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Caven M, Baiano CX, Robinson EM, Stephens B, Macpherson I, Dillon JF. Hepatitis C reinfection by treatment pathway among people who inject drugs in Tayside, Scotland. J Viral Hepat 2021; 28:1744-1750. [PMID: 34525228 DOI: 10.1111/jvh.13614] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 09/06/2021] [Accepted: 09/08/2021] [Indexed: 01/03/2023]
Abstract
The efficacy of direct-acting antivirals (DAA) provides an excellent opportunity to scale up HCV diagnosis and treatment, achieving the WHO target of HCV elimination by 2030. However, HCV reinfection among people who inject drugs (PWID) remains a concern and may impede elimination efforts. We assessed reinfection rates among PWID across six specialized treatment pathways, following DAA-based and interferon-based therapies in Tayside, Scotland. Data were collected retrospectively for every treatment episode that resulted in a sustained viral response (SVR) after undergoing treatment. Reinfection rates were calculated for each treatment pathway: hospital outpatient clinic; community pharmacy; drug treatment outreach; prison clinic; nurse-led outreach clinic; and injection equipment provision site. Reinfection is defined as a positive RNA test result after SVR. Incidences of reinfection are expressed in 100 person-years (PYs). In total, 916 treatment episodes met selection criteria. Of these, 100 reinfections were identified, generating an overall reinfection rate of 5.27 per 100 PYs (95%CI: 4.36-6.38). The hospital outpatient clinic had the lowest reinfection incidence (1.81 per 100 PYs, 95%CI: 1.11-2.93), with the injection equipment provision site treatment pathway having the highest reinfection incidence (19.89 per 100 PYs, 95%CI: 14.91-26.54). The incidence of reinfection among those treated with interferon-based therapies and those treated with DAA-based therapies was 4.93 per 100 PYs (95%CI: 3.97-6.11) and 7.17 per 100 PYs (95%CI: 4.75-10.82), respectively. Specialized treatment pathways in Tayside yield varying reinfection incidence rates, with different subpopulations of patients at varying risk of reinfection post-SVR. Results suggest that resources should be targeted at the injection equipment provision site pathway in order to reduce the incidence of reinfection and achieve elimination targets. The study found comparable rates of reinfection following interferon-based and DAA-based therapies, providing support for widening access to treatment services.
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Affiliation(s)
- Madeleine Caven
- Gut Group, Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, United Kingdom
| | - Cassandra X Baiano
- Gut Group, Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, United Kingdom
| | - Emma M Robinson
- Gut Group, Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, United Kingdom.,Department of Gastroenterology, NHS Tayside, Ninewells Hospital, Dundee, United Kingdom
| | - Brian Stephens
- Gut Group, Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, United Kingdom
| | - Iain Macpherson
- Gut Group, Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, United Kingdom
| | - John F Dillon
- Gut Group, Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, United Kingdom.,Department of Gastroenterology, NHS Tayside, Ninewells Hospital, Dundee, United Kingdom
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Baiano CX, Caven M, Robinson EM, Dillon JF. Evaluating and communicating hepatitis C cascades of care data in Tayside, Scotland: A journey towards elimination. J Viral Hepat 2021; 28:909-915. [PMID: 33759258 DOI: 10.1111/jvh.13505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 01/15/2021] [Accepted: 03/08/2021] [Indexed: 12/09/2022]
Abstract
Chronic hepatitis C virus (HCV) is one of the leading causes of liver cirrhosis and hepatocellular carcinoma. The WHO 2030 Elimination Goals require each country to evaluate their response to their epidemics. This can be achieved by visualization of cascades of care, depicting how infected cases move through disease control stages. However, methods of displaying data are debated and lack practical application. This project proposes a new way of codifying and displaying HCV data using Tayside as a case study. 1464 cases of active HCV infections in Tayside from 2015 to 2019 were analysed from NHS Tayside's HCV Database. Variables were evaluated to create a systematic coding framework that was then used to code each patient's diagnosis, treatment and cure status each year from 2015 to 2019. Graphical representation of the data in the form of a stacked clustered bar chart demonstrates general trends and conversion rates. For example, Tayside has seen an increase in diagnosis-to-cure rates from 18% to 49% (2015-2019). This method also demonstrates the portion of newly and previously diagnosed people accessing treatment, those with unsuccessful or incomplete treatments, completed treatments with unconfirmed cure, and the number of deaths and relocations. In conclusion, this project proposes a novel way of displaying cascades of care data that relays yearly snapshots of an epidemic, cumulative progression over time, nuanced information of each stage and progression towards elimination targets. This method can be meaningfully used to improve local service planning, knowledge exchange across health systems and reporting to bodies like the WHO.
