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Biomedical subjects

J Coles

Publications and source records attributed to J Coles.

At least 19 recordsLinked to original sources
PubMed2003

Evolution of heart rate control after transplantation: conduction versus autonomic innervation.

In cardiac transplantation, the donor organ is not initially innervated and demonstrates decreased heart rate variability (HRV). However, HRV may improve after several months. The mechanism for HRV improvement has not been elucidated; autonomic "reinnervation" of the donor heart has been proposed. The role of atrioatrial conduction from recipient to donor organ has not been evaluated. We prospectively evaluated cardiac transplant patients with a limited electrophysiology study at the time of their surveillance biopsies. Recordings were made of recipient and donor signals, observing conduction properties between recipient and donor atria. Holter recordings were analyzed and HRV was determined using spectral analysis techniques, recording mean RR interval, low-frequency power (LF), high-frequency power (HF), and the LF/HF ratio. These were compared to published norms. From November 1999 to May 2000, 21 patients (6 female) who underwent cardiac transplantation participated at a median age of 101 months (range, 4.1-217 months). Time posttransplant ranged from 26 days to 71 months. Holter data were available for 20 patients and demonstrated dissociated P waves in 13 (65%). The mean heart rate on Holter was 111 beats per minute (bpm) (range, 85-161 bpm). We were able to record distinct recipient atrial signals in 16 of 21 (76%) patients. The average recipient tissue heart rate was 55% that of the donor heart rate. We documented atrioatrial association in only 1 patient. HRV did not reach normal values for most patients and did not increase with time posttransplantation. The LF values were in the normal range for most patients, whereas 3 patients had normal HF values and 2 patients had values just below normal. Recipients of heart transplantation have a predominantly sympathetic influence of HRV. These preliminary data suggest that atrioatrial conduction does not play a role in reestablishing normal heart rate control following pediatric cardiac transplantation.

Adolescent↗
PubMed2001

Outcomes of intraoperative device closure of muscular ventricular septal defects.

BACKGROUND: The surgical management of muscular ventricular septal defects (mVSD) in the small infant is a challenge particularly when multiple and associated with complex cardiac lesions. Devices for percutaneous implantation have the advantage of ease of placement and for the double umbrella designs a wide area of coverage. We reviewed our experience and clinical outcomes of intraoperative mVSD device closure for such defects in small infants. METHODS: Since October 1989, intraoperative VSD device closure was a component of the surgical strategy in 14 consecutive patient implants (median age, 5.5 months; range, 3 to 11 kg), whose defects were thought difficult to approach using conventional techniques. Nine patients had associated complex cardiac lesions, 10 multiple mVSDs, and 4 patients had a previous pulmonary artery banding. RESULTS: There were 2 early deaths, 1 in a severely ill child who preoperatively had pulmonary hypertension and left ventricular failure and another in a patient with a hypoplastic left heart. Mean pulmonary to systemic flow ratio before device insertion was 3.5:1. Complete closure was achieved in 5 patients and clinically insignificant residual shunts persisted in 7. In 2 infants with significant residual lesions concomitant pulmonary artery banding was required. Postoperative mean pulmonary to systemic flow ratio was 1.7:1. In follow-up of the 12 surviving infants (mean, 41 months), 8 had complete closure and 3 persistent residual shunts. One patient with no residual shunting required heart transplantation for progressive ventricular failure 9 years after operation. All devices were well positioned on postoperative echocardiograms. There was 1 late death due to aspiration in a patient with a tiny residual shunt. CONCLUSIONS: Infants requiring operative intervention with mVSDs are difficult to manage and have an increased mortality and morbidity. Intraoperative VSD device placement for closure of mVSDs is feasible, can avoid ventriculotomy, division of intracardiac muscle bands, and is ideally suited for the neonate or infant.

Echocardiography↗
PubMed2001

Mycophenolate mofetil in pediatric heart transplant recipients: a single-center experience.

