Showing papers by "Glenfield Hospital published in 2002"
TL;DR: A treatment strategy directed at normalisation of the induced sputum eosinophil count reduces asthma exacerbations and admissions without the need for additional anti-inflammatory treatment.
1,669 citations
TL;DR: The results suggest the presence of a distinct subgroup of patients with mild to moderate asthma who have predominantly neutrophilic airway inflammation and who respond less well to treatment with inhaled corticosteroids.
Abstract: Background: The debate as to whether asthma is a single or heterogeneous disease remains unresolved although pathological studies, mostly using fibreoptic bronchoscopy on small numbers of subjects, have emphasised the similarities between different clinical phenotypes.
Methods: Lower airway inflammation was assessed non-invasively using induced sputum in 34 normal controls and 259 adults with symptomatic asthma receiving treatment at steps 1–3 of the British Thoracic Society (BTS) guidelines. A subgroup of 49 patients treated with as required s2 agonists only who met BTS criteria for a step up in treatment were studied before and 2 months after treatment with inhaled budesonide 400 µg twice daily.
Results: There was considerable heterogeneity in induced sputum cell counts, particularly in non-atopic patients. A subgroup of 60 patients had a distinctive sputum cell profile with a neutrophil count higher than our normal range (>65.3%) and a normal sputum eosinophil count (<1.9%). These patients were older, predominantly female, and were more likely to be non-atopic but otherwise had similar clinical and physiological features to the group as a whole. Among the 49 subjects studied before and after inhaled budesonide, 11 patients had an isolated sputum neutrophilia. Following treatment, these patients showed significantly less improvement in visual analogue symptom scores (–5.5 v –19.4 mm; mean difference 13.9; 95% CI 0.7 to 27.0), forced expiratory volume in 1 second (FEV1) (–0.08 v 0.13 l; mean difference 0.21; 95% CI 0.03 to 0.39), and concentration of methacholine provoking a fall in FEV1 of 20% or more (PC20) (0.15 v 1.29 doubling doses; mean difference 1.11; 95% CI 0.13 to 2.15) than the remaining 38 patients.
Conclusions: These results suggest the presence of a distinct subgroup of patients with mild to moderate asthma who have predominantly neutrophilic airway inflammation and who respond less well to treatment with inhaled corticosteroids.
798 citations
TL;DR: It is suggested that mothers, although not ill themselves, experience many of the consequences of chronic illness, and prevailing cultural discourses about motherhood, childhood and cancer clearly influence the context in which they care for their child, and shape their reflexive constructions of their experiences.
278 citations
TL;DR: Two bedside methods for the measurement of body composition using dual energy X‐ray absorptiometry (DEXA) as a reference method are compared and there are significant intermethod differences.
Abstract: The measurement of body composition is of value in the nutritional assessment of patients with chronic obstructive pulmonary disease (COPD). The purpose of the present study was to compare two bedside methods for the measurement of body composition using dual energy X-ray absorptiometry (DEXA) as a reference method. Fat-free mass (FFM) was measured using DEXA, bioelectric impedance analysis (BIA) and skinfold anthropometry (SFA) in a cohort of 85 COPD patients accepted for pulmonary rehabilitation. Patients whose body mass index was >30 were excluded. Relative to DEXA, BIA underestimated FFM, whereas it was overestimated by SFA. There was a systematic increase in bias with mean FFM for both DEXA versus BIA and DEXA versus SFA, but this was almost eliminated when results were expressed as FFM index. Significant sex differences in the bias of BIA and SFA measurements of FFM were found. Forty-two (49.4%) patients were identified as nutritionally depleted using DEXA. Compared to DEXA, the sensitivity for detecting nutritional depletion was 86 and 74% for BIA and SFA, respectively, and the specificity 88 and 98%, respectively. There are significant intermethod differences in the measurement of body composition in chronic obstructive pulmonary disease patients. The choice of measurement method will have implications for nutritional assessment in chronic obstructive pulmonary disease.
254 citations
TL;DR: It is concluded that methacholine airway responsiveness and the sputum differential eosinophil count are the most useful objective tests in patients with mild asthma.
192 citations
TL;DR: In this article, the authors presented the clinical, radiologic, and induced sputum features of 25 patients with chronic obstructive pulmonary disease (COPD) who had never smoked or had a less than 5 pack years smoking history.
