Showing papers by "Derriford Hospital published in 2003"

Metformin in polycystic ovary syndrome: systematic review and meta-analysis

Abstract: Objective To assess the effectiveness of metformin in improving clinical and biochemical features of polycystic ovary syndrome. Design Systematic review and meta-analysis. Data sources Randomised controlled trials that investigated the effect of metformin compared with either placebo or no treatment, or compared with an ovulation induction agent. Selection of studies 13 trials were included for analysis, including 543 women with polycystic ovary syndrome that was defined by using biochemical or ultrasound evidence. Main outcome measure Pregnancy and ovulation rates. Secondary outcomes of clinical and biochemical features of polycystic ovary syndrome. Results Meta-analysis showed that metformin is effective in achieving ovulation in women with polycystic ovary syndrome, with odds ratios of 3.88 (95% confidence interval 2.25 to 6.69) for metformin compared with placebo and 4.41 (2.37 to 8.22) for metformin and clomifene compared with clomifene alone. An analysis of pregnancy rates shows a significant treatment effect for metformin and clomifene (odds ratio 4.40, 1.96 to 9.85). Metformin has an effect in reducing fasting insulin concentrations, blood pressure, and low density lipoprotein cholesterol. We found no evidence of any effect on body mass index or waist:hip ratio. Metformin was associated with a higher incidence of nausea, vomiting, and other gastrointestinal disturbance. Conclusions Metformin is an effective treatment for anovulation in women with polycystic ovary syndrome. Its choice as a first line agent seems justified, and there is some evidence of benefit on variables of the metabolic syndrome. No data are available regarding the safety of metformin in long term use in young women and only limited data on its safety in early pregnancy. It should be used as an adjuvant to general lifestyle improvements and not as a replacement for increased exercise and improved diet.

Insulin‐sensitising drugs (metformin, troglitazone, rosiglitazone, pioglitazone, D‐chiro‐inositol) for polycystic ovary syndrome

Abstract: Background Polycystic ovary syndrome (PCOS) is characterised by anovulation, hyperandrogaenemia and insulin resistance. Hyperinsulinaemia is known to be associated with an increase in cardiovascular risk and the development of diabetes mellitus. If insulin sensitising agents such as metformin are effective in treating features of PCOS, then they could have wider health benefits than just treating the symptoms of the syndrome. Objectives To assess the effectiveness of insulin sensitising drugs in improving clinical and biochemical features of PCOS. Search strategy We searched the Cochrane Menstrual Disorders & Subfertility Group trials register (December 2002), the Cochrane Central Register of Controlled Trials (Cochrane Library, Issue 4, 2002), MEDLINE (January 1966 to December 2002), and EMBASE (January 1985 to December 2002). Selection criteria Randomised controlled trials which investigated the effect of insulin sensitising drugs compared with either placebo or no treatment, or compared with an ovulation induction agent. Data collection and analysis Performed by two reviewers, one blinded to information that could have identified the authors, publisher or results of each study. Fifteen trials were included for analysis, 13 of them using metformin and involving 543 participants. Main results Meta-analysis showed that metformin is effective in achieving ovulation in women with PCOS with odds ratios of 3.88 (CI 2.25 to 6.69) for metformin versus placebo and 4.41 (CI 2.37 to 8.22) for metformin and clomiphene versus clomiphene alone. An analysis of pregnancy rates suggests a significant treatment effect for metformin and clomiphene (OR 4.40, CI 1.96 to 9.85). Metformin has a significant effect in reducing fasting insulin levels (WMD -5.37, CI -8.11 to -2.63), blood pressure and low-density lipoprotein cholesterol (LDL). There was no evidence of effect on body mass index or waist:hip ratio. Metformin was associated with a significantly higher incidence of nausea, vomiting and other gastrointestinal disturbance, but no serious adverse effects were reported. Authors' conclusions Metformin is an effective treatment for anovulation in women with PCOS. Its choice as a first line agent seems justified, and there is some evidence of benefit on parameters of the metabolic syndrome. Ovulation rates are higher when combined with clomiphene (76% versus 46% when used alone), but there is no evidence to indicate whether there is an increased multiple pregnancy rate with this combination. There is no data regarding its safety in long-term use in young women. It should be used as an adjuvant to general lifestyle improvements, and not as a replacement for increased exercise and improved diet.