Mycophenolate mofetil (MMF) is emerging as an effective agent for the treatment of both established rejection and primary rejection prophylaxis in solid-organ transplantation (Tx). However, little data is available on the use of MMF in the pediatric population. We therefore report on our experience with MMF in 21 pediatric heart transplant recipients. Data were obtained by retrospective chart review. Median age at time of review was 12.3 yr (range 11 months to 16.9 yr). Median age at Tx was 10.7 yr (range 55 days to 16.7 yr). MMF was started at a median of 4.3 months after Tx (range 1 day to 4.5 yr). At the time of MMF institution, all patients were concurrently on prednisone and azathioprine; 20 of these patients were also undergoing treatment with tacrolimus (median dose 0.18 mg/kg, range 0.03-0.64 mg/kg) and one with cyclo-sporin A (10 mg/kg). Azathioprine was discontinued at the time of commencing MMF. The average MMF dose was 40 +/- 14 mg/kg. The rationale for switching to MMF included rejection (International Society for Heart and Lung Transplantation [ISHLT] 3A/B), 66%; inability to wean steroids, 14%; ABO blood group donor-recipient mismatch, 10%; coronary artery disease (CAD), 5%; and side-effects of immuno-suppression, 5%. Of the patients switched for rejection, 93% demonstrated resolved or improving rejection. Both ABO donor-recipient mismatch patients were started on tacrolimus/MMF as primary therapy and had no significant episodes of rejection. Two patients had rejection classified as unchanged (one with CAD, one treated with addition of sirolimus prior to improvement). Corticosteroids were successfully discontinued in 28% of patients, and 20% are currently on a reduced dose. Fourteen per cent developed significant rejection while attempting to reduce the steroid dose. Steroid reduction has not yet been attempted in 38% of patients. The following side-effects were reported in 38% of the patients: diarrhea, 10%; gastrointestinal discomfort, 20%; and leukopenia, 20%. Dose reduction or temporary discontinuation was required in 63% of the patients who experienced side-effects (24% of the total number of patients). Opportunistic infections developed in 10% (cryptococcus, cytomegalovirus). Hence, MMF appears to be effective for treatment of rejection in the pediatric heart transplant population and has an acceptable side-effect profile. In addition, it may have a role in primary rejection prophylaxis and may facilitate a reduced steroid dosage or a steroid-free immunosuppression regimen.

Adolescent↗
PubMed2001

Extracardiac conduit versus lateral tunnel cavopulmonary connections at a single institution: impact on outcomes.

OBJECTIVE: To compare outcomes of extracardiac conduit and lateral tunnel Fontan connections in a single institution over a concurrent time period. METHODS: Between January 1994 and September 1998, 60 extracardiac conduit and 47 lateral tunnel total cavopulmonary connections were performed. Age, sex, and weight did not differ between the 2 groups. Compared with the lateral tunnel group (LT group), patients undergoing the extracardiac conduit procedure (EC group) had a trend to a higher incidence of morphologically right ventricle (EC group 48% vs LT group 32%; P <.09), a higher incidence of isomerism/heterotaxy syndrome (EC 22% vs LT 0%; P <.001), worse atrioventricular valve regurgitation (EC 11% moderate-plus vs LT 0%; P <.06), and lower McGoon indices (EC 1.8 +/- 0.5 vs LT 2.1 +/- 0.5; P <.03). Preoperative arrhythmias, transpulmonary gradients, room air oxygen saturations, ejection fractions, ventricular end-diastolic pressure, and pulmonary artery distortion did not differ between groups. Cardiopulmonary bypass times and fenestration usage were similar in both groups. RESULTS: Overall operative mortality was 5.6% and did not differ between groups. The LT group had a significantly higher incidence of postoperative sinoatrial node dysfunction (45% vs EC group 15%; P <.007), supraventricular tachycardia (33% vs EC group 8%; P <.0009), and need for temporary postoperative pacing (32% vs 12%; P <.01). Median duration of intensive care unit stay (EC 2 days, range 1-10 days, vs LT 2.8 days, range 1-103 days; P <.07) and ventilatory support (EC 1 day, range 0.25-10 days, vs LT 1 day, range 0.25-99 days; P <.03) were all longer in the LT group. Median chest tube drainage (EC 8 days, LT 9 days) was similar in both groups. Follow-up averaged 2.5 +/- 1.4 years in the EC group and 2.8 +/- 1.9 years in the LT group. There were 2 late deaths. Overall survival is 94% at 1 month, 92% at 1 year, and 92% at 5 years. Late ejection fraction or atrioventricular valve function did not differ between groups. Intermediate follow-up Holter analysis showed a higher incidence of atrial arrhythmias in the LT group (23% vs 7%; P <.02). Multivariable analysis showed that (1) prolonged cardiopulmonary bypass time was the only independent predictor for perioperative mortality, prolonged ventilation and intensive care unit length of stay, and increased time to final removal of chest tube drains and (2) lateral tunnel Fontan connection is an independent predictor of early postoperative and intermediate atrial arrhythmias. CONCLUSIONS: Although patients in the EC group were at higher preoperative risk, their outcomes were comparable with those of the LT group. Use of the extracardiac conduit technique for the modified Fontan operation reduces the risk of early and midterm atrial arrhythmia.