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Affiliation(s)
- Cassandra X Baiano
- Ninewells Hospital, University of Dundee Medical School, Dundee, Scotland
| | - Madeleine Caven
- Gut Group, Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, Scotland
| | - Emma M Robinson
- Gut Group, Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, Scotland.,Department of Gastroenterology, NHS Tayside, Ninewells Hospital, Dundee, Scotland
| | - John F Dillon
- Gut Group, Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, Scotland.,Department of Gastroenterology, NHS Tayside, Ninewells Hospital, Dundee, Scotland
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Macpherson I, Nobes JH, Dow E, Furrie E, Miller MH, Robinson EM, Dillon JF. Intelligent Liver Function Testing: Working Smarter to Improve Patient Outcomes in Liver Disease. J Appl Lab Med 2020; 5:1090-1100. [DOI: 10.1093/jalm/jfaa109] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Accepted: 06/18/2020] [Indexed: 12/30/2022]
Abstract
Abstract
Chronic liver disease (CLD) is a significant health problem affecting millions of people worldwide. In Scotland, CLD is a major cause of premature mortality. Liver function tests (LFTs) are a panel of frequently requested blood tests which may indicate liver disease. However, LFTs commonly contain at least one abnormal result, and abnormalities are rarely investigated to the extent recommended by national guidelines. The intelligent Liver Function Testing (iLFT) pathway is a novel, automated system designed to improve early diagnosis of liver disease. Initial abnormal LFT results trigger a cascade of reflexive testing to help identify the cause of any liver dysfunction. Algorithms combine these results with demographic and clinical data (such as patient age, body mass index, and alcohol intake) and fibrosis estimates to produce an electronic diagnosis and management plan. The pilot trial demonstrated that iLFT increased diagnosis of liver disease whilst remaining cost-effective. As such, iLFT has been fully operational across our region (NHS Tayside, Scotland) since August 2018. In the first year, iLFT generated over 2000 diagnoses from 1824 patient samples with an abnormality in the initial LFTs. The majority of these patients could be safely managed in primary care. iLFT allows maximal value to be obtained from liver blood tests across biochemistry, virology, immunology, and hematology with only minor changes to working practices. ‘Intelligent’, algorithm-led testing pathways break down the barrier between clinical and laboratory medicine and offer solutions to many of the challenges experienced in modern healthcare systems.
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Affiliation(s)
- Iain Macpherson
- Division of Clinical and Molecular Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Jennifer H Nobes
- Department of Blood Sciences, NHS Tayside, Ninewells Hospital and Medical School, Dundee, UK
| | - Eleanor Dow
- Department of Blood Sciences, NHS Tayside, Ninewells Hospital and Medical School, Dundee, UK
| | - Elizabeth Furrie
- Department of Blood Sciences, NHS Tayside, Ninewells Hospital and Medical School, Dundee, UK
| | - Michael H Miller
- Department of Gastroenterology and Hepatology, NHS Tayside, Ninewells Hospital and Medical School, Dundee, UK
| | - Emma M Robinson
- Department of Gastroenterology and Hepatology, NHS Tayside, Ninewells Hospital and Medical School, Dundee, UK
| | - John F Dillon
- Division of Clinical and Molecular Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
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Caven M, Robinson EM, Eriksen AJ, Fletcher EH, Dillon JF. Hepatitis C diagnosis and treatment, impact on engagement and behaviour of people who inject drugs, a service evaluation, the hooked C project. J Viral Hepat 2020; 27:576-584. [PMID: 31997542 DOI: 10.1111/jvh.13269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 01/14/2020] [Accepted: 01/16/2020] [Indexed: 12/09/2022]
Abstract
There is emerging evidence that Hepatitis C (HCV) treatment engagement is associated with change in drug behaviours and reduced drug-related death rates among people who inject drugs (PWID). The project aims to investigate whether HCV diagnosis and treatment engagement reduces all-cause mortality and drug-related death, and whether any effect is dependent on treatment regimen and intensity of engagement with staff. Case-control studies comparing: PWID with active HCV infection (PCR positive) to PWID HCV infected but spontaneously resolved (PCR negative); PCR-positive patients who engaged with treatment services to nonengagers; and patients who received interferon vs direct-acting antiviral (DAA) based treatment. No differences in risk of all-cause mortality or drug-related death between PCR-negative controls and PCR-positive cases were detected. The odds of all-cause mortality was 12.2 times higher in nonengaging persons compared to treatment engaging cases (aOR 12.15, 95% CI 7.03-20.99, P < .001). The odds of a drug-related death were 5.5 times higher in nonengaging persons compared with treatment engaging cases (aOR 5.52, 95% CI 2.67- 11.44, P < .001). No differences in risk of all-cause mortality or drug-related death between interferon-treated cases and DAA-treated controls were detected. HCV treatment engagement is significantly protective against all-cause mortality and drug-related death. This engagement effect is independent of treatment regimen, with the introduction of DAA therapies not increasing risk of drug-related death, suggesting intensity of HCV therapy provider interaction is not an important factor.
