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1.  Increased cardiovascular mortality associated with gout: a systematic review and meta-analysis 
Hyperuricaemia, the biochemical precursor to gout, has been shown to be an independent risk factor for mortality from cardiovascular disease (CVD), although studies examining the clinical phenomenon of gout and risk of CVD mortality report conflicting results. This study aimed to produce a pooled estimate of risk of mortality from cardiovascular disease in patients with gout.
Systematic review and meta-analysis.
Electronic bibliographic databases were searched from inception to November 2012, with results reviewed by two independent reviewers. Studies were included if they reported data on CVD mortality in adults with gout who were free of CVD at time of entry into the study. Pooled hazard ratios (HRs) for this association were calculated both unadjusted and adjusted for traditional vascular risk factors.
Six papers, including 223,448 patients, were eligible for inclusion (all (CVD) mortality n = 4, coronary heart disease (CHD) mortality n = 3, and myocardial infarction mortality n = 3). Gout was associated with an excess risk of CVD mortality (unadjusted HR 1.51 (95% confidence interval, CI, 1.17–1.84)) and CHD mortality (unadjusted HR 1.59, 95% CI 1.25–1.94)). After adjusting for traditional vascular risk factors, the pooled HR for both CVD mortality (HR 1.29, 95% CI 1.14–1.44) and CHD mortality (HR 1.42, 95% CI 1.22–1.63) remained statistically significant, but none of the studies reported a significant association with myocardial infarction.
Gout increases the risk of mortality from CVD and CHD, but not myocardial infarction, independently of vascular risk factors.
PMCID: PMC4361356  PMID: 24281251
Cardiovascular disease; coronary heart disease; gout; mortality; myocardial infarction
2.  Developing Objective Metrics for Unit Staffing (DOMUS) study 
BMJ Open  2014;4(9):e005398.
Safe midwifery staffing levels on delivery suites is a priority area for any maternity service. Escalation policies are tools that provide an operational response to emergency pressures. The aim of this study was to assess the feasibility of using a scoring system to contemporaneously assess the required staffing level based on demand and use this to determine delivery suite escalation level and utilise the information generated regarding clinical activity (Demand) and staffing levels (Capacity) to generate unit-specific calculation for the actual number of midwifery staff required.
A maternity unit of a university-affiliated tertiary referral hospital.
Over a 12-month period, specifically designed scoring sheets were completed by delivery suite shift co-ordinators four times a day (04:00, 10:00, 16:00 and 22:00). Based on the dependency score (Demand) and the number of midwifery staff available (Capacity), an escalation level was determined for each shift. The 80th centile of the demand was used to determine optimal capacity.
A total of 1160 scoring sheets were completed. Average staff number throughout the year on any shift was 7 (range 3–11). Average dependency score was 7 (range 1–14). The 80th centile for demand was calculated to be 11.
This study stresses the importance and usefulness of a simple tool that can be used to determine the level of escalation on delivery suite based on an objective scoring system and can also be used to determine the appropriate staffing on delivery suite.
PMCID: PMC4163650  PMID: 25217367
3.  The risk of a subsequent cancer diagnosis after herpes zoster infection: primary care database study 
British Journal of Cancer  2013;108(3):721-726.
Herpes zoster and cancer are associated with immunosuppression. Zoster occurs more often in patients with an established cancer diagnosis. Current evidence suggests some risk of cancer after zoster but is inconclusive. We aimed to assess the risk of cancer following zoster and the impact of prior zoster on cancer survival.
A primary care database retrospective cohort study was undertaken. Subjects with zoster were matched to patients without zoster. Risk of cancer following zoster was assessed by generating hazard ratios using Cox regression. Time to cancer was generated from the index date of zoster diagnosis.
In total, 2054 cancers were identified in 74 029 patients (13 428 zoster, 60 601 matches). The hazard ratio for cancer diagnosis after zoster was 2.42 (95% confidence interval 2.21, 2.66) and the median time to cancer diagnosis was 815 days. Hazard ratios varied between cancers, and were highest in younger patients. There were more cancers in patients with zoster than those without for all age groups and both genders. Prior immunosuppression was not associated with change in risk, and diagnosis of zoster before cancer did not affect survival.
This study establishes an association between zoster and future diagnosis of cancer having implications for cancer case finding after zoster diagnosis.
