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D J Scott

Publications and source records attributed to D J Scott.

At least 109 records · Page 6Linked to original sources
PubMed1997

Quality of life analysis in patients with lower limb ischaemia: suggestions for European standardisation.

INTRODUCTION AND OBJECTIVES: In this era of evidence-based medicine and limited resources we seem obliged, on clinical and economic grounds, to demonstrate that we improve not only patient survival but also the quality of patients' lives. This study aims to determine the impact of increasing lower limb ischaemia on quality of life (QOL) and which of three commonly used generic QOL instruments is the most valid, reliable, and responsive to change in patients with lower limb ischaemia. PATIENTS AND METHODS: Two hundred and thirty-five patients, 144 men and 91 women, median age 68 years (range 41-87 years) were graded according to ISCVS suggested reporting standards, i.e. 16 mild, 116 moderate and 25 severe claudicants; 33 patients had rest pain and 45 tissue loss. Patients completed Short Form 36 (SF36), EuroQol (EQ-5D) and Nottingham Health Profile (NHP) questionnaires at interview. Additional copies of questionnaires were posted to 80 patients prior to attendance. Correlation between the two sets of responses reflects test-retest reliability. Correlation between domains measured by the three instruments reflects convergent and divergent validity. Kruskal Wallis ANOVA detected QOL changes across the whole group. Spearman Rank was used to analyse validity and reliability. Responsiveness was analysed using the Mann-Whitney U-test. RESULTS: Increasing lower limb ischaemia confers significant (p < 0.05) deterioration in: SF36 measured: physical functioning, physical role, pain, general health, vitality, social functioning and mental health. EQ-5D measured: mobility, self-care, usual activities, pain and anxiety/depression. NHP measured: energy, pain, emotional reaction, sleep, social isolation and physical mobility. All three instruments are significantly reliable (rs > 0.7). The validity of SF36 and NHP (rs = 0.68-0.78) is superior to EQ-5D (rs = 0.37-0.7). SF36 & NHP are equally responsive to changes in physical activity and pain. SF36 and EQ-5D are most responsive to changes in social activity. SF36 is most responsive to changes in psychological status. CONCLUSIONS: QOL deteriorates markedly with increasing lower limb ischaemia. The SF36 would appear to be the most appropriate generic QOL analysis tool for these patients. We recommend its widespread adoption throughout Europe, thus providing a standardised tool for reporting generic QOL.

Activities of Daily Living↗
PubMed1997

The regulation of neutrophil activation and adhesion during femorodistal bypass surgery.

OBJECTIVE: To determine the effect that revascularising chronic critically ischaemic legs has no neutrophil activation and adhesion. DESIGN: Prospective clinical study. SETTING: University Hospital. MATERIALS: Twenty-five patients, 16 men and nine women undergoing femorodistal surgery. CHIEF OUTCOME MEASURES: Venous blood assays for neutrophils expression of CD11b, neutrophil adhesion, and the plasma concentration of the shed endothelial adhesion receptor, soluble intracellular adhesion molecule 1 (sICAM-1). Urinary microalbuminaemia was measured and expressed as an albumin/creatinine ratio (ACR), as a marker of vascular permeability and plasma neutrophil elastase as evidence of neutrophil activation. Venous blood was taken preoperatively, during surgery and for the first 7 days postoperatively. MAIN RESULTS: Neutrophil CD11b expression fell following reperfusion of the limb (21.4 mcf to 9.7 mcf, p < 0.02 Mann Whitney U-test) as did neutrophil adhesion (preop. 75% adhesion, postop. 28% p < 0.01). However, the plasma elastase levels rose from 95 micrograms/l to 345 micrograms/l at 4 h and the ACR increased from 5.3 mg/ml to 304.2 mg/ml. The concentration of sICAM-1 fell following reperfusion (p < 0.04). CONCLUSION: The change in CD11b, sICAM-1 and adhesion may represent a normal immunological response to ischaemia/reperfusion.

Aged↗
PubMed1997

Allogeneic versus autologous blood during abdominal aortic aneurysm surgery.