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Affiliation(s)
- Madeleine Caven
- Gut Group, Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, Scotland
| | - Emma M Robinson
- Gut Group, Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, Scotland.,Department of Gastroenterology, NHS Tayside, Ninewells Hospital, Dundee, Scotland
| | - Ann J Eriksen
- Public Health Directorate, NHS Tayside, Kings Cross Hospital, Dundee, Scotland
| | - Emma H Fletcher
- Gut Group, Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, Scotland.,Public Health Directorate, NHS Tayside, Kings Cross Hospital, Dundee, Scotland
| | - John F Dillon
- Gut Group, Division of Molecular and Clinical Medicine, School of Medicine, University of Dundee, Dundee, Scotland.,Department of Gastroenterology, NHS Tayside, Ninewells Hospital, Dundee, Scotland
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Lazarus JV, Pericàs JM, Picchio C, Cernosa J, Hoekstra M, Luhmann N, Maticic M, Read P, Robinson EM, Dillon JF. We know DAAs work, so now what? Simplifying models of care to enhance the hepatitis C cascade. J Intern Med 2019; 286:503-525. [PMID: 31472002 DOI: 10.1111/joim.12972] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Globally, some 71 million people are chronically infected with hepatitis C virus (HCV). Marginalized populations, particularly people who inject drugs (PWID), have low testing, linkage to care and treatment rates for HCV. Several models of care (MoCs) and service delivery interventions have the potential to improve outcomes across the HCV cascade of care, but much of the relevant research was carried out when interferon-based treatment was the standard of care. Often it was not practical to scale-up these earlier models and interventions because the clinical care needs of patients taking interferon-based regimens imposed too much of a financial and human resource burden on health systems. Despite the adoption of highly effective, all-oral direct-acting antiviral (DAA) therapies in recent years, approaches to HCV testing and treatment have evolved slowly and often remain rooted in earlier paradigms. The effectiveness of DAAs allows for simpler approaches and has encouraged countries where the drugs are widely available to set their sights on the ambitious World Health Organization (WHO) HCV elimination targets. Since a large proportion of chronically HCV-infected people are not currently accessing treatment, there is an urgent need to identify and implement existing simplified MoCs that speak to specific populations' needs. This article aims to: (i) review the evidence on MoCs for HCV; and (ii) distil the findings into recommendations for how stakeholders can simplify the path taken by chronically HCV-infected individuals from testing to cure and subsequent care and monitoring.
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Affiliation(s)
- J V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain
| | - J M Pericàs
- Infectious Diseases and Clinical Microbiology Territorial Direction, Translational Research Group on Infectious Diseases of Lleida (TRIDLE), Biomedical Research Institute Dr Pifarré Foundation, Lleida, Spain
| | - C Picchio
- Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain
| | - J Cernosa
- Clinic for Infectious Diseases and Febrile Illnesses, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - M Hoekstra
- Barcelona Institute for Global Health (ISGlobal), Barcelona, Spain
| | - N Luhmann
- Médecins du Monde France, Paris, France
| | - M Maticic
- Clinic for Infectious Diseases and Febrile Illnesses, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - P Read
- Kirketon Road Centre, Sydney, NSW, Australia
| | - E M Robinson
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, UK
| | - J F Dillon
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital, University of Dundee, Dundee, UK
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Dillon JF, Miller MH, Robinson EM, Hapca A, Rezaeihemami M, Weatherburn C, McIntyre PG, Bartlett B, Donnan PT, Boyd KA, Dow E. Intelligent liver function testing (iLFT): A trial of automated diagnosis and staging of liver disease in primary care. J Hepatol 2019; 71:699-706. [PMID: 31226388 DOI: 10.1016/j.jhep.2019.05.033] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 05/10/2019] [Accepted: 05/18/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND & AIMS Liver function tests (LFTs) are frequently requested blood tests which may indicate liver disease. LFTs are commonly abnormal, the causes of which can be complex and are frequently under investigated. This can lead to missed opportunities to diagnose and treat liver disease at an early stage. We developed an automated investigation algorithm, intelligent liver function testing (iLFT), with the aim of increasing the early diagnosis of liver disease in a cost-effective manner. METHODS We developed an automated system that further investigated abnormal LFTs on initial testing samples to generate a probable diagnosis and management plan. We integrated this automated investigation algorithm into the laboratory management system, based on minimal diagnostic criteria, liver fibrosis estimation, and reflex testing for causes of liver disease. This algorithm then generated a diagnosis and/or management plan. A stepped-wedged trial design was utilised to compare LFT outcomes in general practices in the 6 months before and after introduction of the iLFT system. Diagnostic outcomes were collated and compared. RESULTS Of eligible patients with abnormal LFTs, 490 were recruited to the control group and 64 were recruited to the intervention group. The primary diagnostic outcome was based on the general practitioner diagnosis, which agreed with the iLFT diagnosis in 67% of cases. In the iLFT group, the diagnosis of liver disease was increased by 43%. Additionally, there were significant increases in the rates of GP visits after diagnosis and the number of referrals to secondary care in the iLFT group. iLFT was cost-effective with a low initial incremental cost-effectiveness ratio of £284 per correct diagnosis, and a saving to the NHS of £3,216 per patient lifetime. CONCLUSIONS iLFT increases liver disease diagnoses, improves quality of care, and is highly cost-effective. This can be achieved with minor changes to working practices and exploitation of functionality existing within modern laboratory diagnostics systems. LAY SUMMARY There is a growing epidemic of advanced liver disease, this could be offset by early detection and management. Checking liver blood tests (LFTs) should be an opportunity to diagnose liver problems, but abnormal results are often incompletely investigated. In this study we were able to substantially increase the diagnostic yield of the abnormal LFTs using the automated intelligent LFT system. With the addition of referral recommendations and management plans, this strategy provides optimum investigation and management of LFTs and is cost saving to the NHS.