Abstract: Epidemiologic studies show that 5-12% of subjects with chronic obstructive pulmonary disease (COPD) are nonsmokers. Little is known about the pathophysiology of the fixed airflow obstruction in these subjects. We have prospectively identified 25 patients with COPD who had never smoked or had a less than 5 pack years smoking history and present the clinical, radiologic, and induced sputum features. Our population represented 5.7% of total referrals with fixed airflow obstruction over 2 years. Patients had a mean age of 70 years, were predominantly female (86%), and had a mean duration of respiratory symptoms of 7 years. The mean FEV(1) was 58%, and the FEV(1)/FVC was 55%. Features on high-resolution computed tomographic scanning were nonspecific and were considered typical of a wider population with COPD. An induced sputum differential inflammatory cell count suggested the presence of two distinct groups. Nine had significant sputum eosinophilia (mean, 8.1%; normal, less than 1.9%), and the remaining 13 had a normal sputum eosinophil and tended to have a raised sputum neutrophil count (mean, 70.1%; normal, less than 65%). Organ-specific autoimmune disease was present in 7 of the 22 patients (32%) and was particularly prevalent in those without sputum eosinophilia (6 of 13). In conclusion, COPD in nonsmokers predominantly affects females and has at least two pathologic subgroups, one of which may be associated with organ-specific autoimmune disease. Further investigation of this group may disclose novel mechanisms of fixed airflow obstruction.
170 citations
TL;DR: The study clearly demonstrates both the difficulties treating this fracture surgically and a procedure to be avoided (acromio-clavicular bridging), which, again has not been previously addressed.
Abstract: Symptomatic clavicular fracture non-union is rare. When it does occur, however, it may pose a difficult problem causing pain and functional impairment. The emphasis of this paper is on preopertive disabilities and the postoperative outcome and complications. Twenty patients with clavicular non-union treated operatively from 1989 to 1997 were reviewed, the average follow up was thirty-four months. Eleven fractures were midshaft, eight were lateral third and one medial third. A detailed proforma was completed with the patients documenting preoperative symptoms, outcome after surgery and complications. A literature search was carried out to find out the incidence of complications related to operating on post-traumatic clavicular non-union. All of the twenty fractures non-unions duly united after surgical intervention although three required early adjustment or change of metal work. The subjective and objective outcomes were good in 19 cases and poor in one. The postoperative complications included three implant failures, one stiff shoulder, two patients with numbness below the scar and one patient with an infected donor site wound. The literature search revealed that from 24 publications and 301 patients who had operations for clavicular non-union ther were 18 (6%) reported complications related to metal work, 45 (15%) reported complications related to soft tissues, seven (2%) complications related to the scar and 24 (8%) failures of union. Symptomatic clavicular non-union can cause severe disabilities. Good outcome, at low risk, can be expected from internal fixation and bone grafting of midshaft non-unions. Although there are only eight cases of lateral third clavicular non-unions, this is the largest series in the literature. Furthermore, the study clearly demonstrates both the difficulties treating this fracture surgically and a procedure to be avoided (acromio-clavicular bridging), which, again has not been previously addressed.
120 citations
TL;DR: Six possible predictors of intestinal ischaemia may be useful in alerting medical staff to the possibility of gastro-intestinal ischaemic complications after cardiac surgery particularly that early surgical intervention reduces mortality.
Abstract: Objective: Mesenteric ischaemia is an uncommon (,1%) but serious complication of cardiac surgery associated with a mortality .50%. Predictors of this complication are not well defined, and diagnosis can be difficult and prompt surgical intervention can be lifesaving. Methods and results: In a retrospective case-note analysis from May 1994 through to May 2000, we identified mesenteric ischaemia in 39 of 5349 consecutive patients (0.07%) undergoing cardiac surgery with cardiopulmonary bypass. By logistic multivariate analysis, we have identified six possible predictors of intestinal ischaemia: duration of cross-clamp, use of significant inotropic support, intra-aortic balloon counterpulsation for low cardiac output, need for blood transfusions, triple vessel disease and peripheral vascular disease. In all patients a combination of four predictors were present. Patients who survived this complication had surgical intervention earlier (6.4 ^ 3.8 h) than those who did not (16.9 ^ 10 h). Conclusions: The diagnosis and prompt treatment of mesenteric ischaemia post cardiac surgery requires a high degree of awareness. These predictors may be useful in alerting medical staff to the possibility of gastro-intestinal ischaemic complications after cardiac surgery particularly that early surgical intervention reduces mortality. q 2002 Elsevier Science B.V. All rights reserved.