Arrhythmias, Cardiac↗
PubMed1999

Public disclosure of health care performance reports: a response from the UK.

In the UK, the experience with public disclosure of health care performance data related to provider organizations is limited to a small set of administrative data known as the 'Patient's Charter' which has concentrated mainly on aspects of efficiency and which is currently being reviewed, and, most recently, to a set of reference costs by case type (known as Healthcare Resource Groups). Clinically oriented performance data has been published in Scotland since 1994 and will be published in England and Wales early in 1999. Knowledge about the impact and effect of such publication is limited, even in the USA, but there is some evidence that consumers and purchasers become gradually familiar with them and confident in their use. However, even with this scant knowledge, it would appear that the publication of data across the public services will continue to be a policy of the current UK Government for the foreseeable future. It would seem likely that this policy will have the tacit approval of the general population who have been educated to be somewhat wary of professional self-regulation. The greater public accountability that public disclosure of information brings, needs to be evaluated against the overall costs of the exercise, particularly within a publicly financed system, and against the disadvantages in public confidence and impact on the patient-doctor relationship that might occur if not managed appropriately.

Consumer Advocacy↗
PubMed1999

'Failure to rescue' as a measure of quality of hospital care: the limitations of secondary diagnosis coding in English hospital data.

Although it is widely recognized that quality of care varies between hospitals, a robust and valid measure of outcome that can be used in comparisons has proven elusive. One measure that has recently been proposed by US researchers is the 'failure to rescue' (FTR) rate. This is based on the assumption that, whereas complications may reflect both patient severity and health care factors, the ability to save patients once complications arise is much more closely related to the quality of health care. We describe an evaluation of FTR in a national sample of English hospitals using hospital episode data. We found that the rate of secondary diagnosis recording in England is about one-tenth that in the United States. The FTR rate would be highly sensitive to variations in the completeness of coding of secondary diagnoses. Unless coding is of uniformly high quality, any attempt to compare severity adjusted outcomes will be potentially unreliable.

Adolescent↗
PubMed1999

Local shielding of high dose rate brachytherapy in an operating theatre.

A high-dose rate brachytherapy facility was installed into an established operating theatre by using local shielding in the form of mobile lead screens and by taking advantage of the ease with which staff movements can be controlled in an operating suite. This facility was inexpensive to develop, and has proved clinically efficient and entirely adequate from a radiation safety standpoint.

Brachytherapy↗
PubMed1997

Complication of ventricular demand pacing after orthotopic heart transplantation: unusual case of pacemaker syndrome in an infant.

BACKGROUND: Sinus node dysfunction is the most common indication for antibradycardiac permanent pacing after heart transplantation. Lack of atrioventricular synchrony during pacing can result in symptoms ranging from mild chest discomfort to severe manifestations such as dyspnea, hypotension, and cardiovascular collapse, all of which are ascribed to pacemaker syndrome. In infants pacemaker syndrome is often only recognized in the face of marked hemodynamic compromise. RESULTS: This report details an unusual account of pacemaker syndrome in an infant after orthotopic heart transplantation. CONCLUSIONS: Careful assessment of atrioventricular synchrony is important after infant transplantation.

Angina Pectoris↗
PubMed1996

The standard primipara as a basis for inter-unit comparisons of maternity care.