PMCID: PMC3593559  PMID: 23361054
herpes zoster; cancer; risk; database; epidemiology
4.  Statin Use and Clinical Osteoarthritis in the General Population: A Longitudinal Study 
One hypothesis has posited whether abnormal lipid metabolism might be a causal factor in the pathogenesis of osteoarthritis (OA). Routine statin use in clinical practice provides the basis for a natural experiment in testing this hypothesis.
To test the hypothesis that statins reduce the long-term occurrence of clinically defined OA.
Cohort design with a 10-year follow-up.
16,609 adults cardiovascular disease cohorts aged 40 years and over from the UK General Practice Research Database with data available to 31 December 2006.
Statins were summarised as annual mean daily dose and dose change over two-year time periods.
Incident episode of clinically defined osteoarthritis was assessed within 2 years, and at 4-year and 10-year follow-up time periods, using Cox and discrete time survival analysis. Covariates included age, gender, deprivation, body mass index, cholesterol level, pain-modifying drug co-therapies, and duration and severity of cardiovascular disease.
Higher therapeutic dose of statin, with a treatment duration of at least 2 years was associated with a significant reduction in clinical OA compared to non-statin users in the follow-up time period. The estimated adjusted rate ratios were as follows: lowest statin dose quartile 1: 2.5 (95 % CI 2.3, 2.9); quartile 2: 1.3 (1.1, 1.5); quartile 3: 0.8 (0.7, 0.95); and highest statin dose quartile 4: 0.4 (0.3, 0.5). The largest statin dose increments were associated with significant reductions estimated at 18 % in OA outcome within 2 years and 40 % after 4 years, compared to non-statin users.
This longitudinal study from a national clinical practice setting provides evidence that higher statin dose and larger statin dose increments were associated with a reduction in clinically defined OA outcome.
PMCID: PMC3682050  PMID: 23471638
drug therapy; osteoarthritis; cardiovascular diseases
5.  Influence of Acetabular and Femoral Version on Fractures of the Femoral Neck 
Fractures through the proximal femur are broadly grouped into intertrochanteric fractures and intracapsular fractures. It is not clear why a patient may sustain an intertrochanteric fracture as compared with an intracapsular fracture. There is an established relationship between relative hip retroversion and the development of osteoarthritis. We postulate retroversion also may be a risk factor for having intracapsular fractures develop.
We looked specifically at the geometry of the hip to analyze the possibility of a relationship between acetabular version, femoral version, and Mckibbin’s instability index and fracture type.
Patients and Methods
We recruited 40 patients with fractures of the femoral neck for the study. There were 15 men and 25 women with a mean age of 80 years (range, 57–92 years). There were 14 intertrochanteric fractures and 26 intracapsular fractures. After treating their fracture, the contralateral hip was scanned in a CT scanner and assessed by two independent observers to establish the acetabular and femoral version.
We found no correlation between proximal femoral fracture type and the contralateral femoral version, femoral neck length, acetabular version, or Mckibbin’s instability index or between fracture type and age or gender.
There appears to be no correlation between proximal femoral fracture type and acetabular or femoral version.
Level of Evidence
Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.
PMCID: PMC2895831  PMID: 19967473
6.  Should smoking be banned in prisons? 
Tobacco Control  2007;16(5):291-293.
Consequences and effectiveness
PMCID: PMC2598573  PMID: 17897977
prisons; smoking cessation; smoking bans
7.  Human Cytomegalovirus Causes Endothelial Injury Through the Ataxia Telangiectasia Mutant and p53 DNA Damage Signaling Pathways 
Circulation research  2004;94(10):1310-1317.
