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Biomedical subjects

I J Beckingham

Publications and source records attributed to I J Beckingham.

At least 55 records · Page 3Linked to original sources
PubMed1997

Impact of cyclosporin on the incidence and prevalence of chronic rejection in renal transplants.

Over a 14-year period, 435 patients underwent renal transplantation. Chronic rejection has occurred in 58 (13%) of all grafts and has accounted for 18% of all graft losses. After the first 6 months following transplantation, chronic rejection was the most common cause of graft failure, accounting for 40% of losses. The median time (interquartile range) from transplantation to graft failure was 3 years (2-5.5 years). Comparison of azathioprine versus cyclosporin treated patients showed no significant difference in the incidence of graft loss (Cox regression score 2.55, P = 0.11). Furthermore, there were significantly more grafts with deteriorating function owing to chronic rejection in cyclosporin-treated patients (n = 16, 11% of surviving grafts) than in azathioprine-treated patients (n = 2, 3% of surviving grafts). These data suggest that cyclosporin does not prevent the development of chronic rejection in renal transplants.

Azathioprine↗
PubMed1997

Endoscopic management of pancreatic pseudocysts.

BACKGROUND: Pancreatic pseudocysts may produce pain, or biliary or duodenal obstruction. Those over 6 cm in diameter or associated with chronic pancreatitis are unlikely to resolve and usually require intervention. There are a number of treatment modalities available and this paper reviews the role of endoscopic drainage. METHODS: All articles and case reports quoted on Medline (National Library of Medicine, Washington DC, USA) containing the text words 'endoscopy' and 'pseudocyst', and citations from these references were reviewed. RESULTS: Endoscopic drainage is technically feasible in around 50 per cent of pancreatic pseudocysts associated with chronic pancreatitis. Successful drainage occurred in 82-89 percent. The major complication is bleeding which required surgery for control in 5 per cent of procedures. One death attributable to the procedure has been reported. Recurrence rates range from 6 to 18 per cent with up to 4 years' follow-up. As in open surgery, recurrence is highest with drainage via the stomach. CONCLUSION: Endoscopic drainage provides a minimally invasive approach to pseudocyst management, with success and recurrence rates similar to those of open surgery but with lower morbidity and mortality rates. It should be considered the treatment of choice for pseudocysts less than 1 cm thick which bulge into the stomach or duodenum, or for those which communicate with the main pancreatic duct.

Drainage↗
PubMed1996

Prospective evaluation of dynamic contrast enhanced magnetic resonance imaging in the evaluation of fistula in ano.

Forty-two patients with a suspected diagnosis of fistula in ano underwent prospective comparison of digital rectal examination, dynamic contrast enhanced magnetic resonance imaging (DCEMRI) and surgical exploration. There were five discordancies: DCEMRI showed an ischiorectal abscess and track with no enteric connection in one patients who at operation was found to have a well epithelialized primary fistula. Four patients with fistulas on DCEMRI had no enteric opening found at surgery and were treated as having sinuses. Long-term follow-up has shown failure to heal in all patients and further surgery confirmed missed fistula. Compared with final outcome measures DCEMRI had a sensitivity of 97 per cent and specificity of 100 per cent in the detection of fistula. DCEMRI also identified more secondary tracks and was more accurate at identifying complex fistulas than either digital rectal examination alone or surgical exploration.

Adult↗
PubMed1996

Dynamic contrast-enhanced MR imaging of perianal fistulas.

OBJECTIVE: The objective of this study was to prospectively compare dynamic contrast-enhanced MR imaging with MR sequences previously described for assessing perianal fistulas in order to determine the best MR protocol for their evaluation. SUBJECTS AND METHODS: MR examinations of 42 consecutive patients with clinically suspected perianal fistulas were independently evaluated by two experienced observers blinded to the findings of digital rectal examination. The observers' evaluations occurred before definitive surgical exploration. All patients had body-coil MR imaging examinations, including the following sequences that were ranked for anatomic and pathologic information: spin-echo T1-weighted, short inversion time inversion recovery, and dynamic contrast-enhanced MR imaging in the coronal plane; and spin-echo T2-weighted imaging in the axial plane. Surgical findings were accepted as the gold standard and were recorded independently by the surgeon, who was unaware of the findings of the MR assessment. MR findings were subsequently correlated with digital rectal examination before surgery and with clinical follow-up. RESULTS: MR imaging correctly allowed our blinded observers to predict the surgical anatomy of perianal disease in 37 of the 42 patients (accuracy, 88%). For detection of the presence and site of an enteric fistulous entry, MR imaging had a sensitivity of 97%, a specificity of 67%, a positive predictive value of 88%, and a negative predictive value of 89%. On MR imaging examination, eight patients had no fistula, 12 had simple intersphincteric fistulas, and 22 had complex fistulas. MR imaging revealed all 14 perianal abscesses and fluid collections found at surgery. Digital rectal examination before surgery failed to reveal abscesses or important secondary tracks in eight of the 22 complex fistulas. For anatomic and pathologic depiction of fistulas, dynamic contrast-enhanced MR imaging ranked as the best sequence for 22 of 34 fistulas. The short inversion time inversion recovery sequence, which was unable to distinguish small abscesses from perianal inflammation and showed spurious high signal in old fibrotic tracks, led our observers to misdiagnose five cases. In four patients for which initial surgery did not confirm enteric entry sites that our observers had predicted by MR imaging, follow-up has confirmed the observers' diagnoses. The observers' evaluations of the MR examinations agreed in 37 (88%) of the 42 cases. CONCLUSION: MR imaging is more accurate than digital rectal examination before surgery in detecting complex features of perianal fistulas. MR imaging is noninvasive, is highly accurate, and has low interobserver variability. With MR imaging, observers may better predict outcome than with initial surgical exploration. MR assessment that includes dynamic contrast-enhanced MR imaging and axial T2-weighted sequences (examination time, 20 min) provides the anatomic and pathologic information required to guide surgical management.