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Affiliation(s)
- John F Dillon
- Division of Clinical and Molecular Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Michael H Miller
- Division of Clinical and Molecular Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Emma M Robinson
- Division of Clinical and Molecular Medicine, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK.
| | - Adrian Hapca
- Dundee Epidemiology and Biostatistics Unit, University of Dundee, Dundee, UK
| | | | | | - Paul G McIntyre
- Department of Microbiology and Virology, Ninewells Hospital and Medical School, Dundee, UK
| | - Bill Bartlett
- Department of Clinical Sciences, Ninewells Hospital and Medical School, Dundee, UK
| | - Peter T Donnan
- Dundee Epidemiology and Biostatistics Unit, University of Dundee, Dundee, UK
| | - Kathleen A Boyd
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Ellie Dow
- Department of Clinical Sciences, Ninewells Hospital and Medical School, Dundee, UK
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Groome M, Robinson EM, Mowat C, Morieux AML, Allstaff S. Are patients in the IBD clinic at risk of proctitis secondary to sexually transmitted infections? Frontline Gastroenterol 2017; 8:267-271. [PMID: 29067152 PMCID: PMC5641844 DOI: 10.1136/flgastro-2016-100790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 01/11/2017] [Accepted: 01/19/2017] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE To gauge the potential risk of sexually transmitted infection (STI) as a cause of proctitis in a cohort of patients with inflammatory bowel disease (IBD) and to gauge whether this cohort could benefit from STI testing in the future. DESIGN Patients attending the IBD clinic were given an anonymous questionnaire recording demographics, sexual behaviour, rectal symptoms, history of receptive anal intercourse (RAI), STIs and attitudes towards sexual health screening. SETTING A gastroenterology teaching hospital IBD clinic. PATIENTS 280 consecutive patients attending a teaching hospital IBD clinic over a consecutive 6-week period. All patients had an endoscopic, radiological and/or histological diagnosis of IBD. RESULTS 280 questionnaires were distributed and 274 analysed (3 incomplete, 2 not returned, 1 no sexual activity). 167 female (median: 46 years, range 17-81 years) and 107 males. Two males disclosed RAI and were used as a control. Of the 167 females, 96% were heterosexual, 2.4% were same-sex partners and 1.2% were bisexual. 14% had a history of RAI-this group had more previous STIs (40%) versus those with no history RAI (5%) (p<0.0001; relative risk (RR) 13.41). Chronic rectal pain was more frequent in women with RAI (RR 2.4; p≤0.03). No difference in rectal discharge (RR 1.75; p=0.72) or bleeding (p=0.3). CONCLUSIONS This is the first report of sexual behaviours in a non-genitourinary medicine clinic; giving a unique insight into sexual practices in a cohort of patients with IBD. A past history of STI and RAI can identify risk and we propose testing for those with a history of STI, RAI, men who have sex with men and women aged under 25 years.
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Affiliation(s)
- Maximillian Groome
- Department of Gastroenterology, Ninewells Hospital and Medical School, Dundee, UK
| | - Emma M Robinson
- Department of Gastroenterology, Ninewells Hospital and Medical School, Dundee, UK
| | - Craig Mowat
- Department of Gastroenterology, Ninewells Hospital and Medical School, Dundee, UK
| | | | - Sarah Allstaff
- Tayside Sexual and Reproductive Health Service, Ninewells Hospital and Medical School, Dundee, UK
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Barrett TE, Robinson EM, Usenko S, Sheesley RJ. Correction to Source Contributions to Wintertime Elemental and Organic Carbon in the Western Arctic Based on Radiocarbon and Tracer Apportionment. Environ Sci Technol 2015; 49:13733. [PMID: 26536490 DOI: 10.1021/acs.est.5b05128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
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Barrett TE, Robinson EM, Usenko S, Sheesley RJ. Source Contributions to Wintertime Elemental and Organic Carbon in the Western Arctic Based on Radiocarbon and Tracer Apportionment. Environ Sci Technol 2015; 49:11631-11639. [PMID: 26325404 DOI: 10.1021/acs.est.5b03081] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
To quantify the contributions of fossil and biomass sources to the wintertime Arctic aerosol burden source apportionment is reported for elemental (EC) and organic carbon (OC) fractions of six PM10 samples collected during a wintertime (2012-2013) campaign in Barrow, AK. Radiocarbon apportionment of EC indicates that fossil sources contribute an average of 68 ± 9% (0.01-0.07 μg m(-3)) in midwinter decreasing to 49 ± 6% (0.02 μg m(-3)) in late winter. The mean contribution of fossil sources to OC for the campaign was stable at 38 ± 8% (0.04-0.32 μg m(-3)). Samples were also analyzed for organic tracers, including levoglucosan, for use in a chemical mass balance (CMB) source apportionment model. The CMB model was able to apportion 24-53% and 99% of the OC and EC burdens, respectively, during the campaign, with fossil OC contributions ranging from 25 to 74% (0.02-0.09 μg m(-3)) and fossil EC contributions ranging from 73 to 94% (0.03-0.07 μg m(-3)). Back trajectories identified two major wintertime source regions to Barrow: the Russian and North American Arctic. Atmospheric lifetimes of levoglucosan, ranging from 50 to 320 h, revealed variability in wintertime atmospheric processing of this biomass burning tracer. This study allows for unambiguous apportionment of EC to fossil fuel and biomass combustion sources and intercomparison with CMB modeling.