89 citations
TL;DR: Clinical studies pointing to the usefulness of induced sputum analysis in the following conditions: asthma; 2) cough; 3) COPD; and 4) other respiratory conditions are summarised.
Abstract: Airway diseases account for a significant proportion of the respiratory physician's workload. Traditionally, conditions are classified according to clinical symptoms and abnormalities of function, although the major categories of airway disease (asthma, chronic cough and chronic obstructive pulmonary disease (COPD)) show considerable overlap in terms of both clinical picture and response to antiinflammatory treatment with corticosteroids. All of the above conditions are associated with airway inflammation, although to date there has been little interest in its routine measurement in clinical practice. The recent development of simple, safe and valid noninvasive techniques for the assessment of airway inflammation has increased interest in such an approach 1, 2. A number of techniques are available, ranging from measurement of exhaled nitric oxide levels to performing differential cell counts and assessment of mediator concentrations in induced sputum. Relatively little is known about the relationship between these different markers, although it is likely that they measure different aspects of the inflammatory response 3. A clearer understanding is desirable since some techniques are more suited to routine clinical use than others. Induced sputum cell and mediator measurements are particularly well validated 1, and normal ranges from a relatively large adult population have been published 4.
The present article summarises clinical studies pointing to the usefulness of induced sputum analysis in the following conditions: 1) asthma; 2) cough; 3) COPD; and 4) other respiratory conditions.
Asthma is commonly associated with sputum eosinophilia. Up to 80% of corticosteroidnaive subjects 1, 2 and >50% of corticosteroidtreated subjects 5 with currently symptomatic asthma have a sputum eosinophil count that is outside the normal range. Subjects with severe acute asthma usually exhibit marked sputum eosinophilia, although predominant neutrophilia has been noted in some studies in which subjects …
81 citations
TL;DR: Pneumonectomy can be avoided in a large proportion of patients with non-small cell lung cancer of a main stem bronchus without adversely affecting outcome but with preservation of lung function.
Abstract: Background: Lung cancer resection rates are suboptimal in the UK. Pneumonectomy has a higher perioperative mortality risk than lobectomy. To increase resection rates and improve outcomes we have implemented a policy of parenchymal sparing surgery for tumours involving a main stem bronchus. Methods: In a prospective 4 year study of 119 consecutive patients operated upon by a single surgeon the perioperative course, pathology and survival were compared for 81 patients undergoing pneumonectomy and 38 patients in whom pneumonectomy was avoided by bronchoplastic ^ angioplastic procedures. Results: The rate of pneumonectomy decreased significantly with increasing experience with parenchymal sparing surgery (R 2 ¼ 0:98, P , 0:001) with 21 of the last 30 patients (70%) avoiding pneumonectomy. There were no significant inter-group differences in patient characteristics, perioperative course or outcome. One-year survival was 64% after pneumonectomy and 73% after sleeve lobectomy. However the perioperative loss of respiratory function was significantly lower in the patients in whom pneumonectomy was avoided (P ¼ 0:0003). Conclusions: Pneumonectomy can be avoided in a large proportion of patients with non-small cell lung cancer of a main stem bronchus without adversely affecting outcome but with preservation of lung function q 2002 Elsevier Science B.V. All rights reserved.
74 citations
TL;DR: Surgical closure of atrial septal defects in adult patients can improve clinical status and prevent right ventricular dilatation, and the greatest benefit is seen in younger patients.
Abstract: Objective: To determine whether age has an effect on the long term outcome after surgical closure of atrial septal defects in patients aged 35 years and over.
Methods: Retrospective analysis of 89 patients (64 women) operated on between 1989 and 1999. Patients were divided into two age groups: group I (aged 35–50 years, n = 51) and group II (> 50 years, n = 38). Follow up was between 1–11 years.
Results: One operative death and two late deaths occurred in the study period (both in group II). Preoperatively, 29 (57%) patients were in New York Heart Association functional class III–IV in group I compared with 22 (58%) patients in group II (NS). After operation, 44 (86.2%) patients in group I were found to be in class I–II compared with 25 (71.5%, p < 0.05) in group II. Group I patients had a lower incidence of preoperative atrial fibrillation than those in group II (12 (23.5%) v 17 (43.6%), p < 0.05) and only four (7.8%) patients in group I were in atrial fibrillation requiring long term warfarin after surgery compared with 12 (34%, p < 0.05) in group II. Furthermore, echocardiography showed a greater reduction in right ventricular dimension in group I patients (mean (SD) 4.26 (0.82) v 2.71 (0.41) cm, p < 0.001) than in group II patients (4.36 (0.43) v 3.87 (0.29) cm, p = 0.21). No residual intracardiac shunts were identified during follow up.