Atherosclerosis is the leading cause of death in the United States, and human cytomegalovirus (HCMV), a member of the herpes virus family, may play a role in the development of the disease. We previously showed that HCMV regulated endothelial apoptosis. In this study, we investigated the induction of apoptosis and signal transduction pathways regulating this process in HCMV-infected endothelial cells. As observed previously, HCMV induced a typical cytopathic effect in human aortic endothelial cells (HAECs), ie, the formation of single nucleated or multinucleated giant cells. Although infected HAECs were resistant to apoptosis at earlier stages of infection, they became apoptotic with prolonged infection as demonstrated by positive staining using terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling (TUNEL). This apoptotic process was mediated by the caspase-dependent mitochondrial apoptotic pathway as indicated by increased expression and cleavage of caspases 3 and 9 as well as increased expressions of pro-apoptotic molecules Bax and Bak. Blocking caspases 3 or 9 significantly inhibited the HCMV-induced apoptosis. Further exploration of the upstream pathway demonstrated upregulation of the tumor suppressor p53 gene and activation of the ataxia telangiectasia mutant (ATM) pathway in the infected cells. Blocking p53 inhibited HCMV-stimulated Bax and Bak expression as well as caspase-3 activation and blocking the ATM pathway inhibited HCMV-stimulated p53 activation. Although early infection may render cells antiapoptotic, prolonged infection, however, induced endothelial apoptosis through ATM and p53-dependent activation of the mitochondrial death pathway. This proapoptotic effect may be relevant to endothelial dysfunction and HCMV-associated vascular diseases.
PMCID: PMC1350949  PMID: 15105295
cytomegalovirus; endothelium; ATM; p53; apoptosis
8.  Development of an expert system for the interpretation of serial peak expiratory flow measurements in the diagnosis of occupational asthma. Midlands Thoracic Society Research Group 
If asthma is due to work exposures there must be a relation between these exposures and the asthma. Asthma causes airway hyperresponsiveness and obstruction; the obstruction can be measured with portable meters, which usually measure peak expiratory flow, or sometimes forced expiratory volume in 1 second (FEV1). These can be measured serially (for instance 2 hourly) over several weeks at and away from work. Once occupational asthma develops, the asthma will be induced by many non-specific triggers common to non-occupational asthma. The challenge is to identify changes in peak expiratory flow due to work among other non-occupational causes. Standard statistical tests have been found to be insensitive or non-specific, principally because of the variable period for deterioration to occur after exposure, and the sometimes prolonged time for recovery to occur, such that days away from work may initially have lower measurements than days at work. A computer assisted diagnostic aid (Oasys) has been developed to separate occupational from non-occupational causes of airflow obstruction. Oasys-2 is based on a discriminant analysis, and achieved a sensitivity of 75% and a specificity of at least 94%; therefore peak expiratory flow monitoring combined with Oasys-2 analysis is better to confirm than to exclude occupational asthma. A neural network version in development has improved on this. Both have been based on expert interpretation of peak flow measurements plotted as daily maximum, mean, and minimum, with the first reading at work taken as the first reading of the day. Oasys has been evaluated with independent criteria against measurements made in a wide range of occupational situations. Oasys is sufficiently developed to be the initial method for the confirmation, although less so for exclusion of occupational asthma.
PMCID: PMC1757688  PMID: 10658562
9.  Delays in orthopaedic trauma treatment: setting standards for the time interval between admission and operation. 
Delay in operating on trauma patients leads to increased morbidity, mortality, length of hospital stay and overall cost. The urgency of operative intervention depends on the injury sustained. There are no published guidelines on what constitutes a reasonable delay between admission and operation. As part of the clinical governance in our unit, an audit was undertaken to examine the structure and process of trauma operating. Patients were allocated to groups defined by the Bath Orthopaedic Department, according to urgency of need for surgery. Group A: patients (for example, open fractures and dislocations) should have definitive treatment within 6 h of admission. Group B: patients (for example, hip fractures, long bone injuries and ankle fractures) should have operations on the day that they are presented to the consultant trauma meeting, or on the day that they are declared fit/ready for theatre. Group C: patients (for example, tendon injuries, simple hand fractures) should have operations within 5 days of presentation to the trauma meeting. Over 3 months, there were 401 acute orthopaedic admissions requiring surgery (61 group A, 277 group B, 63 group C). 78% of group A patients, 58% of group B patients and 86% of group C patients were operated on within the target times. In total, 137 out of 401 operations (34%) missed the targets set. 119 of these (87%) were delayed due to lack of available operating time. This was despite the fact that 59 operations (15% of total) were done on lists normally used for elective operating. Most of the other delays were due to the need for an appropriately experienced surgeon to be available. If these targets are to be achieved for the majority of patients, the trauma theatre must become more efficient, or more flexible time must be made available during evenings or weekends to clear the backlog of trauma operations.