OBJECTIVE: To assess the suitability of the standard primipara (a subset of the obstetric population that has relatively low risk or intervention and of adverse outcome) for making inter-unit comparisons of indicators of the process and outcome of maternity care. DESIGN: Inter-unit comparison of 10 indicators of obstetric intervention and adverse outcome derived from routinely collected computerised data held on the St Mary's Maternity Information System. SETTING: Fifteen maternity units in the former North West Thames Region. PARTICIPANTS: 15,463 primiparae who were delivered in 1992. MAIN OUTCOME MEASURES: Proportion of primiparae within the standard definition; degree to which standard primiparae are associated with lower rates of intervention and adverse outcome, as compared to other primiparae. RESULTS: Within the database, 42.6% of all primiparae were found to be standard, with rates varying between units from 25.9% to 57.7%. As expected, the standard primiparous woman is at less risk of intervention or adverse outcome than other primiparae. All but one component variable of the standard definition is a significant risk factor for at least four of the 10 indicators. Statistically significant differences in indicator rates are seen between standard and nonstandard primiparae within units. Within the standard group, significant differences in rates of intervention and adverse outcome are seen between units. Units with relatively high levels of intervention within the higher risk nonstandard group also have relatively high levels of intervention within the standard group. CONCLUSIONS: Use of the standard primipara, rather than the whole obstetric population, as the basis for inter-unit comparisons of maternity care will control for the substantial difference in case mix seen in different units, thereby increasing the validity of those comparisons. The technique has the additional benefit of clarifying the relationship between everyday clinical decision making and a unit's performance in comparative indicator reports. The approach must be combined with a separate study of the other groups in the case mix, such as multiparae and high risk primiparae. Additional nonoverlapping groups, homogeneous in terms of risk factors, should be defined and used to extend the basis on which comparisons may be made.

Adult↗
PubMed1995

The successful removal of a bleeding intracranial tumour in a severe haemophiliac using an adjusted dose continuous infusion of monoclonal factor VIII.

Ten per cent of patients with haemophilia A develop intracranial haemorrhage (ICH) with a mortality rate of 30% and an incidence of psycho-neurological sequelae in 50% of survivors. ICH may be spontaneous or in association with trauma and other pathology. The generally recommended management is conservative replacement therapy using bolus injections of factor VIII and no neurosurgical intervention. Adjusted dose continuous infusion therapy provides an alternative method of factor VIII administration that is simple, more cost effective and safer through the maintenance of stable plasma VIII:C levels. This method has been successfully used to cover general surgery and the conservative treatment of subarachnoid haemorrhage but is not widely used due to unfamiliarity with the technique. This paper describes the use of continuous infusion of factor VIII concentrates to cover the successful neurosurgical management of a young man with severe haemophilia A who presented with an ICH associated with a bleeding choroid plexus tumour. Surgery was complicated by the development of a factor VIII inhibitor which disappeared following treatment with an immune-tolerance induction programme.

Adolescent↗
PubMed1995

Nottingham health profile measurement in the assessment of clinical outcome after prostatectomy. Northern Regional Prostate Audit Group.

OBJECTIVE: To compare the changes in pre- and post-operative symptom scores with changes in Nottingham health profile (NHP) scoring, and thus determine whether NHP scoring offers a reliable assessment of outcome after transurethral resection of the prostate (TURP), and whether NHP scoring could usefully supplement the more traditional method of symptom scoring in this assessment. PATIENTS AND METHODS: An 8-month audit of 1396 TURPs, involving 12 hospital sites, was performed in the Northern region between April 1 and November 31, 1991. A cohort of 371 of these patients, for whom pre- and post-operative NHPs and irritative and obstructive voiding symptoms had been recorded, were investigated. RESULTS: There was a significant decrease in both obstructive and irritative voiding symptom scores 3 months after TURP and a significant fall in the NHP scores for all stations except social isolation. There were significantly higher irritative symptom scores both before and after operation in men with prostate cancer compared with those with benign prostatic hypertrophy, and significantly higher post-operative obstructive symptom scores in men with prostate cancer. However, there were no significant differences in the pre- and post-operative NHP scores for these two subgroups of patients. In patients who had a good outcome on symptom scoring, there was a significant reduction in NHP scores for all stations except social isolation. However, in those patients who had a poor outcome on symptom score, there was no correlation with changes in the NHP scores, with some NHP stations showing a significant reduction after operation. CONCLUSION: NHP quality-of-life scoring cannot replace symptom scoring in the assessment of outcome after TURP and when used alone, added little further information. However, for a comprehensive assessment of outcome, symptom scores and quality-of-life assessments should be used together.

Cohort Studies↗
PubMed1994

Written consent about sexual function in men undergoing transurethral prostatectomy.