Adult↗
PubMed1995

A randomized placebo-controlled study of enalapril in the treatment of erythrocytosis after renal transplantation.

BACKGROUND: Erythrocytosis is a common complication of renal transplantation with an incidence of up to 17%. It is associated with an increased risk of complications due to thromboembolic events and has traditionally been treated by intermittent venesection. More recently, angiotensin-converting enzyme inhibitors have been shown to cause a fall in haematocrit in a number of groups of subjects and some uncontrolled studies have shown these drugs to be of possible therapeutic benefit in post renal transplant erythrocytosis. METHODS: We performed a randomized double-blind placebo-controlled study in 25 patients with post-transplant erythrocytosis. Subjects received either 2.5 mg of enalapril daily or a placebo for 4 months and all patients completed the study period without any serious adverse effects. RESULTS: Haematocrit fell from 52.7 (+/- SEM 0.7) to 47.1 (+/- 1.8) at 1 month and 46.1 (+/- 1.2) after 4 months in patients receiving enalapril, with no change in the placebo group (P = 0.004). We did not demonstrate any change in serum erythropoietin in either group. CONCLUSIONS: Angiotensin-converting enzyme inhibitors are a safe and effective form of treatment for erythrocytosis developing after renal transplantation. The mechanism of action, however, is not mediated by changes in erythropoietin production and remains uncertain.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed1994

Effect of human leucocyte antigen matching on the incidence of acute rejection in renal transplantation.

The influence of human leucocyte antigen (HLA) matching on the incidence of acute rejection and graft survival was examined in 181 consecutive patients receiving cadaveric renal transplants. Allografts with better HLA-DR and HLA-B matching showed significantly lower rejection rates than less well matched grafts on both univariate (rejection rates 25, 62 and 82 per cent for zero, one and two DR mismatches; P < 0.001) and multivariate analysis. Rejection episodes occurred earlier in mismatched grafts (P < 0.001). Superior matching was associated with improved graft function at 1 year after transplantation (mean serum creatinine level 137, 180 and 225 mumol l-1 for zero, one and two DR mismatches; P < 0.05). No association was, however, demonstrated between the degree of matching and overall graft survival. Good HLA matching reduces the number of acute rejection episodes, producing significant savings in drug costs and hospital stay. Long-term graft function is improved and minimizing early graft damage helps to avoid later development of chronic rejection.

Acute Disease↗
PubMed1994

Comparison of three methods to obtain percutaneous needle core biopsies of a renal allograft.

During 280 renal transplant biopsy procedures, 440 biopsy cores were obtained using three techniques: blind vertical pass, ultrasonographic guidance and ultrasonographic guidance with immediate specimen examination by stereoscopic microscopy. The success rates per procedure in obtaining renal cortex by blind vertical pass, ultrasonographic guidance and ultrasonographic guidance with microscopy were 75, 91 and 100 per cent respectively. Ultrasonographic guidance improves the success rate of percutaneous renal allograft biopsy. The additional use of immediate examination by stereoscopic microscopy yields a 100 per cent success rate for individual biopsy procedures.

Biopsy, Needle↗
PubMed1994

The use of DNA typing to clarify the origin of metastatic carcinoma after renal transplantation. A clinical and medico-legal problem.

We present an unusual diagnostic problem in a transplant patient whose failed renal transplant was found to contain undifferentiated carcinoma. When the patient later developed metastatic renal carcinoma, he began legal proceedings against the hospital for the transmission of a tumour with his renal transplant. He subsequently died of carcinomatosis. Post-mortem examination revealed acquired renal cystic disease in his native kidneys with a 1-cm adenocarcinoma arising from the wall of one of the cysts. We used DNA typing to determine the origin of the metastatic tumour and resolve the medico-legal problem.

Adenocarcinoma, Clear Cell↗
PubMed1994

Long-term results of intermittent low-friction self-catheterization in patients with recurrent urethral strictures.