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Affiliation(s)
- T E Barrett
- The Institute of Ecological, Earth, and Environmental Sciences, Baylor University , One Bear Place #97205, Waco, Texas-76798, United States
| | - E M Robinson
- The Institute of Ecological, Earth, and Environmental Sciences, Baylor University , One Bear Place #97205, Waco, Texas-76798, United States
| | - S Usenko
- The Institute of Ecological, Earth, and Environmental Sciences, Baylor University , One Bear Place #97205, Waco, Texas-76798, United States
- Department of Environmental Science, Baylor University , One Bear Place #97266, Waco, Texas-76798, United States
| | - R J Sheesley
- The Institute of Ecological, Earth, and Environmental Sciences, Baylor University , One Bear Place #97205, Waco, Texas-76798, United States
- Department of Environmental Science, Baylor University , One Bear Place #97266, Waco, Texas-76798, United States
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Abstract
BACKGROUND AND AIM Data from renal transplant and rheumatoid arthritis patients suggest that there is an increased risk of malignancy after treatment with azathioprine. Whether this is true for patients with inflammatory bowel disease remains uncertain. METHOD A retrospective review of clinical notes was performed. RESULTS Azathioprine was given to 626 of 2204 patients (855 with Crohn's disease and 1349 with ulcerative colitis). The mean total duration of azathioprine use was 27 months. The mean follow-up from diagnosis was 13.7 years and the mean follow-up from the start of azathioprine treatment was 6.9 years. Thirty-one cancers were observed in 30 patients treated with azathioprine (4.5%) and 77 cancers were observed in 70 patients not treated with azathioprine (4.5%; P=N.S.). Logistic regression analysis (including in the model the age, sex, diagnosis and extent of disease) showed that treatment with azathioprine did not significantly affect the risk of the development of cancer. Eight patients had lymphoma; three had been given azathioprine (P=N.S.). For patients with ulcerative colitis, the number of colorectal cancers (including high-grade dysplasia) in patients given azathioprine was eight of 355 (2.2%), compared with 28 of 994 (2.8%) for patients not given azathioprine (P=N.S.). The cumulative risk of colorectal cancer or dysplasia/dysplasia-associated lesion or mass (adjusted to exclude post-colectomy patients) after 10, 20, 30 and 40 years of ulcerative colitis was 0.4%, 1.3%, 9%and 15.5%, respectively. CONCLUSION No increased risk of cancer diagnosis following azathioprine treatment was observed.
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Affiliation(s)
- A G Fraser
- Department of Medicine, University of Auckland, New Zealand.
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Affiliation(s)
- E M Robinson
- Massachusetts General Hospital, Boston, MA 02114, USA
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12
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Jackson W, Hofman PL, Robinson EM, Elliot RB, Pilcher CC, Cutfield WS. The changing presentation of children with newly diagnosed type 1 diabetes mellitus. Pediatr Diabetes 2001; 2:154-9. [PMID: 15016180 DOI: 10.1034/j.1399-5448.2001.20403.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Although it is known that the incidence of type 1 diabetes mellitus (DM) in childhood is progressively increasing, it is less clear whether the presentation of newly diagnosed DM is changing. The aim of this study was to establish whether any biochemical or clinical presentation parameters have altered over time. A retrospective study was performed comparing newly diagnosed children with DM in two 24 month time intervals, 8 yrs apart (1988-89 and 1995-96). Fifty-seven children were diagnosed with type 1 DM in 1988-89 and 70 children in 1995-96. At presentation, children born in the later cohort had a higher pH (p < 0.001) and lower serum glucose (p < 0.05). Although the frequency of diabetic ketoacidosis (DKA) was higher in the 1988/89 cohort (63% vs. 42% in 1995/96) the absolute number of children with DKA in each time interval was similar (33 subjects in 1988-89 vs. 30 subjects in 1995/96). Islet cell antibody (ICA) levels were very different between the two cohorts; higher antibody levels were found in the 1988/89 group (p < 0.01). DKA was also associated with higher ICA titres (p < 0.05). Hospital admission stay decreased from 6.5 DS to 3.4 DS over the 8-year period (p < 0.0001). At our institution, the presentation of children with type 1 DM is changing with many more children diagnosed before developing DKA. We speculate that a new environmental factor(s) may be responsible for the absolute increase in patients presenting without DKA, while older etiologies (both genetic and environmental) are responsible for the steady, unchanging number of patients with a more severe presentation. Greater awareness of diabetes in children is not the factor contributing to earlier diagnosis before DKA develops.
