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Reich K.,Dermatologikum Hamburg | Burden A.D.,Western Infirmary | Eaton J.N.,Health Economics | Hawkins N.S.,Health Economics
British Journal of Dermatology | Year: 2012

Background Ustekinumab, a novel monoclonal antibody for the treatment of moderate to severe plaque-type psoriasis, has recently received regulatory approval in Europe, bringing the total number of biologic agents licensed in this indication to five. To assist treatment selection in daily practice it is essential to understand the benefit/risk profile of these agents and in the absence of a clinical trial comparing all available biologics a number of reviews have used statistical techniques to generate estimates of the comparative effectiveness of these therapies through the available network of randomized clinical trials. These estimates have previously been published for a limited range of psoriasis biologic treatments, although, to date no review has compared all the currently available agents in Europe. Objectives To estimate the comparative effectiveness of all biologic agents indicated in the treatment of moderate to severe psoriasis currently available in Europe based on the primary trial endpoints. Methods A number of databases were searched for details of randomized controlled trials of available biologics in the treatment of plaque-type psoriasis in adults. Comparative effectiveness was estimated based on the reported Psoriasis Area and Severity Index (PASI) 50, 75 and 90 response rates. A network meta-analysis conducted on the ordered probit scale and implemented as a Bayesian hierarchical model provided estimates for the probability of response and relative risk vs. placebo, based on all observed comparisons. Results Twenty trials were included in the meta-analysis including patients with a mean disease duration of 18-22 years. Based on the indirect comparison and given a placebo PASI 50 response of 13%, infliximab had the highest predicted mean probability of response at PASI levels 50 (93%), 75 (80%) and 90 (54%), followed by ustekinumab 90 mg at 90%, 74% and 46%, respectively, and then ustekinumab 45 mg, adalimumab, etanercept and efalizumab. Conclusions The ordered probit model allowed a quantitative comparison of all currently licensed biologics, providing estimates on comparative effectiveness and a suggested ranking of treatments that is of potential use to decision-makers. However, the analysis is based on indirect comparisons of the primary endpoint reported from short-term randomized trials. © 2011 British Association of Dermatologists.


Yeung B.P.M.,Western Infirmary | Gourlay T.,University of Strathclyde
International Journal of Surgery | Year: 2012

Background: Further development of advanced therapeutic endoscopic techniques and natural orifice translumenal endoscopic surgery (NOTES) requires a powerful flexible endoscopic multitasking platform. Methods: Medline search was performed to identify literature relating to flexible endoscopic multitasking platform from year 2004-2011 using keywords: Flexible endoscopic multitasking platform, NOTES, Instrumentation, Endoscopic robotic surgery, and specific names of various endoscopic multitasking platforms. Key articles from articles references were reviewed. Results: Flexible multitasking platforms can be classified as either mechanical or robotic. Purely mechanical systems include the dual channel endoscope (DCE) (Olympus), R-Scope (Olympus), the EndoSamurai (Olympus), the ANUBIScope (Karl-Storz), Incisionless Operating Platform (IOP) (USGI), and DDES system (Boston Scientific). Robotic systems include the MASTER system (Nanyang University, Singapore) and the Viacath (Hansen Medical). The DCE, the R-Scope, the EndoSamurai and the ANUBIScope have integrated visual function and instrument manipulation function. The IOP and DDES systems rely on the conventional flexible endoscope for visualization, and instrument manipulation is integrated through the use of a flexible, often lockable, multichannel access device. The advantage of the access device concept is that it allows optics and instrument dissociation. Due to the anatomical constrains of the pharynx, systems are designed to have a diameter of less than 20 mm. All systems are controlled by traction cable system actuated either by hand or by robotic machinery. In a flexible system, this method of actuation inevitably leads to significant hysteresis. This problem will be accentuated with a long endoscope such as that required in performing colonic procedures. Systems often require multiple operators. To date, the DCE, the R-Scope, the IOP, and the Viacath system have data published relating to their application in human. Conclusion: Alternative forms of instrument actuation, camera control and master console ergonomics should be explored to improve instrument precision, sphere of action, size and minimize assistance required. © 2012 Surgical Associates Ltd.


Burton F.,Western Infirmary
Emergency Medicine Journal | Year: 2012

A short cut review was carried out to establish whether capnography should be routinely used during procedural sedation in Emergency Departments. 206 papers were found using the reported searches, of which nine presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. It is that capnography may provide early warning of ventilatory changes that could result in hypoxia.