OBJECTIVES: To determine if cell-salvaged autologous blood can serve as an alternative to homologous blood, and to examine the incidence of infected complications and length of postoperative stay. DESIGN: A prospective randomised study comprising autologous and homologous blood transfusions in patients undergoing elective infrarenal abdominal aortic surgery. METHODS: Fifty patients undergoing AAA surgery were prospectively randomised to homologous blood (n = 27), or autologous blood transfusion (n = 23), using a cell salvage autotransfusion device. RESULTS: The haemoglobin at the time of hospital discharge was similar for both groups (11.0 vs. 10.8 g/dl) with no difference in perioperative mortality. The length of stay was reduced in those patients who received autologous blood (9 days vs. 12 days, p < 0.05 Mann-Whitney U test). There were four infected cases in the autologous group and 12 in the homologous group (p = n.s., Fisher's exact probability test). However, patients who received 3-4 units of homologous blood had an increased risk of infection compared to those who received a similar amount of autologous blood (50% vs. 0%). CONCLUSIONS: Cell salvage autologous blood can safely replace, or at least decrease, exposure to homologous blood transfusion, with a reduction in the mean hospital stay.

Aged↗
PubMed1997

p53 protein expression in ductal carcinoma in situ (DCIS) of the breast.

Abnormalities in p53 gene expression have been implicated in many inherited and sporadic forms of malignancies in humans. Immunohistochemical staining using monoclonal antibody D0-7 for the p53 protein expression was performed in 81 cases of pure DCIS, 14 benign breast lesions and 2 cases with normal breast tissue. Expression of p53 protein was detected in 15 (18.5%) cases of pure DCIS. Thirteen (25%) of the 52 comedo type DCIS showed p53 protein expression compared with 2 (6.9%) of the 29 non-comedo types (P < 0.02). p53 protein expression was also associated with high nuclear grade (P < 0.001) and high mitotic index (P < 0.05). The pattern of p53 protein staining was diffuse in one comedo type DCIS, regional in 6 comedo types, and focal in the remaining 8 cases (6 comedo type and 2 micropapillary type DCIS). The patient with comedo type DCIS showing diffuse staining has a family history of breast cancer in the first and second degree relatives (sister and maternal aunt). Clinical follow-up data was available in 52 cases. Follow-up period ranged from 9 to 55 months. Three patients, who were primarily treated by local excision, have had a documented local recurrence in the form of residual tumor within a short interval of 5 to 11 months. In all these three patients both the original and the recurrent tumors are negative for p53 protein expression. The difference in the local recurrence rate between p53 positive (0/15) and p53 negative (3/37) cased does not reach statistical significance (p > 0.05). We interpret that the local tumor recurrence in these three cases within a short period after primary excision is due to the presence of residual tumor at the excision site and is independent of the p53 gene alteration. It is concluded that p53 protein expression in DCIS is associated with comedo subtype, high nuclear grade, and high mitotic index, and is a promising new parameter to evaluate the cellular biology and prognosis of DCIS.

Breast Neoplasms↗
PubMed1997

Analysis of renal artery geometry may assist in the design of new stents for endovascular aortic aneurysm repair.

BACKGROUND: Endovascular repair of infrarenal aortic aneurysms is a feasible technique, but up to 30 per cent of patients may be excluded on the basis of a short proximal aortic neck. METHODS: A dissection study was performed on 65 cadavers to measure the distance between the superior mesenteric and renal artery ostia, and to document the points of origin of the renal arteries. RESULTS: The interostial distance did not differ significantly between aneurysmal and non-aneurysmal aortas (P = 0.90 for the left renal artery; P = 0.72 for the right). The median distance was 0.7 cm. The renal arteries originated between 2 and 4 o'clock on the left and between 9 and 10 o'clock on the right. CONCLUSION: The relative consistency of the anatomy in this region may allow the development of a new stent which would increase the number of patients suitable for endovascular repair.

Aged↗
PubMed1997

Optimising a varicose vein service to reduce recurrence.