Intravenous immunoglobulin for the treatment of Kawasaki disease in children

Abstract: Background Kawasaki disease is the most common cause of acquired heart disease in children in developed countries. The coronary arteries supplying the heart can be damaged in Kawasaki disease. The principal advantage of timely diagnosis is the potential to prevent this complication with early treatment. Intravenous immunoglobulin (IVIG) is widely used for this purpose. Objectives The objective of this review was to evaluate the effectiveness of IVIG in treating, and preventing cardiac consequences, of Kawasaki disease in children. Search strategy Electronic searches of the Cochrane Peripheral Vascular Disease Group Specialised Register, CENTRAL, MEDLINE, EMBASE, and CINAHL were performed (last searched April 2003). We also searched references from relevant articles and contacted authors where necessary. In addition we contacted experts in the field for unpublished works. Selection criteria Randomised controlled trials of intravenous immunoglobulin to treat Kawasaki disease were eligible for inclusion. Data collection and analysis Fifty-nine trials were identified in the initial search. On careful inspection only sixteen of these met all the inclusion criteria. Trials were data extracted and assessed for quality by at least two reviewers. Data were combined for meta-analysis using relative risk ratios for dichotomous data or weighted mean difference for continuous data. A random effects statistical model was used. Main results The meta-analysis of IVIG versus placebo, including all children, showed a significant decrease in new coronary artery abnormalities (CAAs) in favour of IVIG, at thirty days RR (95% CI) = 0.74 (0.61 to 0.90). No statistically significant difference was found thereafter. A subgroup analysis excluding children with CAAs at enrollment also found a significant reduction of new CAAs in children receiving IVIG RR (95%) = 0.67 (0.46 to 1.00). There was a trend towards benefit from IVIG at sixty days (p=0.06). Results of dose comparisons showed a decrease in the number of new CAAs with increased dose. The meta-analysis of 400 mg/kg/day for five days versus 2 gm/kg in a single dose showed statistically significant reduction in CAAs at thirty days RR (95%) = 4.47 (1.55 to 12.86). This comparison also showed a significant reduction in duration of fever with the higher dose. There was no statistically significant difference noted between different preparations of IVIG. There was no statistically significant difference of adverse effects in any group. Reviewer's conclusions Children fulfilling the diagnostic criteria for Kawasaki disease should be treated with IVIG (2 gm/kg single dose) within 10 days of onset of symptoms.

Rapid Diagnosis of Bacteremic Pneumococcal Infections in Adults by Using the Binax NOW Streptococcus pneumoniae Urinary Antigen Test: a Prospective, Controlled Clinical Evaluation

Abstract: The diagnosis of severe pneumococcal infections is inadequate, relying heavily on culture of Streptococcus pneumoniae from blood or other normally sterile fluids, and is severely limited by prior administration of antibiotics. We evaluated prospectively the Binax NOW S. pneumoniae urinary antigen test, a rapid immunochromatographic assay, for the diagnosis of bacteremic pneumococcal infections in hospitalized adult patients. Antigen was detected in 88 of 107 cases overall, resulting in a test sensitivity of 82% (95% confidence interval [95% CI], 74 to 89%). Antigen detection was greater in those with pneumonia (67 of 77 [87%]) than in those without pneumonia (21 of 30 [70%]) (P = 0.04). Urinary antigen was also detected in 3 of 106 adult patients with community-acquired septicemic infections caused by other organisms, giving a test specificity of 97% (95% CI, 92 to 99%). For 45 pneumococcal bacteremia patients with a positive test on treatment day 1, urinary antigen excretion was monitored for the first week of antibiotic treatment. Antigen was still detectable in 83% (29 of 35 tested; 95% CI, 66 to 93%) on treatment day 3. Detection of urinary antigen is a valuable, sensitive, and rapid test for the early diagnosis of bacteremic pneumococcal infections in adult patients, even after antibiotic treatment has commenced.