McArthur C.,Western Infirmary | Geddes C.C.,Western Infirmary | Baxter G.M.,Western Infirmary
Radiology | Year: 2011

Purpose: To correlate pulsatility index (PI) and resistive index (RI) measured at early specific intervals after transplantation with 1-year estimated glomerular filtration rate (eGFR) and death-censored transplant survival to assess the long-term prognostic value of these Doppler indexes. Materials and Methods: The local ethics committee was consulted, and no formal approval was required. This retrospective review included 178 consecutive patients (111 male, 67 female; mean age, 43.9 years ± 13.4 [standard deviation]; age range, 16-72 years) undergoing first deceased-donor renal transplantation between 1997 and 2000. All patients were identified from a prospectively maintained database. Spectral Doppler analysis was performed within 1 week after transplantation in all patients and between 1 week and 3 months after transplantation in 124 patients. Average PI and RI were determined from measurements obtained in the upper, lower, and interpolar regions. For statistical analysis, the χ2 test, analysis of variance, the Student t test, Kaplan-Meier survival plots, and Cox proportional hazards models were used. Results: Within 1 week after transplantation, there was a significant association between PI and 1-year eGFR when analyzed as tertiles(P = .02). Between 1 week and 3 months after transplantation, there was a significant relationship between 1-year eGFR and both PI and RI when comparing the lowest and highest tertiles (47.5 mL/min/1.73 m2 for PI <1.26 vs 32.7 mL/min/1.73 m2 for PI >1.49 [P = .01], 42.8 mL/min/1.73 m2 for RI <0.69 vs 32.3 mL/min/1.73 m2 for RI >0.74 [P = .03]). Both PI and RI were independent predictors of death-censored transplant survival (hazard ratio, 1.68 per unit [P < .001] and 260.4 per unit, respectively [P = .02]). Conclusion: PI and RI in the early posttransplantation period correlate with long-term transplant function and can potentially be used as prognostic markers to aid risk stratification for future transplant dysfunction. © RSNA, 2011.


Jackson A.J.,Western Infirmary
Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association | Year: 2012

Renal failure is a major cause of morbidity in western Europe, with rising prevalence. Vascular access complications are the leading cause of morbidity among patients on haemodialysis. Considering the health care burden of vascular access failure, there is limited research dedicated to the topic. Randomised control trials of medications aimed at improving vascular access patency were identified using a medline search between January 1950 and January 2011. Thirteen randomised trials were identified, investigating antiplatelets, anticoagulants and fish oil in preserving vascular access patency. Outcomes are presented and reviewed in conjunction with the underlying pathophysiological mechanisms of failure of vascular access. Vascular access failure is a complex process. Most clinical trials so far have involved medications primarily aimed at preventing thrombosis. Other contributing pathways such as neointimal hyperplasia have not been investigated clinically. Improved outcomes may be seen by linking future therapies to these pathways.


Leman J.,Western Infirmary
The British journal of dermatology | Year: 2012

A number of biologic agents, including the tumour necrosis factor (TNF) antagonists etanercept, adalimumab and infliximab, and the interleukin (IL)-12/IL-23 antagonist ustekinumab, are available for the treatment of moderate-to-severe plaque psoriasis in the U.K. Currently, the selection of the first biologic, and the choice of sequential biologics in the event of efficacy/tolerability concerns, is made using a limited evidence base. The efficacy of biologics, the potential mechanisms of primary and secondary failure and the evidence for sequencing therapy among TNF antagonists and between TNF antagonists and IL-12/IL-23 blockade are reviewed. As psoriasis biologics registers begin to produce long-term safety and efficacy data, therapy decisions in plaque psoriasis may become more objective, and it may be possible to individualize treatment based on clinical or pharmacogenetic information. © 2012 The Authors. BJD © 2012 British Association of Dermatologists.