PMCID: PMC2503628  PMID: 11041030
10.  Development of OASYS-2: a system for the analysis of serial measurement of peak expiratory flow in workers with suspected occupational asthma. 
Thorax  1996;51(5):484-489.
BACKGROUND: Serial peak expiratory flow (PEF) measurement is usually the most appropriate first step in the confirmation of occupational asthma. Visual assessment of the plotted record is more sensitive and specific than statistical methods so far reported. The use of visual analysis is limited by lack of widespread expertise in the methods. A computer assisted diagnostic aid (OASYS-2) has been developed which is based on a scoring system developed from visual analysis. This removes the requirement for an experienced interpreter and should lead to the more widespread use of the technique. METHODS: PEF records were collected from workers attending an occupational lung disease clinic for investigation of suspected occupational asthma and from workers participating in a study of respiratory symptoms in a postal sorting office. PEF records were divided into two development sets and two gold standard sets. The latter consisted of records from workers in which a final diagnosis had been reached by a method other than PEF recording. An experienced observer scored individual work and rest periods for the two development set PEF records; linear discriminant analysis was used to compare measurements taken from development set 1 records with visual scores. Two equations were produced which allowed prediction of scores for individual work or rest periods. The development set 2 was used to determine how these scores should be used to produce a whole record score. The first gold standard set was used to determine the whole record score which best separated those with and without occupational asthma. The second set determined the sensitivity and specificity of the chosen score. RESULTS: Two hundred and sixty eight PEF records were collected from 169 workers and divided into two development sets (81 and 60 records) and two gold standard sets (60 and 67 records). Linear discriminant analysis produced equations predicting the score for work periods incorporating five indices of PEF change and one for rest periods using seven indices. These equations correctly predicted the score for development set 1 work and rest periods on 61% of occasions (kappa = 0.47). The whole record score for development set 2 records, after weighting for definite or definitely no occupational effect, correlated with the visual score (correlation coefficient 0.86). Comparison with gold standard set 1 identified a cut off which proved to have a sensitivity of 75% and a specificity of 94% for an independent diagnosis of occupational asthma when applied to gold standard set 2. CONCLUSIONS: These results suggest that the sensitivity and specificity of analysing PEF records for occupational asthma using OASYS-2 approaches that of visual analysis, but it should be absolutely reproducible. The performance of OASYS-2 is more specific and approaches the sensitivity of other statistical methods of analysis. The evaluation of a large number of PEF records from workers exposed to different sensitising agents suggests that these results should be robust and should be repeatable in clinical practice.
PMCID: PMC473592  PMID: 8711675
11.  Serologic evidence of Chlamydia trachomatis infection and risk of preterm birth. 
OBJECTIVE: To determine whether serologic evidence of Chlamydia trachomatis during pregnancy is a risk factor for preterm delivery (before 37 weeks' gestation). DESIGN: Chart review. SETTING: Antenatal clinics associated with a teaching hospital. PATIENTS: A group of 103 unselected consecutive patients presenting for routine prenatal care. OUTCOME MEASURES: Pregnancy outcome and C. trachomatis serologic status. RESULTS: A total of 21 women (20%) were found to be seropositive for IgG antibodies to C. trachomatis. They were similar to the seronegative women with respect to maternal age, parity, history of preterm birth, obstetric or medical problems, smoking status, history of drug abuse, educational status and psychosocial stressors. The seropositive women were significantly more likely than the seronegative women to have a preterm birth (24% [5/21] v. 7% [6/82]i p = 0.029, odds ratio 3.96, 95% confidence interval 1.08 to 14.57), an infant with a lower mean gestational age at birth (262 [standard deviation (SD) 19] days v. 273 [SD 15] days; p = 0.0052) and an infant with a lower mean birth weight (3125 [SD 692] g v. 3473 [SD 696] g; p = 0.0434). The positive predictive value of a seropositive result for preterm birth was 31% (5/16); the negative predictive value of a seronegative result for preterm birth was 8% (6/76). CONCLUSION: Women with serologic evidence of C. trachomatis may be at risk for preterm birth. Further study is required to determine whether serologic testing for C. trachomatis should be a routine part of prenatal care.
PMCID: PMC1487198  PMID: 7614441
12.  Helicobacter bilis sp. nov., a novel Helicobacter species isolated from bile, livers, and intestines of aged, inbred mice. 