A prospective observational study of 63 legs in 49 patients was undertaken to evaluate the adequacy of primary varicose vein surgery performed by surgical trainees. Appropriate surgery was carried out by a surgical senior house officer (SHO) under direct consultant supervision. All patients underwent pre- and postoperative duplex scanning. The preoperative duplex scan demonstrated incompetence of the saphenofemoral junction (SFJ) or long saphenous vein (LSV) in 59 limbs, a mid-thigh perforator (MTP) in 11 limbs, and saphenopopliteal junction (SPJ) in 5 limbs. Surgery successfully abolished all sites of pre-existing reflux. The postoperative duplex scan revealed that 17 new sites of reflux, not identified preoperatively, had developed in 12 limbs. With a consultant-led service and accurate preoperative identification of sites of reflux, the surgical trainee can adequately perform varicose vein surgery. This would seem a reasonable approach to training and eliminating recurrence owing to inadequate surgery. The development of new sites of reflux within 6 months of varicose vein surgery may be owing to altered venous haemodynamics consequent upon this surgery.

Adult↗
PubMed1996

Radical lymphadenectomy in the management of early gastric cancer.

Lymph node metastasis in patients with early gastric cancer was evaluated prospectively to determine whether radical (D2) lymphadenectomy is appropriate in such cases. Twenty-eight (18 per cent) of 156 patients having surgery for gastric cancer had early disease. Lymph node metastasis was found in 12 of the 28 patients. Metastasis was more likely in submucosal than mucosal early gastric cancer (nine of 14 versus three of 14; P = 0.024, Fisher's exact test). In two of three patients with metastasis at the N2 level, the N1 nodes were entirely clear. This study shows a higher incidence of lymph node metastasis than has been reported previously in both the UK and Japan. The high incidence of lymph node metastasis in early gastric cancer supports the continuing use of radical lymphadenectomy in patients who are fit for such major surgery.

Adenocarcinoma↗
PubMed1996

Bayesian meta-analysis, with application to studies of ETS and lung cancer.

Meta-analysis enables researchers to combine the results of several studies to assess the information they provide as a whole. It has been used to give a systematic overview of many areas in which data on a possible association between an exposure and an outcome have been collected in a number of studies but where the overall picture remains obscure, both as to the existence or size of the effect. This paper outlines some innovations in meta-analysis, based on using Markov chain Monte Carlo (MCMC) techniques for implementing Bayesian hierarchical models, and compares these with a more well-known random effects (RE) model. The new techniques allow different aspects of variation to be incorporated into descriptions of the association, and in particular enable researchers to better quantify differences between studies. Both the classical and Bayesian methods are applied, in this paper, to the current collection of studies of the association between incidence of lung cancer in female never-smokers and exposure to environmental tobacco smoke (ETS), both in the home through spousal smoking and in the workplace. In this paper it is demonstrated that compared with the RE model, the Bayesian methods: (a) allow more detailed modeling of study heterogeneity to be incorporated; (b) are relatively robust against a wide choice of specifications of such information on heterogeneity; (c) allow for more detailed and satisfactory statements to be made, not only about the overall risk but about the individual studies, on the basis of the combined information. For the workplace exposure data set, the Bayesian methods give a somewhat lower overall estimate of relative risk of lung cancer associated with ETS, indicating the care that needs to be taken in using point estimates based on any one method of analysis. On the larger spousal data set the methods give similar answers. Some of the other concerns with meta-analysis are also considered. These include: consistency between different geographic areas (Asia and the United States), and our studies show that Bayesian methods permit an account of the overall picture to be taken, thus improving the ability to estimate accurately in the subgroups; and publication bias which, as shown with the spousal exposure data, may lead to an inflated excess risk.

Air Pollution, Indoor↗
PubMed1996

Audit of vascular surgical workload: use of data for service development.