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Affiliation(s)
- W Jackson
- Department of Paediatrics, University of Auckland, Auckland, New Zealand
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Watson PD, Denny SJ, Adair V, Ameratunga SN, Clark TC, Crengle SM, Dixon RS, Fa'asisila M, Merry SN, Robinson EM, Sporle AA. Adolescents' perceptions of a health survey using multimedia computer-assisted self-administered interview. Aust N Z J Public Health 2001; 25:520-4. [PMID: 11824987 DOI: 10.1111/j.1467-842x.2001.tb00316.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To ascertain young people's perceptions of an adolescent health survey when administered by multimedia computer assisted self-administered Interview (M-CASI) through analysis of (1) questionnaire item responses and (2) focus group interviews. METHODOLOGY SETTING Auckland, New Zealand, 1999. STUDY TYPE Pilot testing of a 488-item branching questionnaire delivered using a youth-oriented and user-friendly M-CASI interface in a variety of settings using both desktop and laptop computers. Post pilot focus groups of participants identifying their perceptions and experiences of the survey. SAMPLE 110 school students aged 12 to 18 years. RESULTS The mean number of questions answered by participants was 316 with the median time to completion being 48 minutes. On average 65% of the total number of questions were seen and of these 1.5% were deliberately not answered. A high level of acceptability and enjoyment of M-CASI was found in the analysis of focus group responses and agreed with the item responses relating to M-CASI within the questionnaire itself. Participants identified privacy and confidentiality as being particularly important for the honesty of their responses. The passive matrix screens of the computers were popular as they could only be viewed from in front. CONCLUSIONS M-CASI is an acceptable instrument for the administration of a youth health survey. Laptop computers with passive matrix screens are able to enhance perceptions of privacy and confidentiality, which may improve honesty of responses. IMPLICATIONS M-CASI is now feasible and offers advantages in health surveying.
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Affiliation(s)
- P D Watson
- Department of Paediatrics, Faculty of Medicine and Health Sciences, University of Auckland, New Zealand.
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Robinson EM. Advanced practice nursing: virtue ethics as guiding light. Clin Excell Nurse Pract 2001; 5:1-3. [PMID: 11154386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/15/2023]
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Cutfield WS, Luk W, Skinner SJ, Robinson EM. Impaired insulin-mediated glucose uptake in monocytes of short children with intrauterine growth retardation. Pediatr Diabetes 2000; 1:186-92. [PMID: 15016214 DOI: 10.1046/j.1399543x.2000.010403.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
AIMS To determine whether there was an impairment in insulin-mediated glucose uptake in monocytes from short children with intrauterine growth retardation (IUGR) when compared with control subjects. METHODS Circulating monocytes were isolated by histopaque gradient separation followed by adherence. Monocytes were incubated with insulin at the following concentrations; 0, 0.1, 0.2, 0.6, 1, 2 and 6 nm. 2-deoxyglucose (2-DG) uptake was measured after incubation with [(3)H]2-DG and expressed as pmol/min/10(6) cells. Insulin-stimulated glucose uptake was determined in two ways: 6 nm insulin concentration minus baseline (6-0 nm) and the regression slope of glucose uptake over the range of log insulin concentrations (slope value). Insulin sensitivity was determined from a 90-min frequently sampled intravenous glucose tolerance test with the minimal model. RESULTS Short children with IUGR (n = 16) had lower slope (4.6 +/- 1.1 vs. 9.5 +/- 2.0, p = 0.002) and 6-0 nm (8 +/- 2 vs. 15 +/- 3 pmol/min/10(6) cells, p = 0.048) glucose uptake values than normal children (n = 11). There was no difference in baseline glucose uptake between IUGR and normal children (36 +/- 5 vs. 48 +/- 7 pmol/min/10(6) cells). In the five subjects with IUGR that were evaluated, the in vivo insulin sensitivity index and glucose effectiveness were found to be positively correlated with insulin-mediated glucose uptake in monocytes (r = 0.54) and baseline glucose uptake in monocytes, respectively (r = 0.69). CONCLUSIONS Short children with IUGR have impairment in insulin-mediated glucose uptake in monocytes when compared with normal children. Our hitherto limited data indicate that insulin-mediated glucose uptake in monocytes is correlated with in vivo assessment of insulin sensitivity in children with IUGR.
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Affiliation(s)
- W S Cutfield
- Department of Paediatrics, University of Auckland, Auckland, New Zealand.
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Robinson EM. Wives' struggle in living through treatment decisions for husbands with advanced Alzheimer's disease. J Nurs Law 2000; 7:21-39. [PMID: 12545984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
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Abstract
OBJECTIVE To evaluate if the positive effects of an initially successful emergency department protocol of care for victims of partner abuse (PA) were maintained at one year follow-up. METHOD A community intervention trial compared two public hospital EDs in Auckland, NZ, at baseline (BL), following implementation of a PA intervention (PI), and at one year follow-up (FU). The initial intervention involved training staff at one ED in a protocol for the identification and acute management of abused women. Later, an on-site protocol co-ordinator worked to ensure that new staff received training in protocol use. Outcomes were assessed by reviewing a random sample of women's medical records. Identification of PA was assessed for each record on a yes/no basis. Identified cases were classified as 'confirmed' or 'suspected' PA. Acute management was assessed by ascertaining staff use of interventions and documentation of abuse. RESULTS Approximately equal numbers of records were reviewed at each ED at BL, PI and FU (total n = 10,961). Significant interactions were found for classification of PA and acute management offered to victims between EDs over the different study phases. However, the increase in identification of confirmed cases and the improved acute management offered to identified victims found at the intervention ED in the PI phase were not maintained at follow-up. CONCLUSION Although staff training in the use of protocols for victims of partner abuse can result in improved care, these effects were not maintained. IMPLICATIONS More intensive institutional efforts are needed if protocol benefits are to be maintained.
