Epilepsy in the Lunatic Asylums of South Australia (1852-1913)

Epilepsy is a common and sometimes life-threatening condition that can have profound physical, psychological and social consequences. Whilst much has been written about how the medical understanding of epilepsy changed during the nineteenth century, little is known of the individual experiences of people. This thesis addresses this by questioning why people with epilepsy were placed in lunatic asylums. In so doing it engages with the scholarly debate about whether the purpose of lunatic asylums was for cure or custody. Some scholarship describes asylums in humanitarian terms, stressing the importance of ‘moral treatment’ and situating it as a forerunner to psychiatry. This view was challenged by Michel Foucault who contended that moral treatment merely replaced physical restraints with another form of repression, imposed by power-seeking doctors. Materialist scholars also reject the idea that asylums were curative, describing them as places of social control and citing low cure rates and the accumulation of ‘hopeless’ cases. Using a ‘bottom-up’ approach, social historians regard families as central to the admission and discharge process. Opinions vary however, as to whether families sought cure or custody. In this study, patient information obtained from two South Australian lunatic asylums has been used. South Australia provides a useful case study as there were no private lunatic asylums, union workhouses or poor law. Nevertheless, as with asylums elsewhere, epileptic patients accounted for nearly ten percent of the asylum population between 1852 and 1913. Only the worst cases were admitted; the majority of people with epilepsy remaining in the community. Those admitted posed a significant burden to poorer families as they exhibited difficult behaviours and had little or no capacity to look after themselves. However, their families (if indeed they had families) did not readily relinquish their epileptic charges to the asylum, typically only seeking admission after years of home care. My thesis argues that the asylum was used for three purposes: respite care, palliative care and long-term care. The argument proposed is that moral treatment benefitted incurable patients, such as those with epilepsy. Families did not place kin in the lunatic asylum for custodial purposes. Instead they recognised that it provided a safe and caring environment for those debilitated by the condition.Thesis (MPhil) -- University of Adelaide, School of Humanities, 201

Circulating biomarkers are not associated wtih endoleaks after endovascular repair of abdominal aortic aneurysms

Objective: Endoleak is a common complication of endovascular repair (EVAR) for abdominal aortic aneurysm (AAA), but can only be detected through prolonged follow-up with repeated aortic imaging. This study examined the potential for circulating matrix metalloproteinase-9 (MMP9), osteoprotegerin (OPG), D-dimer, homocysteine (HCY) and C-reactive protein (CRP) to act as diagnostic markers for endoleak in AAA patients undergoing elective EVAR. Methods: Linear mixed effects models were constructed to assess differences in AAA diameter after EVAR, between groups of patients who did, and did not develop endoleak during follow-up, adjusting for potential confounders. Circulating MMP9, OPG, D-dimer, HCY and CRP concentrations were measured in pre- and post-operative plasma samples. The association of these markers with endoleak diagnosis was assessed using linear mixed effects adjusted as above. The potential for each marker to diagnose endoleak was assessed using receiver operator characteristic (ROC) curves. Results: Seventy-five patients were included in the current study, 24 of whom developed an endoleak during follow-up. Patients with an endoleak had significantly large AAA sac diameters than those that did not have an endoleak. None of the assessed markers showed a significant association with endoleak. This was confirmed through ROC curve analyses indicating poor diagnostic ability for all markers. Conclusions: Circulating concentrations of MMP9, OPG, D-dimer, HCY and CRP were not associated with endoleak in patients undergoing EVAR in this study

Convalescent plasma in patients admitted to hospital with COVID-19 (RECOVERY): a randomised controlled, open-label, platform trial

