British medical bulletin
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British medical bulletin · Jan 1999
ReviewOptimal use of resources for the treatment and prevention of injuries.
Injuries are an important cause of mortality and morbidity. Although accidental injury rates have been declining throughout the twentieth century in the UK, this pattern has been variable. ⋯ Although there is little evidence that road traffic accident case fatality rates have been improving, there is some evidence that improvements in trauma care have been responsible for reducing injury death rates in children. Thus, although there have been considerable successes in the primary prevention of accidents, and the secondary prevention of injuries in accidents, there is an important role for tertiary prevention, that is in the prevention of avoidable outcomes through good trauma care.
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Since the introduction of manual positive pressure ventilation during the Copenhagen polio epidemic of 1952, a range of mechanical devices and methods of ventilatory support have been developed to provide life-saving respiratory therapy to critically ill patients. In addition to the development of the equipment hardware to enable effective mechanical ventilation, there has been a gradual realisation that a single mode of ventilation is not universally applicable to all patients, individual pathologies, or to individual patients at various stages in the evolution of their pulmonary pathology. ⋯ This iatrogenic problem is known as ventilator induced lung injury and, although it may be a problem in any patient requiring mechanical ventilation for any reason, is of particular importance to those patients requiring mechanical ventilation as a consequence of trauma. This chapter describes the range of ventilatory support techniques available, the problem of ventilator induced lung injury with specific reference to trauma patients and offers a strategy for ventilatory support in the trauma patient.
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British medical bulletin · Jan 1999
ReviewCerebral protection in severe brain injury: physiological determinants of outcome and their optimisation.
The primary role of intensive care in acute head injury lies in the prevention, detection and reversal of secondary neuronal injury. The maintenance of optimal systemic and cerebrovascular physiology can substantially contribute to these aims. There is, however, a role for novel neuroprotective interventions, many of which are currently under investigation.
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British medical bulletin · Jan 1999
ReviewFolic acid deficiency and cancer: mechanisms of DNA instability.
Folic acid deficiency in humans has been linked with megaloblastic anaemia, neural tube defects in the neonate, and heart disease. Folate has also been implicated in the development of cancer, especially cancer of the colorectum. There appear to be two principal mechanisms through which low folate status may increase the risk of malignancy. ⋯ Folate deficiency may cause an imbalance in DNA precursors, uracil misincorporation into DNA, and chromosome breakage. This chapter briefly describes the epidemiological data supporting the involvement of folic acid in the aetiology of cancer. It also assesses the evidence from cellular, animal and human studies that folic acid can modulate DNA by such mechanisms.
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Osteoporosis is a common condition, which is recognised by the occurrence of fragility fractures and leads to considerable mortality and morbidity with huge financial implications world-wide. Based on predicted demographic changes, the implications of this disease are set to increasingly affect the healthcare budgets of all nations. The determinants of fracture are skeletal factors, such as peak bone mass, the rate of bone loss and extra-skeletal factors, which include trauma and the response to that trauma. ⋯ On current evidence, it is certainly not appropriate to target hormone replacement therapy for women at the menopause on the basis of a bone density screening programme. However, newer bone-specific agents are being developed which might be administered at later ages, closer to the time when fracture incidence rates rise steeply. Bone densitometry has been shown to predict fractures even in the elderly, and high risk strategies for the targeting of such agents (for example, the bisphosphonates or selective oestrogen receptor modulators) will remain important research issues for the future.