Journal of Clinical Microbiology  1995;33(2):445-454.
A fusiform bacterium with 3 to 14 multiple bipolar sheathed flagella and periplasmic fibers wrapped around the cell was isolated from the liver, bile, and lower intestine of aged, inbred mice. The bacteria grew at 37 and 42 degrees C under microaerophilic conditions, rapidly hydrolyzed urea, were catalase and oxidase positive, reduced nitrate to nitrite, did not hydrolyze indoxyl acetate or hippurate, and were resistant to both cephalothin and nalidixic acid but sensitive to metronidazole. On the basis of 16S rRNA gene sequence analysis, the organism was classified as a novel helicobacter, Helicobacter bilis. This new helicobacter, like Helicobacter hepaticus, colonizes the bile, liver, and intestine of mice. Although the organism is associated with multifocal chronic hepatitis, further studies are required to ascertain whether H. bilis is responsible for causing chronic hepatitis and/or hepatocellular tumors in mice.
PMCID: PMC227964  PMID: 7536217
13.  Work patterns of general practitioners before and after the introduction of the 1990 contract. 
A questionnaire survey was undertaken to examine the work patterns of general practitioners before and after the introduction of the 1990 contract. A total of 408 and 697 general practitioners responded to the questionnaire in 1989 and 1991, respectively (response rates of 47% and 82%). In 1991 general practitioners reported spending significantly more evenings on paperwork than in 1989 and significantly more reported being exhausted or stressed at the end of five or more working days. General practitioners were significantly less likely to work four or more sessions per week outside the practice in 1991 than in 1989. There was no difference between 1989 and 1991 in the number of surgeries carried out per week or the number of nights spent on call in a month. In 1991 there was no correlation between the Jarman index allocated to a practice principal and the numbers of surgeries per week, sessions worked outside the practice per week, nights on call per month, weekdays exhausted or stressed, or evenings each week spent on paperwork. Older doctors in 1991 were significantly more likely to work 12 or more nights on call per month, to spend more time doing paperwork in the evenings and more likely to report exhaustion than younger doctors. Women doctors in 1991 were significantly more likely to report doing 10 or more surgeries per week than their men colleagues. It has become more common for general practitioners to complete paperwork at home and report exhaustion or stress since the introduction of the 1990 contract.
PMCID: PMC1372586  PMID: 8260218
14.  Comparison of the health and lifestyle of general practitioners and teachers. 
A total of 704 general practitioners and 588 teachers responded to a questionnaire about their health and lifestyle in 1991 (response rates 82% and 87%, respectively). The results for lifestyle measures were compared with those of a similar questionnaire completed by about half of each group two years before--there were no changes in the answers of either occupational group in the intervening two years. In 1991, 9% of general practitioners and 15% of teachers drank 22 units of alcohol per week or more; 13% of general practitioners and 23% of teachers reported troublesome depression and 31% of doctors and 37% of teachers excessive anxiety in the preceding 12 months. Teachers had more sickness absence, and significantly more experienced a need for daily alcohol and binge eating, and reported sleep difficulties, depression and anxiety than general practitioners. Self-medication among general practitioners was common and overall accounted for 83% of the medication taken by doctors. A follow-up survey of non-respondents found that only 11% of general practitioners and 11% of teachers indicated they had a health problem they wished to conceal or that they felt the questions were too intimate. General practitioners' lifestyle habits are better than those of teachers and published figures for the general population. The frequency of reported mental health problems in both professions gives cause for concern.
PMCID: PMC1372524  PMID: 8251235
15.  Characterization and pathological significance of monoclonal DNA-binding antibodies from mice with experimental malaria infection. 
Infection and Immunity  1994;62(5):1982-1988.