Conclusions: Surgical closure of atrial septal defects in adult patients can improve clinical status and prevent right ventricular dilatation. The greatest benefit is seen in younger patients.
TL;DR: Local drug delivery has great interest since the early 1990s as it became clear that stents were becoming central to the attainment of a better clinical response to intervention by their inherent physical properties and it also became obvious that stent could be used to deliver agents.
TL;DR: This study demonstrates that minimally invasive harvesting can be performed at a satisfactory speed and should be considered to help reduce early post-operative morbidity.
Abstract: Objectives: Minimally invasive saphenous vein harvesting is advocated to reduce wound morbidity. Our early experience with minimally invasive techniques, however, suggested that increased tissue traction and trauma might follow. We aimed to test the hypothesis that minimally invasive harvesting reduces post-operative pain and inflammation. A secondary objective was to determine if minimally invasive harvesting could be performed efficiently. Methods: Forty patients were prospectively randomised into minimally invasive harvesting (Minimal, n ¼ 22) and traditional open harvesting (Open, n ¼ 18). A modified bridging technique was used for minimally invasive harvesting (SaphLITEe, Genzyme Surgical Products, Cambridge, MA, USA). One surgeon performed all operations. Primary end points were signs of impaired healing (a composite score) and pain (visual analogue score). Secondary end-points (operation variables) were also collected. Continuous variables were analysed by Student’s t-test and categorical variables were analysed by Mann‐Whitney U-test. Results: There were no significant demographic differences between the two groups (height, weight, albumin, diabetes, and peripheral vascular disease). In the early post-operative period, Minimal group had significantly less leg wound pain (P ¼ 0:04) and wound sepsis scores (P ¼ 0:01). Sternal pain was the same in both groups. After 6 weeks, wound scores and leg pain scores were not significantly different. There were no significant differences in rate of harvest (1.1 cm/min in each group). In Minimal group, 4 cm veins were harvested for each 1 cm skin incision compared with 1 cm in Open group (P , 0:01). Conclusions: Minimally invasive saphenous vein harvesting significantly reduces early post-operative leg pain and wound sepsis. Our study demonstrates that minimally invasive harvesting can be performed at a satisfactory speed and should be considered to help reduce early post-operative morbidity. q 2002 Elsevier Science B.V. All rights reserved.
TL;DR: In this article, the prevalence of dysfunctional breathing in adults with asthma treated in the community was estimated using questionnaire survey using Nijmegen questionnaire, and the results indicated that women and men were more likely to have dysfunctional breathing than men.
Abstract: Objectives: To estimate the prevalence of dysfunctional breathing in adults with asthma treated in the community. Design: Postal questionnaire survey using Nijmegen questionnaire. Setting: One general practice with 7033 patients. Participants: All adult patients aged 17–65 with diagnosed asthma who were receiving treatment. Main outcome measure: Score >23 on Nijmegen questionnaire. Results: 227/307 patients returned completed questionnaires; 219 (71.3%) questionnaires were suitable for analysis. 63 participants scored >23. Those scoring >23 were more likely to be female than male (46/ 132 (35%) v 17/87 (20%), p=0.016) and were younger (mean (SD) age 44.8 (14.7) v 49.0 (13.8), p=0.05). Patients at different treatment steps of the British Thoracic Society asthma guidelines were affected equally. Conclusions: About a third of women and a fifth of men had scores suggestive of dysfunctional breathing. Although further studies are needed to confirm the validity of this screening tool and these findings, these prevalences suggest scope for therapeutic intervention and may explain the anecdotal success of the Buteyko method of treating asthma. (BMJ 2001;322:1098–100)
TL;DR: The expression of the mesothelial markers, cytokeratin (CK 5/6, calretinin and thrombomodulin in a series of mediastinal thymic epithelial tumours is investigated to illustrate the macroscopic, light microscopic and immunophenotypic similarities that exist between primary pleural thymo-epithelial tumour types.
Abstract: Aims: To illustrate the macroscopic, light microscopic and immunophenotypic similarities that exist between primary pleural thymic epithelial tumours and diffuse malignant mesothelioma. To investigate the expression of the mesothelial markers, cytokeratin (CK) 5/6, calretinin and thrombomodulin in a series of mediastinal thymic epithelial tumours.
