SSTI) are being seen. Recurrent SSTI, including folliculitis, furunculosis and abscesses account for an increasing proportion of SSTI seen in the emergency department. Empirical antimicrobial management choices can be difficult, but clues to the nature of the MRSA may be gleaned from the history and clinical presentation. More severe SSTI due to necrotising fasciitis and purpura fulminans are emerging and warrant the broadest possible empirical Gram-positive cover, ideally with antimicrobials that stop exotoxin production, and sometimes intravenous immunoglobulin to neutralise exotoxins already produced. © 2011 Elsevier Ltd. All rights reserved.

Akram A.,Royal Devon and Exeter NHS Foundation Trust
Orthodontics : the art and practice of dentofacial enhancement | Year: 2011

Previous studies have reported significant discrepancies between the surgical treatment objectives and final surgical results in orthognathic surgery patients. When dealing with complex asymmetrical maxillary movements in bimaxillary osteotomy patients, it can often be difficult to reposition the maxilla with a desirable degree of accuracy at the planning stage. Inaccurate placement of the maxilla can result in an unwanted repositioning of the mandible, which can lead to less than ideal functional and esthetic outcomes. The use of a model respositioning frame for orthognathic surgical planning is demonstrated. This can be utilized to position the maxilla at the model surgery stage with increased accuracy in both the vertical and horizontal plane. This frame can be used on semiadjustable articulators.

McDonald T.J.,Royal Devon and Exeter NHS Foundation Trust | McDonald T.J.,University of Exeter | Ellard S.,University of Exeter
Annals of Clinical Biochemistry | Year: 2013

Maturity-onset diabetes of the young (MODY) is a monogenic disorder that results in a familial, young-onset non-insulin dependent form of diabetes, typically presenting in lean young adults before 25 years. Approximately 1% of diabetes has a monogenic cause but this is frequently misdiagnosed as Type 1 or Type 2 diabetes. A correct genetic diagnosis is important as it often leads to improved treatment for those affected with diabetes and enables predictive genetic testing for their asymptomatic relatives. An early diagnosis together with appropriate treatment is essential for reducing the risk of diabetic complications in later life. Mutations in the GCK and HNF1A/4 A genes account for up to 80% of all MODY cases. Mutations in the GCK gene cause a mild, asymptomatic and non-progressive fasting hyperglycaemia from birth usually requiring no treatment. In contrast, mutations in the genes encoding the transcription factors HNF1A and HNF4A cause a progressive insulin secretory defect and hyperglycaemia that can lead to vascular complications. The diabetes in these patients is usually well controlled with sulphonylurea tablets although insulin treatment may be required in later life. In this review, we outline the key clinical and laboratory characteristics of the common and rarer causes of MODY with the aim of raising awareness of this condition amongst health-care scientists. © The Author(s) 2013.

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