Malaria infection is accompanied by the production of a number of autoantibodies, including some that react with DNA. Epidemiological evidence implicates these in the nephritides that arise in human quartan malaria and in experimental malaria infections in mice. Through parallels with the involvement of DNA-reactive antibodies in the autoimmune syndrome systemic lupus erythematosus, a role for DNA-reactive antibodies in forming phlogistic immune deposits in the kidneys is implied. To more fully understand the relationship between antibodies of this specificity made in malaria and systemic lupus erythematosus, we prepared monoclonal DNA-reactive antibodies from BALB/c mice infected with Plasmodium berghei (clone RC) and compared their properties with those of other antibodies previously isolated from lupous MRL/Mp lpr/lpr and (NZB x NZW)F1 mice. Antibodies from malarial mice were all immunoglobulin M class and bound to single-stranded but not double-stranded DNA in an enzyme-linked immunosorbent assay. They also reacted with synthetic polyribonucleotides in the enzyme-linked immunosorbent assay and with parasitized erythrocytes and parasite pigment in kidney sections. None of the antibodies from lupous mice had identical specificities. The potential involvement of the DNA-reactive antibodies in malarial nephritis was demonstrated, by use of immunocytochemical methods, on the basis of their binding to existing immune deposits in kidney sections from malarial mice, a similar property having been previously demonstrated for antibodies from lupous mice. Furthermore, antibodies from malarial mice expressed public idiotypes, notably Id.V-88, which is a member of the Id.16/6 family, commonly found on DNA-reactive antibodies in lupus and other infectious and connective tissue diseases. This study indicates that DNA-reactive antibodies in malaria have immunochemical properties similar but not identical to those of such antibodies in systemic lupus erythematosus and that they have the potential to participate in the formation of immune deposits in nephritic malarial kidneys.
PMCID: PMC186457  PMID: 8168966
16.  Self-reported health care over the past 10 years: a survey of general practitioners. 
To investigate how and where doctors receive their health care, 275 general practitioners were given a questionnaire about their health care in the previous 10 years; responses were received from 247 doctors (90%). Thirty nine per cent of the subjects were registered with a general practitioner who was independent of them. All but one of the remainder were registered with a practice partner, close friend or relative. Whatever the relationship of the subjects with their own general practitioner, personal health problems were managed to a great extent by themselves. Most (84%) of the medication taken in the previous five years had been self-prescribed and one third of medical investigations had been self-initiated. Over half of the general practitioners studied had seen a specialist about their health in the preceding 10 years; 51% had referred themselves. A 'jury' of seven general practitioners compared the subjects' referrals to a specialist with the care that would be expected for a non-general practitioner patient. Where the jury reached agreement, 68% of referrals were thought to have been appropriate; self-referrals were significantly more likely to be thought inappropriate (P less than 0.05); and self-treatment prior to self-referral to a specialist was considered inappropriate in 78% of cases. The amount of self-prescribed medication and frequency of consultation was the same, whatever relationship the subject held with the general practitioner. This study shows that most general practitioners manage their own health care. The question of whether this is always appropriate is raised and the provision of an occupational health service for general practitioners is discussed.
PMCID: PMC1371893  PMID: 1586551
17.  Survey of outpatient sputum cytology: influence of written instructions on sample quality and who benefits from investigation. 
Quality in Health Care  1992;1(1):48-50.
OBJECTIVES--To evaluated quality of outpatient sputum cytology and whether written instructions to patients improve sample quality and to identify variables that predict satisfactory samples. DESIGN--Prospective randomised study. SETTING--Outpatient department of a district general hospital. PATIENTS--224 patients recruited over 18 months whenever their clinicians requested sputum cytology, randomized to receive oral or oral and written advice. INTERVENTIONS--Oral advice from nurse on producing a sputum sample (114 patients); oral advice plus written instructions (110). MAIN MEASURES--Percentages of satisfactory sputum samples and of patients who produced more than one satisfactory sample; clinical or radiological features identified from subsequent review of patients' notes and radiographs associated with satisfactory samples; final diagnosis of bronchial cancer. RESULTS--588 sputum samples were requested and 477 received. Patients in the group receiving additional written instructions produced 75(34%) satisfactory samples and 43(39%) of them one or more sets of satisfactory samples. Corresponding figures for the group receiving only oral advice (80(31%) and 46(40%) respectively)were not significantly different. Logistic regression showed that radiological evidence of collapse or consolidation (p<0.01) and hilar mass (p<0.05) were significant predictors of the production of satisfactory samples. Sputum cytology confirmed the diagnosis in only 9(17%) patients with bronchial carcinoma. CONCLUSIONS--The quality of outpatients' sputum samples was poor and was not improved by written instructions. Sputum cytology should be limited to patients with probable bronchial cancer unsuitable for surgery. IMPLICATIONS--Collection of samples and requests for sputum cytology should be reviewed in other hospitals.