Methods and results: Over a 10-year period, 64 diffuse pleural tumours of non-mesothelial histogenesis were identified in the files of referrals to the South Wales regional thoracic centre (Llandough Hospital, Cardiff). Of these, five pleural tumours were diagnosed as primary pleural thymic epithelial neoplasms. From the files of the Mesopath group, Caen, three additional cases of thymic epithelial tumours with pleural involvement were identified. The study group comprised eight cases (four males, four females) with median age at presentation of 56 years (range 19–75 years). In one case there was a history of asbestos exposure. Macroscopically, seven tumours formed diffuse pleural masses. No mediastinal abnormality or intraparenchymal lesions were seen in five cases. By light microscopy, seven thymic epithelial neoplasms showed a lobulated architecture, one appeared extensively cystic. The tumours were of varied morphological subtypes: one medullary (WHO Type A), two mixed (WHO Type AB), three predominantly cortical (WHO Type B1) and two cortical (WHO Type B1). The subtypes morphologically mimicked sarcomatoid, biphasic, lymphohistiocytoid variant and epithelioid mesothelioma. The pleural thymic epithelial tumours showed immunoreactivity with broad spectrum cytokeratin AE1/AE3 (8/8; 100%), CK5/6 (8/8; 100%), and 1/8 (13%) expressed thrombomodulin. Calretinin showed variable nuclear and cytoplasmic expression in all cases, but equivocally in the thymic epithelial cell component. In 7/8 (88%) the thymic epithelial cells exhibited focal aberrant expression of CD20. Epithelial membrane antigen (EMA) showed focal expression in the perivascular and organoid areas in 6/8 (75%) cases. Carcinoembryonic antigen (CEA) and CD34 were uniformly negative. In 4/8 (50%) cases the lymphoid cell component was of immature phenotype expressing CD99, terminal deoxynucleotidyl transferase (TdT) and lymphoid precursors had a high proliferation fraction with Ki67. In the series of 20 primary mediastinal thymic epithelial tumours tested, mesothelial marker expression revealed CK5/6 (20/20), thrombomodulin (3/20; 15%) and calretinin (0/20; 0%). Varying amounts of calretinin-positive stromal cells were present.
Conclusion: Primary pleural thymic epithelial tumours are rare but may mimic malignant mesothelioma by forming diffuse serosal-based masses. In addition, both tumours may show morphological diversity (with epithelial, spindled and mixed components present). An awareness that thymic epithelial tumours may variably express the mesothelial markers CK5/6, calretinin and thrombomodulin prevents misdiagnosis. In the distinction from malignant mesothelioma a lobulated architecture and organoid features favour a thymic epithelial neoplasm. The presence of aberrant CD20 expression in a cytokeratin-positive epithelial neoplasm and/or the presence of an immature lymphoid population (by demonstration of CD1a, CD2, CD99 and TdT) indicates a thymic epithelial neoplasm. In contrast, nuclear calretinin expression favours malignant mesothelioma.
TL;DR: A single surgeon's series of 102 procedures in Transanal endoscopic microsurgery, employed in the excision of benign and selected malignant rectal tumours since 1983 is presented.
Abstract: Objectives Transanal endoscopic microsurgery (TEM), a minimally invasive technique has been employed in the excision of benign and selected malignant rectal tumours since 1983. We present a single surgeon's series of 102 procedures.
Patients and methods A retrospective case note review of 102 procedures performed over a 6-year period between 1996 and 2001.
Results One hundred and two TEM procedures were performed on 100 patients. 68 for adenomas, 19 potentially curative excisions for carcinoma, 13 palliative procedures for advanced carcinoma and 2 for solitary rectal ulcer syndrome (SRUS). Four adenomas recurred and were successfully treated by various procedures. None went on to develop malignancy, or a further recurrence. Of the cancers, six T1 and 10 T2 were excised with curative intent. Three T3 cancers were excised before endorectal ultrasound was available in the unit and went on to have definitive procedures. One T1 and two T2 carcinomas were not completely histologically excised. These patients were offered definitive procedure and there have been no recurrences. 11 patients underwent palliative TEM procedures, 2 went on to have a recurrence of symptoms. Both underwent a successful second TEM procedure.
Conclusions Although longer term follow up is still required, TEM appears to be an effective method of excising benign tumours and T1 carcinomas of the rectum. The role of TEM in the treatment of T2 carcinomas is, as yet, unclear and needs further evaluation although the results of our series and others are encouraging.
TL;DR: Stentless AVR is considered the treatment of choice for patients older than 60 years and those having small aortic roots and those needing replacement of two or more valves with encouraging early and mid-term results.