OBJECTIVE: To ascertain the duration of intermittent low-friction self-catheterization (ILSC) required to cause stricture stabilization. PATIENTS AND METHODS: Over a 4 year period, 101 patients with a median age of 62 years (range 16-85) with recurrent urethral strictures were recruited to the trial. All the strictures were treated by internal urethrotomy and the patients were then randomized to perform ILSC twice weekly for either 6 months (group 1) or 36 months (group 2). Out-patient follow-up with urinary flow rate was initially at 1 month and then at 3 monthly intervals. Stricture recurrence rates were compared between the two groups. RESULTS: Of 101 patients, seven failed to attend after the first out-patient appointment. A further 21 died of unrelated disease whilst on ILSC (although 13 had been followed up for at least 24 months and so were included in the analysis). The median follow-up was 67 months (range 24-78). Ten patients in group 2, who had suffered from recurrent strictures, refused to stop catheterizing at the appointed time and all remain stricture-free on permanent ILSC. Of the remaining 76 patients, 48 catheterized for 6 months and 28 patients performed ILSC for 12 to 36 months (nine stopped earlier than intended). Forty per cent of patients who stopped at 6 months developed a recurrence compared with 14% who catheterized for more than 12 months (P < 0.05) (chi-square test with Yates' correction). CONCLUSIONS: Our results indicate that ILSC is safe and effective in preventing stricture recurrence in the long term. The recurrence rate of urethral strictures was significantly lower when ILSC was continued for more than 12 months compared with ILSC that was stopped at 6 months. We conclude that catheterization for at least 1 year is required to achieve adequate urethral stabilization.

Adolescent↗
PubMed1994

Analysis of factors associated with complications following renal transplant needle core biopsy.

OBJECTIVE: To determine factors associated with complications in patients undergoing renal transplant biopsy. PATIENTS AND METHODS: A total of 210 consecutive renal transplant patients biopsied for acute graft dysfunction or as part of a long term surveillance programme. Biopsies were performed under ultrasound control at two centres (Nottingham City and Leicester General Hospitals). RESULTS: Seventeen patients developed macroscopic haematuria following biopsy (8%). There were no graft losses. In cases where at least one biopsy core contained only renal medullary tissue, there was a significantly higher risk of a post-biopsy bleed (P < 0.001). CONCLUSION: This study demonstrates that even with careful ultrasound guidance, renal transplant biopsy has an important complication rate. Every effort must be made to obtain very superficial biopsies which consist largely or exclusively of renal cortex.

Adult↗
PubMed1993

Are backup arteriovenous fistulae necessary for patients on continuous ambulatory peritoneal dialysis?

The rationale for backup fistulae for patients on continuous ambulatory peritoneal dialysis (CAPD) is that many will require emergency haemodialysis and, subsequently, permanent haemodialysis. 42% of renal units in the UK have a policy of providing CAPD patients with backup arteriovenous fistulae. We have investigated whether this policy is justified. In our unit, of 176 patients who started CAPD between 1986 and 1989, most (73%) did not require haemodialysis over a median follow-up period of 4 years. Of the 153 backup fistulae created in 114 patients, only 10 were ever used for emergency haemodialysis. 23 other patients required emergency haemodialysis, but when required their fistulae were no longer functioning. The mean fistula patency times among patients in this study compared very favourably with those in other published work. This finding indicates that most fistulae are not available for emergency haemodialysis when required. 94% of fistulae were never used for haemodialysis. Hence it is no longer justifiable to create backup fistulae in CAPD patients.

Arteriovenous Shunt, Surgical↗
PubMed1993

Effect of nifedipine on renal transplant rejection.

The effect of early nifedipine therapy on acute renal allograft rejection was studied in 170 adult cadaveric transplant recipients. Acute rejection occurring in the first 3 months after transplantation was diagnosed by Tru-cut biopsy and the severity of each rejection episode assessed histologically. The incidence of acute rejection was significantly lower in patients treated with nifedipine (29 of 80; 36 per cent) than in controls (52 of 90; 58 per cent) (P < 0.01) and there was a higher proportion of histologically mild rejection episodes in the former group (P < 0.01). Multivariate analysis confirmed that nifedipine exerted a significant independent effect on the incidence of early acute rejection. Other factors identified in the multivariate model as influencing rejection were human leucocyte antigen (HLA) matching at the DR locus, blood level of cyclosporin during the first week, HLA matching at the B locus, donor age and donor sex. The 1-year graft survival rate was 88.6 per cent in patients given nifedipine and 63.8 per cent in controls (P < 0.02). These data suggest that nifedipine therapy has a useful role in human renal transplantation.

Adolescent↗
PubMed1993

Management of extensive facial basal cell carcinoma by excision and microvascular tissue transfer.

Management of large or recurrent basal cell carcinomas (BCCs) on the face can be difficult, especially where radiotherapy has been the primary treatment. Free tissue transfer using microvascular surgery permits wide excision margins ensuring clearance of the tumour without being compromised by concern over closure, since the free flap can be designed after the excision of the tumour and its size and composition can thus be custom made. Age alone should not be a contraindication to this major procedure.

Age Factors↗