Abnormal T-cell Function in B-cell Chronic Lymphocytic Leukaemia

Abstract: There is increasing evidence of T cell dysfunction in B cell chronic lymphocytic leukaemia (B-CLL) which may contribute to the aetiology and progress of the disease. An absolute CD8+ lymphocytosis correlates with disease progression and low expression of CD4 and CD8 (as found in autoimmune disease) is seen with abnormal expression of other surface molecules. Although the expression of T cell surface activation markers, CD25 and CD152, may be increased on culture in B-CLL serum, response to the common mitogens, PHA and PWM, is reduced. This and the excess of CD8 cells may explain partly the variable cooperation of T cells with B cell production of immunoglobulin in B-CLL. In the context of T cell cross-talk with antigen presenting cells, B-CLL B cells are poor antigen presenters. But the T cells themselves have significant abnormalities of expression of the many antigens and ligands necessary for this process. In particular, they exhibit variable expression of the low affinity and non-specific adhesion molecules LFA-1 and ICAM-1, variable, clonally restricted and skewed expression of the TCR repertoire (implying repeated antigenic stimulation possibly by CLL antigens), reduced CD28 and CD152 expression (implying impairment of ability to start or stop an immune response) and reduced IL2 and CD25 (IL2 R) expression (critical for positive feed-back in maintenance and expansion of the T cell response to antigen presentation). Although the production of IL2 and other cytokines by the T cell in B-CLL may be impaired, production of the anti-apoptotic cytokine IL4 is not and there may be a unique and expanded subset of CD8/CD30 cells capable of releasing IL4. The relationship of this T cell subset to the malignant B cell in vivo is unknown. However, T cells which are CD4+/CD152+/CCR4+ migrate selectively in vitro in response to the chemokine CCL22 (specific for the receptor CCR4) produced by the malignant B cells and are always seen amongst the malignant cells in bone marrow and lymph nodes from B-CLL patients. Other abnormalities of cytokine secretion are described. These findings suggest that the T cell in B-CLL may be unable to start, maintain and complete an immune response to the malignant B cell and other antigens and may be involved directly in sustaining the tumour. However, autologous tumour specific cytotoxicity has been shown in vitro and T cells which recognise tumour-derived heavy chain fragments circulate in vivo. If adoptive immunotherapy of any nature is to succeed in B-CLL, manipulation to optimise these CTL responses is needed to overcome the profound and variable T cell dysfunction in this disease.

Contribution of timetabled physical education to total physical activity in primary school children: cross sectional study

Abstract: A recent survey of children at primary schools in England found a marked decline in timetabled physical education between 1994 and 1999.1 Sport England expressed concern about the impact of competing priorities, such as numeracy and literacy, on curricular physical education and concluded that children from poorer backgrounds would be worst affected. We used accelerometers to measure the impact of timetabled physical education at school on overall physical activity in children. We monitored physical activity during waking hours for seven days using accelerometers (Manufacturing Technology, Fort Walton Beach, FL2) in 215 children (120 boys and 95 girls aged 7.0-10.5 (mean 9.0) years) from three schools with different sporting facilities and opportunity for physical education in the curriculum. School 1, a private preparatory school with some boarding pupils, had extensive facilities and 9.0 hours a week of physical education in the curriculum. School 2, a village school awarded Activemark gold status …

Damage control laparotomy.

Abstract: Background: Damage Control Surgery (DCS) is well established in the management of trauma. This study assessed the results of DCS in the management of critically ill patients who had not had trauma. Methods: This was a prospective series of patients treated by DCS. The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) and Portsmouth predictor equation (P-POSSUM) were used to predict the risk of death, which was compared with the observed mortality rate. Results: Fourteen patients were studied. Nine had sepsis from gastrointestinal perforation. Eight of these underwent bowel resection without anastomosis or stoma formation at the initial laparotomy. Six patients later underwent bowel anastomosis and two had an end stoma formed at second laparotomy. A further three patients had a ruptured aortic aneurysm, one had a reactionary haemorrhage after elective aortic surgery, and one had a retroperitoneal bleed; all required haemostatic packing that was removed at second laparotomy. Mortality rates predicted by POSSUM and P-POSSUM scoring were 64·5 and 49·6 per cent respectively. One patient (7·1 per cent) died after operation, giving an observed mortality rate significantly lower than predicted (P = 0·002 and P = 0·038 versus values predicted by POSSUM and P-POSSUM, respectively). Conclusion: The use of DCS in the treatment of critically ill patients resulted in a lower mortality rate than that predicted by POSSUM or P-POSSUM. DCS should not be restricted to trauma. Copyright © 2004 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Is the pelvic organ prolapse quantification system (POPQ) being used? A survey of members of the International Continence Society (ICS) and the American Urogynecologic Society (AUGS)