PMCID: PMC1056807  PMID: 10136830
18.  Thirty years of surgery for carcinoma of the bronchus. 
Thorax  1983;38(6):428-432.
A study has been made of 8781 patients with bronchial carcinoma who were operated on by seven surgeons in England during the years 1949-80. There were 3865 pneumonectomies, 3790 lobectomies, and 1126 thoracotomies. During this period the operative mortality has fallen. Neither the resection rate nor the proportion of lobectomies bears any relation to the survival rate in any series. There has been remarkable similarity between the various survival rates in that the difference at five years was only 1.3% (25.5-26.8%) and at 10 years 4.2% (13.6-17.8%). These figures are reflected in reports published worldwide, where there is also great similarity between the results. If the improvement in operative mortality is excluded, there has been no improvement in the survival rates in the last thirty years.
PMCID: PMC459578  PMID: 6879495
19.  Prognosis of peripheral lung tumours related to size of the primary. 
Thorax  1981;36(1):5-8.
Three hundred and fourteen cases of peripheral lung tumours managed surgically over a 15-year period have been analysed to re-examine the effect of tumour size on the probability of survival up to five years after operation. The cases were classified into four groups according to the size of the primary. There was a significant inverse relationship between tumour size and five-year survival over the four groups (p less than 0.05) but this relationship did not hold for the largest tumours. The tumours over 6 cm did no worse than the group one size smaller (4.5-6.0 cm). Analysis of the survival in each group revealed a different pattern of annual loss in the largest tumours which suggested that this group included carcinomas self-selected for less metastatic potential. The peripheral tumours as a whole included more undifferentiated but fewer small cell carcinomas than the overall chest clinic figures. Within the peripheral tumours squamous carcinomas became more common and adenocarcinomas less common with increasing size. No small cell or adenocarcinomas were found among the five-year survivors in the large tumour group. Because 20% of patients with tumours over 6 cm lived for five years in this group of 314 patients we do not believe that they should be excluded from operative treatment on the basis of size alone.
PMCID: PMC471432  PMID: 7292381
20.  Restenosis of the mitral valve. 
It is suggested that restenosis is inevitable after mitral valvotomy and that only the time taken for it to occur is variable. The major factor affecting the lapse of time between operations is the extent of the original valvotomy. Calification of the valve is less important, and coincident mitral incompetence and the age of the patient have almost no influence on the time taken for restenosis to develop. A study has been made of 281 second closed valvotomies and 53 third ones. The operative mortality for second closed valvotomy was 6.7% and for third closed valvotomy 4%. Late emboli were rare. The average follow-up period after second valvotomies was 12.8 years: the condition of 29% of these patients was still satisfactory; 21% had had third valvotomies. At 5 years the condition of 53% was satisfactory. The average length of follow-up after third valvotomy was 6.4 years: the condition of 47% of patients was still satisfactory and the results were similar to those after second valvotomy. It is concluded that closed valvotomy remains the operation of choice when restenosis has occurred.
PMCID: PMC2492194  PMID: 475268
21.  Choice of treatment in operable lung cancer. 
British Medical Journal  1979;1(6172):1212.
PMCID: PMC1599347  PMID: 445006
22.  Living with artificial valves. 
British Medical Journal  1978;2(6131):200-201.
PMCID: PMC1606300  PMID: 678845
24.  Letter: Changing patterns of cancer. 
British Medical Journal  1976;1(6008):523.
PMCID: PMC1638896  PMID: 1252830
25.  Conservative surgery for bronchial adenomata. 
Thorax  1976;31(1):44-48.
Fifteen patients with bronchial adenomata have undergone surgical treatment and have been followed up for periods of one to 25 years. Management consisted of bronchotomy with local excision in six cases, segmental resection in two, lobectomy in six, and pneumonectomy in one case. One patient who underwent lobectomy subsequently died of an unrelated cause (gastric haemorrhage) in the early postoperative period; of the remaining 14, there have been no cases of recurrence, and all patients have remained sympton-free with normal chest radiographs. These results strongly support a conservative surgical approach where the clinical and histological diagnosis of carcinoid tumour is definite.
PMCID: PMC470360  PMID: 1257937

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