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Affiliation(s)
- J L Fanslow
- Department of Community Health, University of Auckland, New Zealand.
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Gordon DL, Cook CB, Scheer WD, Oalmann M, Boudreau DA, Borne D, Gatchair-Rose A, Weems AH, Turner MN, Robinson EM, Johnson T, Bourgeois PB, DeMourelle KM, Harris D, Post CC, Franklin OM, Arabie MP. Diabetes and obesity in the Louisiana Coushatta Indians. Ethn Dis 1999; 9:48-58. [PMID: 10355474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023] Open
Abstract
OBJECTIVE In order to assist their community in planning intervention and prevention programs, prevalence rates for diabetes and obesity were examined among the Louisiana Coushatta. RESEARCH DESIGN AND METHODS Coushatta individuals participated in a health survey (questionnaires and physical examinations). Those without known diabetes underwent oral glucose tolerance testing and were classified as having normal glucose tolerance (NGT), impaired glucose tolerance (IGT), or diabetes mellitus (DM). Those with known DM had the diagnosis confirmed by history and/or elevated hemoglobin A1c. Waist-to-hip ratio (WHR), body mass index (BMI), and percent body fat (%BF) were determined as measures of central adiposity and obesity. Prevalence rates of diabetes and obesity among those examined were calculated. The prevalence of those with more than one anthropometric index positive for obesity was also determined. RESULTS The prevalence of DM was 30% and IGT was 17% among the first 151 Coushatta participants. For males, the prevalence of obesity was 62%, 57%, and 52%, and for females, 59%, 54%, 45%, as determined by the BMI, %BF, and WHR, respectively. Obesity was more prevalent among those with glucose intolerance (IGT + DM) than those with NGT, and those who were obese had the highest prevalence of glucose intolerance. A greater percentage of those with glucose intolerance had more than one positive obesity measure as compared to those with NGT, and those with more than one index consistent with obesity had a greater prevalence of IGT + DM. CONCLUSIONS Prevalence rates of DM and obesity are high among the Louisiana Coushatta, and obesity is associated with glucose intolerance. Clustering of the three obesity measures occurs in a high percentage of individuals. Data from the current survey are providing information that is being used by the Coushatta community for health planning and development of intervention and prevention programs.
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Affiliation(s)
- D L Gordon
- Diabetes Center, an affiliate of the General Health System, Baton Rouge, USA
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Abstract
STUDY OBJECTIVE To evaluate the impact of a protocol on partner abuse (PA) at increasing identification and improving acute management of abused women by emergency department (ED) staff. METHODS A community intervention trial compared two public hospital EDs at baseline and following implementation of a PA intervention. The intervention involved training staff at one ED in a protocol for the identification and acute management of abused women. Outcomes were assessed by reviewing a random sample of women's medical records. Identification of PA was assessed for each record on a yes/no basis. Identified cases were classified as 'confirmed' or 'suspected' PA. Acute management was assessed by ascertaining staff documentation of abuse and use of interventions. RESULTS Approximately equal numbers of records were reviewed at each ED, pre and post implementation (total n = 8,051). Eighty-nine per cent of ED staff were trained. No difference in the overall identification of PA was found (chi 2 = 0.13, p = 0.72), but logistic regression analyses showed other significant changes. At the intervention site, there was an increase in confirmed cases of PA (chi 2 = 7.6, p = 0.006), a trend towards increased documentation (chi 2 = 3.5, p = 0.06) and a significant increase in interventions offered (chi 2 = 13.8, p = 0.002). Changes at the comparison site failed to reach significance. CONCLUSION Implementation of this protocol resulted in a moderate increase in confirmed cases of abuse and improved the acute management offered to identified victims. The findings reinforce recommendations for widespread implementation of training and protocols to address partner abuse.
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Affiliation(s)
- J L Fanslow
- Injury Prevention Research Centre, Faculty of Medicine and Health Science, University of Auckland, New Zealand.
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Hofman PL, Cutfield WS, Robinson EM, Bergman RN, Menon RK, Sperling MA, Gluckman PD. Insulin resistance in short children with intrauterine growth retardation. J Clin Endocrinol Metab 1997; 82:402-6. [PMID: 9024226 DOI: 10.1210/jcem.82.2.3752] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Epidemiological studies have demonstrated an association between intrauterine growth retardation and an increased risk of adult diseases that include essential hypertension, noninsulin-dependent diabetes mellitus, and ischemic heart disease. A common feature of these diseases is insulin resistance. To investigate whether abnormal insulin sensitivity was a characteristic of subjects with intrauterine growth retardation (IUGR), we compared two groups of short prepubertal children: a group with IUGR (birth weight less than the tenth percentile; n = 15) and a normal birth weight group (n = 12). Subjects underwent a modified frequently sampled iv glucose tolerance test that permitted calculation of the acute insulin response, insulin sensitivity index, and glucose effectiveness. A marked difference in the insulin sensitivity index was noted between groups, with the IUGR group being less insulin sensitive [6.9 vs. 16.9 10(-4)min-1.(microU/mL); P = 0.0048]. The acute insulin response was also significantly different between groups, with IUGR subjects having higher insulin levels (445 vs. 174 microU/mL; P = 0.005). There was no difference in glucose effectiveness between groups. Short prepubertal IUGR children have a specific impairment in insulin sensitivity compared to their normal birth weight peers. In short IUGR children, impaired insulin sensitivity is a potential marker for the early identification and intervention in the development of late adult-onset noninsulin-dependent diabetes mellitus.