The power of surgical audit lies in the ability to clearly record complications and to compare case mix from year to year and between centres in order to compare results. In addition, accurate data about surgical activity is vital for the development of new services. We have analysed 52 weeks of activity in a developing pure vascular surgical service and compared activity against the recommendations previously published for consultant surgical workload. During the 12-month period the mean number of admissions per week was 25.3 (95% CI, 23.43-27.29). Mean elective surgical activity was 18.2 h/week (95% CI, 16.5-19.9) and mean emergency workload 12.7 h (95% CI, 10.7-15.4). Mean intermediate equivalent value (IEV) operations per week was 37 (95% CI, 33.6-40.8) and of these 26.4 IEV (95% CI, 22.96-29.6) were complex major operations. Finally, the mean bed occupancy of vascular patients on the unit was 23.3 (95% CI, 21.15-24.97). The recommendations for surgical activity are 3.5 IEV/list. In our unit this would equate to 21 IEV/week compared with 37.2 in our practice. This data forms the basis of a powerful bid for increased consultant manpower and theatre resources. Surgical audit is time-consuming and should be consultant led, but the benefits are tangible and the data generated can be used to support bids for resource re-allocation.

Elective Surgical Procedures↗
PubMed1994

Femoropopliteal angioplasty for severe limb ischaemia.

Fifty patients undergoing 51 percutaneous transluminal angioplasties of the femoropopliteal segment for severe limb ischaemia were reviewed regularly. They comprised 30 men and 20 women of median age 70 (range 56-85) years. There were two deaths within 30 days. At 2 years the cumulative patient survival rate was 60 per cent. Eleven angioplasties were technical failures, 25 failed in the first 6 months and 14 were successful at 6 months' follow-up; in addition one patient died from myocardial infarction within 30 days of technically successful angioplasty. Subsequent vascular procedures were successful in 11 limbs following failed angioplasty. The primary limb survival rate was 42 per cent at 2 years. There were eight major complications after angioplasty, requiring amputation in five instances. Of the 23 long occlusions (greater than 5 cm) that were recanalized and dilated, 22 procedures failed within 6 months. The run-off score and diabetic status did not predict outcome. In this group of patients angioplasty had a low durability. Dilatation of long occlusions is associated with high rates of reocclusion and, on the basis of these results, should not be performed.

Aged↗
PubMed1994

Preoperative assessment of the pedal arch using pulse generated runoff and subsequent femorodistal outcome.

Calf vessel continuity with an intact pedal arch is an important factor in femorodistal (FD) bypass for critical ischaemia. Pulse generated runoff (PGR) was used in combination with the pedal arch patency test of Roedersheimer to determine preoperatively calf vessel and pedal arch patency. Three pedal arch groups were identified; complete (two calf vessels in continuity), incomplete (one vessel) and occluded (no vessels). One hundred non-reversed FD grafts were performed for critical ischaemia (63 men and 37 women), median age 72 (range 43-89 years). Sixteen grafts were to the above knee popliteal artery, 36 to the distal popliteal, three to the tibioperoneal trunk and 45 to a single calf vessel. There were 25 complete, 64 incomplete and 11 occluded pedal arches. The overall primary patency rate was 73%, nine grafts were successfully revised giving a secondary patency rate of 83.5%. The secondary graft patency rates for the above knee popliteal, below knee popliteal, tibioperoneal and single calf vessel grafts were 100, 92, 66 and 66% respectively. The 1 year graft patency rates for grafts to a complete, incomplete and occluded pedal arch were 88, 75 and 9% respectively (Lee-Desu p < 0.01). Similar results were obtained for limb salvage; 100, 84 and 24% respectively (p < 0.01). These results confirm the value of PGR in the preoperative assessment of patients with critical ischaemia. In reconstructions to the popliteal artery, PGR derived pedal arch status does not appear to influence the outcome. By contrast PGR derived pedal arch status in an excellent predictor of success following reconstructions to a single calf vessel.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1994

Determinants of clinical outcome and survival in acromegaly.