Abstract: The authors performed a web-based questionnaire survey of 667 members of the ICS and AUGS to determine the current use of the pelvic organ prolapse quantification (POPQ) system by members of the professional societies which have advocated its use. Three hundred and eighty (57%) gynecologists responded. This international survey shows that only 40.2% of ICS and AUGS members who responded routinely use the POPQ system in their clinical practice and provides information on the most common reasons for not using it. The results highlight some of the concerns regarding the complex nature of the system and its acceptance and use by specialists worldwide. It also suggests the need for a simplified version of the classification system that is user-friendly and can be adopted by all practitioners.

Evidence-based measurement in multiple sclerosis: the psychometric properties of the physical and psychological dimensions of three quality of life rating scales.

Abstract: The selection of measures of quality of life used in clinical trials of multiple sclerosis (MS) should be evidence-based. Head-to-head comparison of measures facilitates the selection of measures. The aim of the study was to compare the psychometric pro per ties of the physical and psychological dimensions in three measures of quality of life to aid choice of the most appropriate scale for use in clinical trials of MS. One hundred and twenty-one people with MS (rehabilitation = 57; steroids = 64) completed a selection of health measures before and after treatment. The psychometric proper ties of three measures of physical function (MSIS- 29 physical, SF-36 physical functioning, FAMS mobility) and three measures of psycho logical function (MSIS- 29 psychological, SF-36 mental health, FAMS emotional well-being) were compared by examining data quality, scaling assumptions, acceptability, reliability, validity and responsiveness. Physical (0.63 - 0.71) and psycho logical (0.70 - 0.75) scales were substantially correlated indicating they measure related constructs. The MSIS- 29 physical and psychological scales satisfied all criteria for internal consistency reliability (physical = 0.91; psychological = 0.89) and validity. The SF-36 physical scale had a notable floor effect (20%). The FAMS mobility scale had lower reliability (alpha = 0.78) compared to other measures. The MSIS- 29 physical (effect size = 0.91) and psychological (effect size = 0.62) scales were the most responsive. In these three samples, the MSIS- 29 had better measurement proper ties for combined physical and psycho logical health than the SF-36 and the FAMS.

Evidence based guidelines for the performance of the sweat test for the investigation of cystic fibrosis in the UK

Abstract: A well produced evidence based guideline has been developed in response to a national audit that demonstrated wide variations in the performance of sweat tests. Accurate and reliable sweat test results will be particularly important with the advent of neonatal screening. The guideline recommendations include the collection and analysis of sweat samples, and interpretation of results. It emphasises the importance of sweat chloride as the best discriminator.

A prospective study of 1000 hernias: results of the Plymouth Hernia Service.

Abstract: BACKGROUND: A hernia service within a general hospital was prospectively evaluated to establish whether evidence-based protocols could deliver results comparable to those reported from specialist hernia clinics. METHODS: Protocols were devised according to established models. With the support of a nurse specialist, 1015 patients with inguinal hernia were treated. Quality-of-life analysis was undertaken using the Short Form 36. RESULTS: Patients ranged in age from 16-98 years (median, 56 years). Ambulatory day-case surgery was achieved in 820 patients (81%), with local anaesthesia in 891 (88%). Wound infection occurred in 10 patients (0.98%). Wound haematoma requiring surgical intervention occurred in three patients. Two patients formed wound seromas that settled spontaneously. One patient developed ischaemic orchitis resulting in testicular atrophy. At 5 days after operation, 91% of patients had returned to normal activity. At 1 year, 7 patients (0.7%) had pain sufficient to limit normal activity or employment. There were 8 recurrences (0.78%) at a median follow-up of 2.5 years. Quality-of-life was enhanced at 1 year postoperatively. CONCLUSION: A protocol-driven hernia service within a general hospital can provide patient outcomes comparable to specialist hernia clinics.