TL;DR: The Molecular Adsorbent Recirculating System (MARS) was used in five patients aged 19-56 who developed liver failure secondary to a respiratory illness and it is believed that MARS may prove a useful therapy for patients with MSOF.
Abstract: Adults receiving respiratory Extracorporeal Membrane Oxygenation (ECMO) have 66% survival. Nonsurvivors develop multisystem organ failure (MSOF). Once hepatic failure develops, death usually follows shortly. Serum bilirubin > 300 micromol/l predicted death with 87.8% sensitivity and 90.3% specificity in 41 adults who received ECMO in our institution during 1998 and 1999. No patients survive with a peak bilirubin > 400 micromol/l. The Molecular Adsorbent Recirculating System (MARS) is a cell-free extracorporeal liver support device; we hypothesized that using MARS in adult respiratory ECMO patients with a bilirubin >300 micromol/l could improve survival in MSOF. The MARS was used in five such patients aged 19-56 who developed liver failure secondary to a respiratory illness. Mean peak bilirubin was 529 micromol/l and the lowest peak bilirubin was 436 micromol/l. Patients received between 1 and 8 MARS treatments, mean reduction in serum bilirubin for each patient ranging between 30 and 162 micromol/l. Two of five patients survived (40%), survivors showing the greatest reduction in serum bilirubin in response to MARS. All patients would have been expected to die according to our previous experience. We believe that MARS may prove a useful therapy for patients with MSOF.
TL;DR: The ramp protocol leads to a higher WRpeak, and this may have implications for exercise prescription, but there were no significant differences between the two protocols for the peak physiologic responses.
TL;DR: The MRI techniques, normal appearances and a spectrum of abnormalities, and the role of MRI as a useful radiological investigation for the sternum and sternoclavicular joints are emphasized.
Abstract: The sternum and sternoclavicular joints are difficult to evaluate with plain radiographs. The value of CT in assessing lesions of the sternum and sternoclavicular joints has been well documented, but the potential role of MRI has not been emphasized. We present the MRI techniques, normal appearances and a spectrum of abnormalities, and emphasize the role of MRI as a useful radiological investigation for the sternum and sternoclavicular joints.
TL;DR: The long term physiological and health status outcome of LVRS performed on one or simultaneously on both lungs is compared and it is found no benefit from bilateral simultaneous LVRS and prefer unilateral LVRS because of the lower morbidity, resulting in earlier discharge, and slower decline in physiological benefit.
Abstract: Objective: Bilateral lung volume reduction surgery (LVRS) is thought to be preferable to unilateral surgery due to greater initial benefit but the subsequent rate of decline may also be greater. We compared the long term physiological and health status outcome of LVRS performed on one or simultaneously on both lungs. Methods: Prospective data were collected on a consecutive series of 65 patients undergoing LVRS who were all suitable for bilateral surgery. Twenty-six patients: age 59 (8) years underwent bilateral LVRS by videoassisted thoracoscopy (VAT) or sternotomy and 39 patients: age 60 (6) years underwent unilateral VAT. The perioperative effects of LVRS on spirometry were prospectively recorded at 3, 6, 12 and 24 months. Results: The unilateral group had similar preoperative lung volumes to the bilateral patients: forced expiratory volume in 1 s (FEV1) 26 vs. 30% predicted, RV 275 vs. 246% predicted and total lung capacity (TLC) 148 vs. 142% predicted. Unilateral LVRS was associated with significantly lower weight of lung resected: 80 (31) vs. 118 (46) g; hospital stay: 16 (10) days vs. 28 (22) days. Thirty-day mortality was 3% in the unilateral and 8% in the bilateral group (P ¼ 0:34). Postoperative ventilation occurred in 5% in the unilateral and in 42% in the bilateral group (P ¼ 0:0002). The decline of FEV1 during the first postoperative year was significant in the bilateral group (2313 ml/y, P ¼ 0:04) but not significant in the unilateral group (250 ml/y, P ¼ 0:18). SF 36 scores in all eight domains were similar in both groups preoperatively and at any postoperative interval. Conclusion: We have found no benefit from bilateral simultaneous LVRS and prefer unilateral LVRS because of the lower morbidity, resulting in earlier discharge, and slower decline in physiological benefit. q 2002 Elsevier Science B.V. All rights reserved.
TL;DR: With expanding overall experience of video-assisted thoracic surgery in the last decade, its use in postpneumonic pleural infection is increasing, as shown by a larger number of publications advocating its efficacy.