OBJECTIVE: The extent to which treatment modifies the excess in morbidity and mortality in acromegaly remains uncertain. This study investigates the determinants of final outcome following therapy for acromegaly. DESIGN: A retrospective analysis of patients treated at the Departments of Endocrinology and Neurosurgery, Auckland Hospital, New Zealand. PATIENTS: One hundred and fifty-one patients (63 females and 88 males) with acromegaly or gigantism treated between the years 1964 and 1989. The mean duration of follow-up was 12 years (median 11 years). MEASUREMENTS: Patients had their age, estimated duration of symptoms preceding diagnosis, serum GH at diagnosis, presence of diabetes mellitus, cardiovascular disease, hypertension and/or osteoarthritis at diagnosis and the last known serum GH documented. The final outcome at the time of study was graded under three classes: dead (n = 32), those with major complications (n = 47) and those with minor/no complications (n = 67). RESULTS: The mean age at diagnosis of acromegaly was 41 years and the average estimated duration of symptoms prior to diagnosis was 7 years, with older patients showing longer duration of symptoms preceding diagnosis (P = 0.0002). Final outcome (dead, alive with major complications, alive and well) was significantly worse in those with older age at diagnosis (P = 0.008), longer duration of symptoms before diagnosis (P = 0.03) and higher GH at last follow-up (P = 0.0001). In multivariate analysis, survival was significantly influenced by the last known GH (P = 0.0001), presence of hypertension (P = 0.02) or cardiac disease (P = 0.03) at diagnosis, and duration of symptoms prior to diagnosis (P = 0.04). Survival in the acromegalic group, irrespective of treatment, was reduced by an average of 10 years compared with the non-acromegalic population. CONCLUSIONS: Acromegaly has a significant adverse effect on well-being and survival. The predominant determinant of outcome is the final serum GH level following treatment.

Acromegaly↗
PubMed1994

Diabetic nephropathy and microalbuminuria in the community. The South Auckland Diabetes Survey.

OBJECTIVE: To compare the clinical, anthropometric, and metabolic characteristics of New Zealand Europeans, Maori, and Pacific Islanders with non-insulin-dependent diabetes mellitus (NIDDM) with emphasis on risk factors for the development of diabetic nephropathy. RESEARCH DESIGN AND METHODS: A cross-sectional survey of 555 (74% of 750 available) diabetic patients attending diabetes clinics and randomly selected primary care centers was conducted in Auckland, New Zealand. RESULTS: Among those with NIDDM, Maori and Pacific Islanders were younger at diagnosis, more obese, and had poorer glucose control when compared with the Europeans (fructosamine in mumol/l: Maori 335 +/- 78, Pacific Islanders 367 +/- 90, Europeans 318 +/- 55; overall P < 0.001). Systolic blood pressure (sBP) was higher in Maori (145 +/- 31 mmHg) and lower in Pacific Islanders (135 +/- 25 mmHg) when compared with Europeans (141 +/- 25 mmHg; overall P < 0.005). Mean estimated daily urinary albumin excretion (UAE) was 18.2 (15.5-1.3) mg/day in Europeans, 94.8 (60.5-148.7) mg/day in Maori, and 44.2 (32.3-60.3) mg/day in Pacific Islanders. The prevalence of proteinuria and end-stage renal failure were also higher in Maori and Pacific Islanders. The excess prevalence of microalbuminuria and proteinuria in Maori was present within 5 years of diagnosis. Europeans with impaired renal function were least likely to have associated proteinuria or microalbuminuria. Microalbuminuria and nephropathy were not consistently associated with either higher blood pressure or worse glucose control. CONCLUSIONS: NIDDM in Maori and Pacific Islanders is associated with a greater degree of proteinuria and end-stage renal failure than that in Europeans. This observation is not explained by conventional risk factors.

Adolescent↗
PubMed1993

Criteria for gestational diabetes: a cautionary tale.

The diagnosis of gestational diabetes was developed to predict neonatal outcome (particularly perinatal mortality, macrosomia and hypoglycaemia) and future maternal diabetes. A variety of criteria for this diagnosis have evolved over time, assessed predominantly among European women. We describe a Pacific Islands woman with multiple risk factors for future diabetes yet a borderline 100 g glucose tolerance test result, who delivered a stillborn macrosomic baby weighing 6.7 kg at 38 weeks' gestation. Six weeks postpartum, diabetes was diagnosed by 75 g oral glucose tolerance test. This case highlights the need for caution when interpreting the glucose tolerance test in pregnancy and suggests that closer fetal monitoring and involvement of the diabetes team may be necessary among women with a borderline glucose tolerance test in the presence of additional risk factors for future diabetes (eg obesity, ethnic group).

Adult↗