Rating scales for neurologists

Abstract: A neurologist once told me that he found the subject of rating scales “exceedingly dull”, while another found the area “abstruse”. I have therefore attempted to produce an overview that is helpful and conveys some of the basic principals underlying outcomes measurement and rating scales. Clinicians must realise that because this is an alien and somewhat “dry” area, they may need to invest some time to appreciate the issues. Instead of discussing specific scales or rating scales for rehabilitation, which will only be relevant to a limited audience, I have chosen to discuss the importance of rating scales and how to achieve high quality measurement. I hope this makes the text more widely applicable to the neurological community. The take home message is simple; neurologists need to take their rating scales very seriously. Rating scales are important because they are a method of measurement. Measurement is important because inferences are based on it.1 For example, in clinical trials we measure variables (for example, disability), perform statistical tests on the numbers generated by scales, and base conclusions on the results. These conclusions influence patient care, prescribing, policy making, and the expenditure of public funds. Thus, the validity of inferences from clinical trials is directly dependent on the quality of the measurement instruments used. Some measurements are clear cut—for example, mortality rates. However, measurement becomes complex for more abstract, ill defined, “soft” outcomes such as patient’s perspectives of the impact of disease and their quality of life. If we are serious about using these abstract variables to evaluate clinical practice we must be serious about our attempts to measure them as rigorously as possible. Consider clinical trials of interferons and glatiramer acetate in multiple sclerosis (MS). These trials have produced interesting results: an incontrovertible reduction in relapse rate and accumulation of …

Changes in resuscitation practice at birth

Abstract: Aim: To investigate secular changes in neonatal resuscitation at birth. Methods: Single centre observational study of 17 890 infants born between May 1993 and April 1997. T-piece ventilation was introduced in April 1995. Observations: Rates and modes of ventilatory resuscitation, early neonatal encephalopathy, neonatal convulsions, and meconium aspiration syndrome; 1 and 5 min Apgar scores; maternal age and method of delivery; paediatric attendance at delivery and resuscitation. Results: The rate of all forms of ventilatory resuscitation fell during the four year period from 11.0% to 8.9%. The rate of intubation fell from 2.4% to 1.2%. A reduced rate of intubation was seen at all gestations of 30 weeks and above. There was no difference in rates of relevant neonatal problems during the period except for a reduction in neonatal convulsions. The introduction of T-piece ventilation did not contribute to the reduction in intubation in a logistic regression model that included time trend. Conclusion: A marked reduction in the rate of intubation was observed, without any reduction in the efficacy of resuscitation. This may reflect improvements and changing emphasis in resuscitation training.

In vitro dendritic cell-induced T cell responses to B cell chronic lymphocytic leukaemia enhanced by IL-15 and dendritic cell–B-CLL electrofusion hybrids

Abstract: HLA class II-restricted proliferative and cytotoxic T cell (CTL) responses to B cell chronic lymphocytic leukaemia (B-CLL) can be generated using autologous dendritic cells (DCs) pulsed with tumour cell lysate. In this study a number of different approaches were used to optimize further the in vitro system. First, the effects of a variety of maturation agents were studied. The addition of TNF-alpha, polyriboinosinic polyribocytidylic acid (Poly(I:C)) and LPS to autologous DCs resulted in the emergence of only a small percentage of CD83+ DCs, IFN-alpha having no demonstrable effect. Only the addition of Poly(I:C) to DCs resulted in modestly increased specific cytotoxicity to B-CLL targets, IFN-alpha and LPS having no effect. Secondly, T cells were pretreated with IL-15, prior to culturing with lysate-pulsed autologous DCs. A significant increase in T cell activation (P = 0.038), IFN-gamma secretion (P = 0.030) and specific cytotoxicity to B-CLL targets (P = 0.006) was demonstrated compared to untreated T cells. Thirdly, monocyte derived DCs electrofused with B-CLL B cells were compared with lysate-pulsed DCs. T cells stimulated by fused DCs generated higher levels of specific cytotoxicity to autologous B-CLL B cell targets than those stimulated by lysate pulsed DCs (P = 0.013). Blocking studies demonstrated inhibition of this cytotoxicity by both anti-CD4 (P = 0.062) and anti-CD8 monoclonal antibodies (P = 0.018), suggesting the generation of both HLA class I- and HLA class II-restricted CTL responses. In summary, in vitro B-CLL-specific T cell responses can be enhanced further by preincubating T cells with IL-15 and using autologous fused DC-B-CLL hybrids instead of autologous lysate-pulsed DCs. These preliminary data require confirmation with larger numbers of patients. Such an approach, however, may eventually provide effective immunotherapy for treatment of B-CLL.