Abstract: With expanding overall experience of video-assisted thoracic surgery in the last decade, its use in postpneumonic pleural infection is increasing, as shown by a larger number of publications advocating its efficacy. The main areas of study in the use of video-assisted thoracic surgery in this condition are (1) as an alternative to traditional open thoracotomy and (2) as an additional treatment option in the management of earlier-stage disease. The benefits of the minimally invasive approach are particularly attractive in the treatment of pediatric pleural infection. Controversy surrounds its comparative benefits over intrapleural fibrinolysis in early exudative or fibrinopurulent pleural empyema and its usefulness in the treatment of chronic pleural empyema.
TL;DR: It is suggested that TNF-alpha antibody eluting stents may limit restenosis in vivo, which may have important clinical benefits.
TL;DR: The prognostic table has been found to be a useful and workable tool and advocate its use and resulted in increased chemotherapy rates for women with a 4% potential survival advantage.
Abstract: Aim: Understanding the likely net benefit of chemotherapy for the individual patient helps physicians to give objective information. A prognostic table has been constructed detailing the percentage absolute survival advantage offered by polychemotherapy for patients with early breast cancer, according to their age and the Nottingham Prognostic Index of their tumour. This study aims to assess its first year of use in the Leicestershire Breast Unit. Method: Demographic, pathological and treatment data were collected prospectively onto the Leicestershire breast cancer database. Patients with a potential survival advantage of 2% or greater in the year 01/05/99 to 30/04/00 (after the prognostic table was used routinely to determine oncology referrals) were identified. Chemotherapy usage was compared with the previous year's patient group. Results: Two hundred and eighty-eight had early breast cancer, requiring surgery, eligible for consideration of adjuvant therapy. Of these, 98% of women with a potential survival advantage of 6% or more received chemotherapy. Ninety-one percent of those with a survival advantage of 4% or more was seen by an oncologist. Of those with a 2% survival advantage, 48% were referred to discuss the issues with an oncologist. Use of the table resulted in increased chemotherapy rates for women with a 4% potential survival advantage. Conclusions: We have found the prognostic table to be a useful and workable tool and advocate its use.
TL;DR: Use of antihypertensive drugs in the early period poststroke is not detrimental to postural BP regulation, and antihypertensive therapy may be used when indicated in acute stroke, without having to restrict early mobilization; but the results cannot be extrapolated to the postacute phase.
TL;DR: An ex vivo organ culture model of stented mammary artery that allows the effects of stenting on human arterial tissue to be studied for at least 72 h, long enough to demonstrate effects on smooth muscle cell proliferation.
Abstract: Local drug delivery by coronary stents is of current research interest. Organ culture of human vascular tissue is a model of intimal hyperplasia. We report an ex vivo organ culture model of stented vessels. This allows stent-artery interactions to be studied in living tissue. The recognized anti-restenosis agent paclitaxel was chosen to test the organ culture model. Mammary artery specimens were cultured 'closed' (i.e. without opening them flat) for 72 h. Phosphocholine-coated stents, half of them loaded with the anti-restenosis drug paclitaxel, were implanted. The absorption and elution characteristics of paclitaxel were established. Artery tissue remained viable at 72 h when cultured closed, despite stent implantation. Specimens developed smooth muscle cell proliferation. The stents absorbed up to 127+/-29 microg of paclitaxel, with a biphasic elution curve. A mean of 13% of the absorbed paclitaxel remained after a 24 h perfusion. In mammary artery, these paclitaxel stents reduced or abolished smooth muscle cell proliferation compared with controls. This model allows the effects of stenting on human arterial tissue to be studied for at least 72 h, long enough to demonstrate effects on smooth muscle cell proliferation. Phosphocholine-coated stents absorb adequate doses of paclitaxel, which is eluted gradually, inhibiting muscle cell proliferation. Such an organ culture model of stented mammary artery will provide useful data in addition to that from animal or cell culture models of drug-eluting stents.
TL;DR: The values for cardiac BRS obtained using continuous time domain analysis agree well with those calculated using spectral methods and can be used to assess the dynamic changes in BRS to rapid perturbations in BP such as that occur with tilt.
