Biomedical subjects
Publications and source records attributed to B J Harrison.
Awake fibreoptic intubation is well established as the optimum method of securing the airway in patients in whom difficulty is anticipated. We report a patient undergoing awake fibreoptic intubation in whom the use of topical local anaesthetic precipitated acute loss of the airway so that urgent surgical intervention was required.
OBJECTIVE: To determine whether the presence of psoriasis influences the presentation and early outcome of disease in a primary case based inception cohort of patients with early inflammatory polyarthritis. METHODS: In total, 966 patients with early inflammatory polyarthritis referred to the Norfolk Arthritis Register were studied. The clinical and demographic variables of patients with and without psoriasis were compared. RESULTS: Fifty-one patients (5.3%) had psoriasis on examination. Compared to other patients with inflammatory polyarthritis, those with psoriasis were significantly more likely to be male (49 vs 34%) and less likely to be seropositive for rheumatoid factor (RF) (13 vs 31%). The pattern of joint involvement was similar, as was the outcome at one year. Fewer patients with psoriasis developed radiological erosions (22 vs 39%). Multivariate analysis suggested that this was due to RF acting as a confounder. CONCLUSION: Among patients with early inflammatory polyarthritis there are few strong differences between patients with and without psoriasis, some of which may be accounted for by the absence of RF.
Papillary microcarcinomas are a specific subgroup of papillary thyroid cancer. They have the same histological features as papillary thyroid cancer but are 1.0 cm or less in diameter. These tumours are a common incidental finding at autopsy and in thyroid glands excised for other pathology. This tumour can metastasize to regional lymph nodes but its ability to cause significant morbidity and mortality has been questioned. As papillary microcarcinomas can represent up to 30 per cent of all papillary cancers seen in a thyroid surgeon's practice, they are an important group. The aim of this review article is to outline the natural history of papillary microcarcinoma and to offer therapeutic management strategies.
This paper reports the frequency and predictors of remission (no arthritis on examination and no treatment with second-line drugs or steroids within the previous 3 months) in 358 patients with early inflammatory polyarthritis (IP) referred to the Norfolk Arthritis Register. Two years after referral, 91 patients (25%) were in remission, 32 of whom had also been in remission at 1 yr. Remission rates were twice as high in patients with undifferentiated inflammatory polyarthritis at baseline as in those who satisfied criteria for rheumatoid arthritis. To identify predictors of remission, a logistic regression model was developed on a random two-thirds of the patients and validated on the remaining one-third. Remission at 2 yr was associated with male gender and fewer than six tender joints at baseline. However, even the best-fitting model was not sensitive enough to be useful clinically. Thus, amongst patients with early IP in the community, remission rates at 2 yr are low. Further, it was impossible, using simple clinical measures, to predict those patients whose arthritis would resolve.
OBJECTIVE: To predict which patients with early inflammatory polyarthritis presenting to primary care will be functionally disabled one year after presentation, in order to inform treatment and referral decisions. METHODS: The study population consisted of 381 patients notified to the Norfolk Arthritis Register, a primary care based inception cohort of patients with inflammatory polyarthritis. Patients were regarded as functionally disabled if they had a Health Assessment Questionnaire (HAQ) score of one or more. Clinical, laboratory, and demographic variables easily measured at baseline were analyzed for their ability to predict future disability. Recursive partitioning was used to create a simple decision tree to predict those patients who would be disabled at one year. A logistic regression model was generated on a sample of 277 patients and tested on an independent sample of 104 patients. This was compared with other models, one of which consisted of the 1987 ARA criteria. RESULTS: 112 (29%) patients had a HAQ score of at least 1 at one year. The strongest predictors of future disability were a high baseline HAQ, large joint involvement, female sex, and longer disease duration. The decision tree predicted disability accurately in 67% of patients. CONCLUSION: It is possible to predict functional outcome at one year among patients with early inflammatory polyarthritis presenting to primary care using simple clinical variables measured at baseline. Satisfying the 1987 ARA criteria could not be used to predict future disability.
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Breast pain (mastalgia) and macroscopic breast cysts present commonly. Mastalgia may be improved by dietary manipulation to reduce saturated fat or supplement essential fatty acid intake. Fatty acid profiles were measured in women with mastalgia and breast cysts, before and during treatment with evening primrose oil, a rich source of essential fatty acids. The fatty acid profiles of both groups of patients were abnormal, with increased proportions of saturated fatty acids and reduced proportions of essential fatty acids. Treatment with evening primrose oil improved the fatty acid profiles towards normal, but this was not necessarily associated with a clinical response.
Protein C deficiency is a known underlying risk factor for thromboembolic disease. Most commonly it presents as thrombophlebitis, deep venous thrombosis or pulmonary embolism. Less common presentations are becoming increasingly recognized now that assays for protein C are more widely available. We present two cases of mesenteric venous thrombosis who were found to have protein C deficiency.
The University of Michigan Medical Center has a flexible computerized clinic scheduling system that handles approximately 750,000 visits per year at the main hospital and satellite locations. The system includes a wide variety of fully integrated functions, including appointment booking, multiple and series scheduling, wait and reschedule lists, routine reminder notices, routine requests for medical records and radiology reports, no-show follow-up, and managerial reporting at multiple levels of detail. The system is extremely flexible, and allows separate scheduling specifications for every physician and all other resources within the system. The system is available at any of the approximately 1,800 computer terminals throughout the Medical Center, and is regularly used at approximately 400 terminals.