Resuscitation Predictor Scoring Scale for inhospital cardiac arrests

Abstract: Objectives: The purpose of this study was to determine the key factors influencing survival from cardiopulmonary resuscitation attempts and to produce a survival predictor scale for use during a resuscitation attempt. Method: Bivariate analysis of individual survival predictors and a prospective analysis of survival based on logistic regression models. Included in this seven year study (1993–2000) were 2567 inhospital resuscitation calls of which 1633 received full cardiopulmonary resuscitation. Immediate, 24 hour and discharge survival rates were the main outcome measures with additional analysis for the development of the Resuscitation Predictor Scoring Scale (RPS Scale). Results: The immediate survival rate was 41%, 28% at 24 hours, and 19% by discharge. Multivariate analysis showed the main factors influencing 24 hour survival to be the duration of the arrest, primary arrhythmia (VT, VF, asystole, or PEA), age, and the primary mode of arrest (respiratory or cardiac). The RPS Scale was developed from these key predictors giving resuscitation teams an accurate prediction of survival 15 minutes into a resuscitation attempt. Conclusion: Data collection and analysis of cardiopulmonary resuscitation attempts are essential for the formulation of survival indicators. In this case the data have enabled the formulation of a survival predictor scale that will quantify the decision making process regarding the termination of cardiopulmonary resuscitation attempts.

A comparison of total intravenous with balanced anaesthesia for middle ear surgery: effects on postoperative nausea and vomiting, pain, and conditions of surgery.

Abstract: We compared postoperative nausea and vomiting (PONV), pain and conditions for surgery in patients scheduled for middle ear surgery. In a double-blind study, 100 patients were randomly allocated to receive either balanced anaesthesia (group A) using fentanyl, propofol and isoflurane, or total intravenous anaesthesia (group B) using propofol and remifentanil infusions. Pain scores, nausea/vomiting scores, conditions for surgery and analgesic requirements were recorded for 18 h post operatively. In the recovery ward, patients in group B suffered significantly less PONV (p = 0.026) with a reduced requirement for anti-emetic medication (p = 0.023); however, this difference was not maintained on the ward. The overall incidence of PONV was 34% and 17% in groups A and B, respectively. Initial pain scores were higher in group B in the recovery ward (p = 0.003) and patients required more morphine administration (p = 0.002); however, pain scores were similar on the ward. Conditions for surgery were found to be better in group B.

Guidelines on the use of colony‐stimulating factors in haematological malignancies

Abstract: Haematological malignancies are associated with a high rate of infectious morbidity and mortality due to neutropenia, particularly in elderly patients, either as a direct result of the disease itself or as a result of the intensive chemotherapy regimens now used to combat these diseases. In fact, neutropenia and infection are the major doselimiting side-effects of chemotherapy. The incidence of febrile neutropenia (FN) depends on a number of factors, including the dose intensity of the chemotherapy, the prior history of the patient and the presence or absence of any comorbid conditions. In the past decade, there have been many clinical trials investigating the potential benefits of adjunctive therapy with colony-stimulating factors (CSFs), both to ameliorate or prevent profound neutropenia and its potentially life-threatening consequences, and to enhance the outcome of peripheral blood progenitor cell (PBPC) grafting and bone marrow transplantation (BMT). The specific aims of such therapy have been: • to prevent neutropenia-associated infection, with a view to reducing morbidity, improving patient quality of life, decreasing antibiotic usage and duration of hospitalization, and increasing cost-effectiveness of treatment; • to avoid the necessity for chemotherapy dose reduction and ⁄ or delay due to neutropenia (i.e. to achieve ‘planned dose on time’); • to enhance outcome after consolidation chemotherapy in patients achieving complete remission on induction chemotherapy; • to ‘prime’ certain types of malignant cells such that they are more sensitive to some cytotoxic agents; • to mobilize PBPCs before collection; • to stimulate stem cell proliferation after PBPC infusion or BMT. Based on the minimal comparative data available and the results of clinical trials, there is no evidence of any difference between the available CSFs [granulocyte colony-stimulating factor (G-CSF) and granulocyte–macrophage colony-stimulating factor (GM-CSF)] in terms of efficacy or outcome providing the growth factors are given at the recommended dose (Ozer et al, 2000). These guidelines therefore do not differentiate between the two types of agent, although specific agents may be referred to in the context of clinical trial results. The following guidelines present recommendations for primary versus secondary prophylaxis with CSFs, and specific evidence and recommendations for the use of CSFs in the various haematological malignancies and transplant procedures, including those from the most recent update of the American Society of Clinical Oncology (ASCO) guidelines, which are summarized in Appendix 1 (Ozer et al, 2000).