Abstract: Introduction: Abnormalities of cardiac baroreceptor sensitivity (BRS) may contribute towards the high prevalence of orthostatic hypotension and falls in the elderly. Most mathematical analyses used to determine BRS in the time or frequency domains assume a stationary physiological state and cannot be performed under dynamic change and therefore are not valid during tilt. We describe a new method of estimating BRS during tilt. Methods: Twenty-five healthy elderly volunteers with a mean age of 69 ± 3 years underwent head-up tilt to 70°, within 5 s, 3 times on 2 separate visits. Blood pressure (BP) and heart rate were recorded continuously using a Finapres beat-to-beat BP monitor and surface ECG. A continuous estimate of BRS was obtained by combining beat-to-beat linear regression with Legendre polynomial interpolation. Results: The values for supine BRS prior to tilt on the two visits, calculated using the new regression method (10.4 ± 8.2 ms/mmHg and 12.5 ± 9.7 ms/mmHg) were similar to those using fast Fourier analysis (10.7 ± 6.7 ms/mmHg and 12.4 ± 7.1 ms/mmHg). A rapid fall in BP and pulse interval along with cardiac BRS values occurred with tilt within the first 20 s of onset on both visits and remained reduced up to 90 s post tilt (p < 0.01). Conclusions: The values for cardiac BRS obtained using continuous time domain analysis agree well with those calculated using spectral methods and can be used to assess the dynamic changes in BRS to rapid perturbations in BP such as that occur with tilt.
Journal Article•
TL;DR: It was observed in practice that the withdrawal of extracorporeal membrane oxygenation (ECMO) was the cause of much ethical and moral discussion amongst nurses within the ITU where the study took place.
Abstract: It was observed in practice that the withdrawal of extracorporeal membrane oxygenation (ECMO) was the cause of much ethical and moral discussion amongst nurses within the ITU where the study took place. No previous literature was located addressing the withdrawal of ECMO, from either a medical or nursing perspective. A grounded theory study was conducted to explore the experiences of nurses involved with the withdrawal of ECMO, focusing specifically on the withdrawal of this treatment from adult patients. Three major themes emerged: justification for withdrawal of treatment. the role of the nurse in decision-making. the involvement of others in decision-making. The core category that links the three categories is 'facilitating the decision making process' Recommendations for future practice included, the introduction of regular formal meetings and debriefing, and for further research to be conducted to explore 'corporeal anxiety' and the involvement of relatives in decision making.
TL;DR: Routine biennial mammography is scheduled from time of surgery except for those with high risk of early local recurrence such as extensive, high-grade in situ disease, including those generally accepted to be at highrisk of LR.
Abstract: Aims: Prompt detection and treatment of local recurrence (LR) following breast conservation surgery (BCT) may improve subsequent survival. Following early reports demonstrating increased LR in the first years after surgery, a practice of surveillance mammography starting 1 year from diagnosis has become established. Increasing use of adjuvant chemotherapy with adriamycin-containing regimens has resulted in radiotherapy being postponed, so that the first mammogram coincides with the acute radiotherapy reaction, resulting in patient discomfort and poor quality films. We wished to determine if the 1-year mammogram could safely be omitted. Methods: We reviewed 1151 consecutive patients treated with BCT for in situ , stage I or II disease over a 10-year period. All patients had clear resection margins and, where indicated, underwent axillary surgery and adjuvant treatment. This consisted of radiotherapy (40 Gy with a 5 Gy boost), chemotherapy and/or tamoxifen. Results: Overall, the 5-year actuarial rate of local recurrence was 4.8%. The cumulative risk of LR at 12 months was 0.3% (three patients) and 1.9% (20 patients) at 24 months. This included all cases of high-grade DCIS (>30 mm in size) and all but one tumour with a Nottingham Prognostic index (NPI) of >6.0 which recurred locally. Conclusion: Even including those patients generally accepted to be at high risk of LR, the cumulative risk of LR was only 0.3% at 12 months from surgery. We now therefore schedule routine biennial mammography from time of surgery except for those with high risk of early local recurrence such as extensive, high-grade in situ disease.
TL;DR: This technique involves assessing the presence of a hyperaemic flow response to occlusion of the radial artery using an intraoperative transit time flowmeter and is found to be objective and reliable and would advocate its use in patients with a positive Allen's test.
Abstract: The assessment of adequate ulnar collateral supply to the hand is mandatory prior to the harvest of the radial artery as a conduit for coronary artery bypass grafting. However, there is currently no one test which is widely used in all centres. We report a new and objective method of assessing ulnar collateral supply to the hand prior to harvest of the radial artery. This technique involves assessing the presence of a hyperaemic flow response to occlusion of the radial artery using an intraoperative transit time flowmeter. We found this technique to be objective and reliable, and would advocate its use in patients with a positive Allen's test.