SummaryBackground Azithromycin has been proposed as a treatment for COVID-19 on the basis of its immunomodulatoryactions. We aimed to evaluate the safety and efficacy of azithromycin in patients admitted to hospital with COVID-19.Methods In this randomised, controlled, open-label, adaptive platform trial (Randomised Evaluation of COVID-19Therapy [RECOVERY]), several possible treatments were compared with usual care in patients admitted to hospitalwith COVID-19 in the UK. The trial is underway at 176 hospitals in the UK. Eligible and consenting patients wererandomly allocated to either usual standard of care alone or usual standard of care plus azithromycin 500 mg once perday by mouth or intravenously for 10 days or until discharge (or allocation to one of the other RECOVERY treatmentgroups). Patients were assigned via web-based simple (unstratified) randomisation with allocation concealment andwere twice as likely to be randomly assigned to usual care than to any of the active treatment groups. Participants andlocal study staff were not masked to the allocated treatment, but all others involved in the trial were masked to theoutcome data during the trial. The primary outcome was 28-day all-cause mortality, assessed in the intention-to-treatpopulation. The trial is registered with ISRCTN, 50189673, and ClinicalTrials.gov, NCT04381936.Findings Between April 7 and Nov 27, 2020, of 16 442 patients enrolled in the RECOVERY trial, 9433 (57%) wereeligible and 7763 were included in the assessment of azithromycin. The mean age of these study participants was65·3 years (SD 15·7) and approximately a third were women (2944 [38%] of 7763). 2582 patients were randomlyallocated to receive azithromycin and 5181 patients were randomly allocated to usual care alone. Overall,561 (22%) patients allocated to azithromycin and 1162 (22%) patients allocated to usual care died within 28 days(rate ratio 0·97, 95% CI 0·87–1·07; p=0·50). No significant difference was seen in duration of hospital stay (median10 days [IQR 5 to >28] vs 11 days [5 to >28]) or the proportion of patients discharged from hospital alive within 28 days(rate ratio 1·04, 95% CI 0·98–1·10; p=0·19). Among those not on invasive mechanical ventilation at baseline, nosignificant difference was seen in the proportion meeting the composite endpoint of invasive mechanical ventilationor death (risk ratio 0·95, 95% CI 0·87–1·03; p=0·24).Interpretation In patients admitted to hospital with COVID-19, azithromycin did not improve survival or otherprespecified clinical outcomes. Azithromycin use in patients admitted to hospital with COVID-19 should be restrictedto patients in whom there is a clear antimicrobial indication

The Outcome of Endovascular Repair of Small Abdominal Aortic Aneurysms

The management of small abdominal aortic aneurysm is controversial. We describe the outcome of a series of 478 patients treated by endovascular repair. Our findings suggest that intermediate outcome is guarded and longer follow-up is required to establish whether this form of treatment is effective for subgroups of patients with small aortic aneurysms

Patterns of surgical treatment for women with breast cancer in relation to age

Although treatment recommendations have been advocated for all women with early breast cancer regardless of age, it is generally accepted that different treatments are preferred based on the age of the patient. The aim of this study was to assess the pattern of breast cancer surgery after adjusting for other major prognostic factors in relation to patient age. Data on cancer characteristics and surgical procedures in 31,298 patients with early breast cancer reported to the National Breast Cancer Audit between 1999 and 2006 were used for the study. There was a close association between age and surgical treatment pattern after adjusting for other prognostic factors, including tumor size, histologic grade, number of tumors, lymph node positivity, lymphovascular invasion (LVI), and extensive intraduct component. Breast Conserving Surgery (BCS) was highest among women aged £40 years (OR = 1.140; 95% CI: 1.004–1.293) compared to women aged 51–70 years (reference group). BCS was lowest in women aged >70 years (OR = 0.498, 95% CI: 0.455–0.545). Significantly more women aged £50 years underwent more than one operation for breast conservation (20.4–24.8%) compared with women aged >50 years (11.4–17.0%). Women aged >70 years were more likely to receive no surgical treatment, 3.5% versus 1.0–1.3% in all other age groups (£40, 41–50 51–70 years). There is an association between patient age and the type of breast cancer surgery for women in Australia and New Zealand. Women age £40 years are more likely to undergo BCS despite having adverse histologic features and have more than one procedure to achieve breast conservation. Older women (>70 years) more commonly undergo mastectomy and are more likely to receive no surgical treatment.