Neuropathological findings in Sneddon's syndrome.

Abstract: The authors report the neuropathologic findings in a case of Sneddon's syndrome. There were multiple small, predominantly cortical, infarcts, with focal hyperplasia and fibrotic occlusion of arterial vessels in the superficial white matter, cortex, and leptomeninges. A very occasional arterial thrombus was seen. These findings suggest that Sneddon's syndrome is caused by a noninflammatory arteriopathy affecting superficial cerebral vessels.

Prevent medication errors on admission

Abstract: The aim of this study is to quantify prescribing errors relating to pre‐admission medication in patients admitted to hospital. It also assesses the impact of a hospital pharmacist in identifying and correcting these errors. Standard prescription monitoring by the pharmacist took place on admission in phase 1 (526 patients). This was compared with an extension of the pharmacist’s role in phase 2 (506 patients) by taking a detailed medication history, including assessment of patients’ own drugs (PODs). A significant increase (p < 0.001) in errors detected and corrected was identified. In phase 2, 45.1 per cent of prescription charts contained one or more errors. Of these errors, 74.8 per cent could not be identified from checking the drug chart alone. As this is the principal method by which many hospital pharmacists check patients’ medication charts this is an area of concern. More than 50 per cent of errors were considered likely to cause destabilisation of a chronic medical condition, or serious adverse events. It has been shown that an effective way to prevent these errors and ensure the continuity of medication between primary and secondary care is for pharmacists to take a detailed drug history on admission.

The use of speech therapy in the treatment of globus pharyngeus patients. A randomised controlled trial.

Abstract: Introduction : la sensation de paresthesies pharyngees est une situation frequente representant environ 4 % des nouvelles consultation en ORL. Une revue des theories actuelles sur la cause de cette sensation de boule pharyngee permet de voir qu'aucune etiologie simple n'est responsable. Wareing et al pensaient que cette sensation pourrait etre associee a une tension excessive laryngee et pharyngee. Le but de cette etude etait de confirmer dans une etude controlee prospective les resultats d'une etude non-controlee par les memes auteurs ou certaines techniques d'orthophonie avaient ameliore ces symptomes. Methodes : 1) 36 patients presentant des symptomes pharynges typiques ont ete randomises avec un traitement par orthophonie (groupe d'etude) ou par une session unique pour rassurer le patient realisee par une infirmiere (groupe temoin). Les donnees suivantes ont ete recueillies pour chaque patient : duree et type des symptomes (sensation de corps etranger ou d'irritation de la gorge), severite des symptomes evaluee sur une echelle visuelle, nasofibroscopie laryngee, numeration et formule sanguine, transit pharyngo-oesophagien. 2) Au bout de 3 mois, chaque patient dans les deux groupes a note sur l'echelle visuelle la severite de ses symptomes. Resultats : une amelioration significative des symptomes de tenesme pharynge a ete obtenue dans le groupe avec orthophonie par rapport aux symptomes presentes au debut de l'etude (p < 0.001, test de Wilcoxon). Il y avait aussi une amelioration significative des symptomes dans le groupe avec orthophonie compare au groupe temoin (p < 0.001, Mann-Whitney U test). Conclusion: ces resultats initiaux suggerent que les patients avec des symptomes de tenesme pharynge sont ameliores par une prise en charge orthophonique.

The effect of age on the outcome of surgical treatment for carcinoma of the oesophagus and gastric cardia.