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Affiliation(s)
- P L Hofman
- Department of Pediatrics, University of Auckland, New Zealand
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Abstract
In Turner's syndrome there is marked heterogeneity of growth response to growth hormone (GH) therapy. The study aim was to identify pretreatment factors that influence response to GH therapy. The 70 subjects recruited were prepubertal, had not received sex steroids and had received 28 units/m2/week of GH for > or = 1 year. Pretreatment variables associated with the greatest improvement in height SDS (r2 = 0.58) were weight for length index (p = 0.0001), target height (p = 0.004), bone age delay (p = 0.008) and age (p = 0.04). In conclusion, during two years of GH therapy the best growth response occurred in girls who were younger, heavier, had a delayed bone age and tall parents. Height SDS as a continuous variable is the most effective measure of growth when considering pretreatment factors that may influence response to GH therapy.
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Affiliation(s)
- P Hofman
- Department of Paediatrics, University of Auckland, New Zealand
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Abstract
Three hundred and thirty six forensic necropsy specimens of large bowel were examined in order to identify subject related variables that independently predicted the following adenoma characteristics: presence, size (largest), multiplicity and high grade dysplasia. The variables were age, gender, body mass index, race (European origin versus Maori/Polynesian) and presence of hyperplastic (metaplastic) polyp(s). Subjects included 303 New Zealanders of European origin (M = 185, F = 118) yielding 149 adenomas and 251 hyperplastic polyps and 33 Maori/Polynesians (M = 25, F = 8) yielding five adenomas and one hyperplastic polyp. Independent predictors of adenoma presence as determined by regression analysis were age (p = 0.0001), presence of hyperplastic polyps (p = 0.0001) and male gender (p = 0.05). Models were poor at explaining variation in size, multiplicity, and dysplasia. Larger adenomas occurred more frequently in subjects with multiple adenomas (p = 0.03) and multiple adenomas were probably associated with hyperplastic polyps (p = 0.09) and male gender (p = 0.09) in Europeans. High grade dysplasia was more frequent in women (p = 0.05) and possibly in subjects with hyperplastic polyps (p = 0.2). Body mass index and ethnicity did not predict any adenoma characteristics, but hyperplastic polyp prevalence was influenced by European origin (p = 0.04) and to a lesser extent by body mass index (p = 0.08) as well as presence of adenoma (p = 0.0002) and age ( = 0.005). The association of hyperplastic polyp with presence, multiplicity but not size of adenoma and with a high risk group for colorectal cancer (New Zealanders of European origin) suggests that the hyperplastic polyp serves as a marker for a factor which influences neoplastic evolution at the stages of initiation/transformation but not promotion. Fifty nine per cent of individuals with adenoma(s) did not have hyperplastic polyp(s) emphasising that the last would serve only as a marker of populations and not individuals at high risk of bowel cancer. Low intracolonic butyrate may be the factor linking the expression of the two types of polyp.
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Affiliation(s)
- J R Jass
- Department of Pathology, University of Auckland School of Medicine, New Zealand
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Robinson EM. Death in the dental chair. J Forensic Sci 1989; 34:377-80. [PMID: 2651555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Death during dental anesthesia is relatively rare. Review of eight such cases which occurred in our county, including the different anesthetics used, revealed one apparent basic pattern that prevailed...a need for awareness that something might go wrong and recognition of the fact that it was going wrong.
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Affiliation(s)
- E M Robinson
- Case Western Reserve University, School of Dentistry, Cleveland, OH
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Trainor S, Robinson EM, Parlon D. Utilization of a staff development department to promote the philosophy and goals of nursing management. J Nurs Staff Dev 1989; 5:97-9. [PMID: 2723781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Abstract
We present images of the pig knee joint which illustrate the resolution that is easily obtainable in high field (4.7 T) NMR imaging. We also describe a variant of the birdcage resonator which utilizes a novel tuning mechanism of simple construction.
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Abstract
A field-mapping procedure based on volume-selective spectroscopy is described. For proton NMR the method may be used to optimize magnet shimming, on the sample under investigation, prior to spectroscopy or imaging experiments. Examples of field maps obtained on our 4.7-T system, using phantoms and biological samples of up to 6 cm in diameter, are presented.
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Affiliation(s)
- I S Mackenzie
- Department of Physics, Manchester University, United Kingdom
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Robinson EM, Oberhofer M. A sensitive ceramic BeO-TSEE-dosimeter. Health Phys 1970; 18:434-437. [PMID: 5513072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
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Becker K, Robinson EM. Integrating dosimetry by thermally stimulated exoelectron (after-) emission. Health Phys 1968; 15:463-466. [PMID: 5722816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
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Gilley LW, Haywood FF, Jackson JE, Johnson DR, Kerr GD, Poston JW, Ray WD, Robinson EM, Shinpaugh WH, Ward DR. HPRR and DLEA operations. ORNL-4168. ORNL 1967:227-30. [PMID: 5597982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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