Two hundred women with breast cysts proven by aspiration were entered into a randomized double-blind trial of Efamol (evening primrose oil) at a dose of 6 capsules daily or equivalent placebo dose for a year. Cysts were categorized by initial electrolyte composition, and follow-up continued for 1 year posttherapy. Recurrent cyst formation in the first year was slightly (but not significantly) lower in the Efamol group compared with the placebo-treated group. The Efamol treatment was well tolerated as the dropout rate was only 7% and equal in both the active and placebo groups. The initial electrolyte composition did not predict for cyst recurrence.
A double-blind crossover study giving 20 mg/day of medroxyprogesterone acetate during the luteal phase was carried out in 26 women with cyclical mastalgia. Symptomatic response to this progestogen supplementation or placebo was assessed objectively by clinical examination and subjectively by linear analogue scales and breast pain charts. No significant relief of pain or tenderness was found on placebo or active treatment, irrespective of treatment order, and breast nodularity was similarly unaltered. No evidence of progesterone deficiency or prolactin abnormality was found. Side-effects were incurred in 11 patients (five on placebo, five on active treatment and one while on both) and were mostly vague premenstrual symptoms. We conclude that the therapeutic response of medroxyprogesterone acetate in cyclical mastalgia is no better than placebo and that progestogen supplementation can no longer be recommended for routine use in the management of breast pain.
A prospective study of 72 patients with non-cyclical breast pain was carried out. Non-cyclical breast pain was subdivided into true non-cyclical mastalgia (35 patients) and musculoskeletal pain (37 patients), the latter including Tietze's syndrome and other causes of chest wall pain. Mean age at presentation was significantly greater in the musculoskeletal group (39.3 versus 33.9 years) with a shorter mean duration of pain (14.7 versus 35.4 months) compared with the non-cyclical mastalgia group. True non-cyclical mastalgia was commonly bilateral and located within the upper outer quadrant of the breast, whereas musculoskeletal pain was almost always along the lateral chest wall or costochondral junctions and unilateral in 92 per cent of cases. Breast nodularity was present in 54 per cent of patients with non-cyclical mastalgia, but in only four cases (11 per cent) in the musculoskeletal group. Nine of 14 patients (64 per cent) with non-cyclical mastalgia obtained a good clinical response to drug therapy (over half responding to danazol alone); 19 underwent spontaneous remission, but there was a prolonged mean time to pain resolution of 27 months. In the musculoskeletal group 33 of 34 patients (97 per cent) had a good response to steroid and local anaesthetic injection; three resolved spontaneously without treatment, with a mean time to pain resolution of 17 months. This study indicates that differentiation of musculoskeletal pain from non-cyclical mastalgia may lead to more effective treatment with some prediction of the overall prognosis.
A low-dose danazol maintenance therapy (mean total dose 800 mg per month) was given during the luteal phase to 34 women with severe relapsing cyclical mastalgia. On conventional danazol dosage, all subjects had previously obtained a useful clinical response, but side effects occurred in 29 (85 per cent). Using this low-dose regimen, complete relief of symptoms was achieved in 15 women (44 per cent); the remainder obtained a substantial clinical improvement. Side effects were reduced to 12 per cent of women and were considered mild and tolerated by all patients. A low-dose regimen may be suitable for women with severe persistent cyclical mastalgia and minimises side effects that develop on conventional dosage.
In an open study, low-dose danazol (mean total dose 700 mg/month) was given during the luteal phase to 20 women with severe relapsing cyclical mastalgia. All subjects had previously obtained a useful clinical response on conventional dosage of danazol, but side effects occurred in 13 (65%). On the low-dose regimen, complete relief of symptoms was attained by 11 women (55%) and the remainder achieved a substantial clinical improvement; no side effects were reported. A low-dose regimen may be suitable for women with chronic relapsing cyclical mastalgia or those who develop side effects on conventional dosage.
Clinical assessment of 134 patients with hidradenitis suppurativa revealed clinical evidence supporting an androgen-based endocrine disorder underlying the condition. Such features included postpubertal onset maximal during the third decade; female preponderance (13:5); premenstrual flare in 57 per cent of women; absence of this flare associated with irregular or anovulatory menstrual cycles; and an increased incidence of obesity and acne. Detailed hormone profiles in 36 female patients and 14 controls showed evidence of relative androgen excess and decreased progesterone levels in those patients without a premenstrual flare. Obesity and enhanced peripheral androgen conversion by apocrine tissue are possible explanations for normal serum androgen profiles in patients with a flare. Precise elucidation of the hormonal abnormality is a prerequisite for effective medical treatment of early disease.
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From six to 89 months after surgery 82 patients who had been treated by radical surgery (118 excisions) for intractable hidradenitis suppurativa were reviewed. Local recurrence rates varied greatly with the disease site, being low after axillary (3%) and perianal surgery (0%) and high after inguinoperineal (37%) and submammary (50%) excision. Recurrence results from inadequate excision or an unusually wide distribution of apocrine glands, but physical factors such as obesity, local pressure, and skin maceration played a part in a few patients. Recurrence due to inadequate surgery tended to be the most troublesome. At follow up 75 (91%) of the patients were pleased with the results of their operation. A quarter of the patients developed disease at a new anatomical site after operation. Radical surgery gives good symptomatic control of severe hidradenitis suppurativa of the axilla, inguinoperineal, and perianal regions but is less satisfactory for submammary disease.