Aitken E.L.,Western Infirmary | Jackson A.J.,Western Infirmary | Kingsmore D.B.,Western Infirmary
Journal of Vascular Access | Year: 2014

Purpose: Early cannulation arteriovenous grafts (ecAVGs), such as the GORE® Acuseal™, have “low bleed” properties permitting cannulation within 24 hours of insertion. They may provide an alternative to tunneled central venous catheters (and associated line complications) in patients requiring urgent vascular access. Methods: We present our early experience of 37 patients treated with the GORE® Acuseal™ ecAVG. Results: A total of 11 upper limb, 24 lower limb and 2 complex graft procedures were performed. Indications for ecAVG were as follows: bridge to transplantation (21.6%); bridge to arteriovenous fistula (AVF) maturation (8.1%); AVF salvage (8.1%); no native options (67.6%, including 17 patients with bilateral central vein stenosis); 36 AVGs (97.3%) were successfully cannulated. Mean time to first cannulation: 30.4±23.4 hours (range: 2-192). Primary and secondary patency rates at 3, 6 and 12 months were 64.9%, 48.6%, 32.4% and 70.2%, 59.4%, 40.5% respectively. The systemic bacteremia rate was 0.2 per 1,000 access days. There was one perioperative death. Other complications included hematoma at cannulation sites (n=9), pseudoaneurysm (n=3) and local infection at graft site (n=6). A total of 26 of 37 patients (70.6%) achieved a “personal vascular access solution”: bridge to transplantation (n=8), bridge to functioning AVF/interposition AVG (n=5), maintenance hemodialysis via ecAVG (n=13); death with functioning AVG (n=1). Conclusions: Early experience with the GORE® Acuseal™ is encouraging. Patency and bacteremia rates are at least comparable to standard polytetrafluoroethylene grafts. ecAVGs have permitted cannulation within 24 hours of insertion and line avoidance in the majority of patients. Nearly three-quarters of patients achieved a definitive “personal vascular access solution” from their ecAVG. © 2014 Wichtig Publishing.


Plenderleith J.L.,Western Infirmary
Anaesthesia and Intensive Care Medicine | Year: 2013

Clinical information systems (CIS) are used to help manage the large amount of data generated in an intensive care unit every day. Linkage to laboratories, monitoring and other systems simplifies acquisition and increases the accuracy of data entered into the patient record. Once data are in the CIS they can be viewed in different ways without re-entry to improve patient care. The addition of decision support gives another dimension to CIS. The concentration of data in one place simplifies audit, quality improvement and obtains management information more easily compared to paper notes. CIS are large complex systems with challenges and risks that differ from paper notes and need to be considered during introduction. Crown Copyright © 2013 Published by Elsevier Ltd. All rights reserved.


Robertson E.G.,Western Infirmary | Baxter G.,Western Infirmary
Clinical Radiology | Year: 2011

The demand for percutaneous needle biopsy is greater than ever before and with the majority of procedures requiring imaging guidance, radiologists have an increasingly important role in the diagnostic work-up of patients with suspected malignancy. All invasive procedures incur potential risks; therefore, clinicians should be aware of the most frequently encountered complications and have a realistic idea of their likelihood. Tumour seeding, whereby malignant cells are deposited along the tract of a biopsy needle, can have disastrous consequences particularly in patients who are organ transplant candidates or in those who would otherwise expect good long-term survival. Fortunately, tumour seeding is a rare occurrence, yet the issue invariably receives a high profile and is often regarded as a major contraindication to certain biopsy procedures. Although its existence is in no doubt, realistic insight into its likelihood across the spectrum of biopsy procedures and multiple anatomical sites is required to permit accurate patient counselling and risk stratification. This review provides a comprehensive overview of tumour seeding and examines the likelihood of this much feared complication across the range of commonly performed diagnostic biopsy procedures. Conclusions have been derived from an extensive analysis of the published literature, and a number of key recommendations should assist practitioners in their everyday practice. © 2011 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.


McArthur C.,Western Infirmary | Baxter G.M.,Western Infirmary
Clinical Radiology | Year: 2012

The combination of microbubble technology and complementary ultrasound techniques has resulted in the development of contrast-enhanced ultrasound (CEUS) and, although initial clinical applications largely focussed on the liver, these are now becoming more diverse. With regard to the kidney, it is a safe, well-tolerated, and reproducible technique, and in selected cases, can obviate the need for computed tomography or magnetic resonance imaging. A clear advantage is the absence of nephrotoxicity. With respect to the current and potential renal applications, it is a useful technique in the evaluation of pseudotumours, acute pyelonephritis, renal tumours, cystic lesions, vascular insults, and renal transplantation. It may also be of value for monitoring the kidney following anti-angiogenic treatment or nephron-sparing interventional techniques for renal tumours. Assessment of microvascular perfusion using time-intensity curves is also likely to have further far-reaching applications in the kidney as well as other organs. © 2012 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

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