Abstract: Objective: The aim of this study was to examine the effect of age on the outcome of surgical treatment for carcinoma of the oesophagus and gastric cardia. Methods: From 1979 to 1999, 596 patients underwent gastro-oesophagectomy with two-field lymph node clearance for cancer under the care of a single surgeon. The clinicopathologic characteristics and survival of patients aged between 45 and 63 years (n = 198, Group 1), 63 and 71 years (n = 199, Group 2) and 71 and 89 years (n = 199, Group 3) were compared. Results: Thirty-day mortality for the first 300 patients (1979-1993) in this consecutive series was 5, 8 and 18% for Groups 1, 2 and 3, respectively, and 6, 6 and 6% for Groups 1, 2 and 3, respectively, in the second consecutive 296 patients (1993-1999, P = 0.006, chi(2)). Tumours were poorly differentiated in 55.7, 59.1 and 53.4% of patients in Groups 1, 2 and 3, respectively, for 1979-1993 and 64.7, 53.2 and 40.2% of tumours in Groups 1, 2 and 3, respectively, for 1993-1999 (P = 0.02, chi(2)). Adjuvant therapy was significantly more common in younger patients (P = 0.006, chi(2)). Five-year survival in the first period was 22, 15 and 11% for Groups 1, 2 and 3, respectively, (P = 0.02 log-rank) and 18, 16 and 14% for Groups 1, 2 and 3 in the second period (P = NS, log-rank). Conclusions: Elderly patients now have equivalent short and long-term outcomes compared to younger patients following gastro-oesophagectomy. Five-year survival, even in younger patients receiving adjuvant therapy remains poor, however, at approximately 20%. New therapeutic modalities are required to improve long-term survival following surgical treatment of gastro-oesophageal carcinoma. (C) 2003 Elsevier Science B.V. All rights reserved.

The rise and fall in incidence of malignant mesothelioma from a British Naval Dockyard, 1979-1999.

Abstract: Aims This study was carried out to investigate the effects of these control measures on mesothelioma deaths in dockyard workers. Methods Cases of mesothelioma of the pleura and peritoneum between 1979 and 1999 in workers from the Devonport Naval Dockyard, south-west England, were sought from coroners’ and medico-legal records. Results Three hundred and one cases were identified, 7% peritoneal. The peak incidence occurred in 1991 with 25 cases per annum (quadratic model fit R 2 = 74.2%, P < 0.001) and we predict that by 2003 the incidence will fall to fewer than five cases per annum. The mean time between first exposure and presentation was 48.5 years [95% confidence interval (CI) = 47.3–49.8], but this was significantly shorter in the more heavily exposed trades, when compared with the less heavily exposed (42 years, 95% CI = 39.0–45.0, versus 49.5 years, 95% CI = 48.2–50.9). Those with higher exposure were also at significantly greater risk of peritoneal disease (P < 0.023, Fisher’s exact test). Conclusion The reduction in incidence of mesothelioma is greater than can be accounted for by reduction in numbers of dockyard workers over the last 50 years. Changes in insulation materials and improved industrial hygiene measures introduced into the Devonport Dockyard from the mid-1960s have resulted in an earlier decline in the incidence of malignant mesothelioma than that predicted for the British workforce as a whole.

Communication with general practitioners after accident and emergency attendance: computer generated letters are often deficient.

Abstract: Objectives: Accident and emergency departments see large numbers of patients, and computerised administration systems are a useful tool for producing discharge communication. The purpose of this study was to determine the quality of such correspondence. Methods: Retrospective review of 300 discharge letters and case notes. Results: 29% of all computer generated discharge information was incomplete or misleading. Twenty five per cent of all correspondence was lacking or unacceptable overall. The principal reasons for substandard correspondence were inaccurate coding of diagnoses and procedures, and failure to include specific information relevant to patients’ follow up. Conclusions: Computer generated discharge communication is often deficient. Staff using such systems should be made aware of the importance of accurate coding, and use added explanatory text to clarify diagnoses, management, and follow up as required.

Canal wall down mastoidectomy: A long term commitment to the outpatients?

Abstract: Background Canal wall down and canal wall up mastoidectomy represent two surgical approaches to middle ear cleft pathology. Very few studies have examined the effects of these procedures both on the patients' well being and on the resources needed to maintain that state. In this study the authors report the outpatient attendance pattern of canal wall down mastoidectomy patients