OBJECTIVE: To review the written recording of consent about possible sexual dysfunction after transurethral resection of the prostate (TURP), and the incidence of sexual dysfunction in sexually active men after TURP, from a large scale audit of transurethral prostatectomy held in 12 hospital sites in the Northern Region. PATIENTS AND METHODS: Over an 8-month period data were collected from 12 separate hospital sites within the Northern Region by two independent nurse co-ordinators who travelled to each of the sites. Information was gathered from medical records, operation lists and theatre books using a standard proforma. The Nottingham Health Profile (NHP) was used as a quality of life instrument in a subgroup of patients who were asked about sexual function before and after operation. RESULTS: Advice about retrograde ejaculation was recorded infrequently, with only 30% of case notes including a statement about this (inter-site variations 0-78%). The mean age of patients in whom a written record was made was lower (70 [0.44 SEM] years) than those in whom there was no recording (72 [0.25] years; P < 0.001), but marital status did not appear to be a significant factor. No significant differences in NHP were found comparing men who did or who did not have written evidence about consent regarding retrograde ejaculation. In addition, in a subset of men who had been asked pre-operatively about sexual function, no significant differences were found in overall NHP measurements in those who did or who did not develop retrograde ejaculation. In men who were sexually active before operation, the incidence of major sexual problems, impotence and retrograde ejaculation were 12%, 11% and 24% respectively. CONCLUSION: The incidence of sexual dysfunction following TURP in this audit concurred with previously reported studies (4-40%), but despite this most urologists in our audit were not recording that they had advised their patients about this possible outcome.

Aged↗
PubMed1994

Deaths and complications following prostatectomy in 1400 men in the northern region of England. Northern Regional Prostate Audit Group.

OBJECTIVE: To determine the degree of variation in mortality and major morbidity following transurethral resection of the prostate (TURP), and to assess intersite variation for mortality and morbidity over 12 sites within the Northern Region. Further, to determine whether the previously observed effects on morbidity of unit size, patient through-put and emergency admission were borne out in contemporary urological practice in the Northern Region. PATIENTS AND METHODS: For an 8 month period, 1 April 1991-31 November 1991, an independent audit of TURP was performed on 12 different hospital sites throughout the Northern Region. A constant data set was designed which was collected on each patient before and 3 months after operation by two independent clinical co-ordinators who travelled to each of the sites. All case notes were reviewed at 3 months after operation by the co-ordinators using a standard proforma, rather than depending upon self reporting by medical staff. Data on factors potentially affecting mortality and morbidity were collected, including emergency admission, diagnosis of prostate cancer, American Society of Anesthesiologists' co-morbidity scores, and age and differences in throughput in the 12 sites. The effect of through-put or 'volume' on mortality and morbidity was assessed by comparing morbidity and the number of cases performed. RESULTS: The early mean death rate was 13 of 1396 patients (0.9%), with an inter-site variation ranging from 0% to 3.8%. A mean of 2.0% of men were returned to theatre after TURP, 2.4% of patients received a blood transfusion (> 2 units) after operation, and 8.0% of patients developed post-operative sepsis; these complications varied sixfold, sevenfold and 17-fold across the different sites respectively. Those units performing < or = 100 operations over the audit period (equivalent to < 150 operation per year) had a significantly increased rate of deaths and complications which was not related to population differences, though some low volume units had good results. Elderly men who were admitted as emergencies or with prostate cancer were particularly vulnerable to complications. CONCLUSIONS: The overall early mortality rate after TURP for benign prostatic hyperplasia across the Region compares well with other reported large series. The significant variation in morbidity rates found in this study suggests that careful attention needs to be paid by Urologists, Purchasers and Providers to morbidity rates after prostatectomy.

Age Factors↗
PubMed1994

The quality of routinely collected maternity data.

OBJECTIVE: To assess the validity of clinical information held on a regional maternity database, the St Mary's Maternity Information System (SMMIS). DESIGN: A retrospective review of 892 maternity case notes and matched SMMIS records, by a midwife trained in clinical coding techniques. SETTING: Three maternity units in the North West Thames Region. MAIN OUTCOME MEASURES: Percentage agreement for 17 directly recorded SMMIS data items and equivalent data abstracted from the notes. Frequencies of diagnosis codes abstracted from case notes, as compared with those generated by SMMIS on the basis of directly recorded data. RESULTS: A generally high level of agreement was observed between the abstracts of the notes and the SMMIS records. Of the 17 data items examined, 10 showed 95% agreement or better, and all but two exceeded 80% agreement. Little difference was found between the levels of agreement observed at the three sites. A greater number and range of diagnosis codes were abstracted from the notes than were generated by SMMIS. CONCLUSIONS: The directly recorded clinical data held on the SMMIS regional database is largely accurate and consistently recorded across a variety of units. The database can therefore be considered a valuable resource for the comparative audit of maternity practice. The SMMIS technique for deriving, on a semi-automatic basis, diagnosis codes from the directly recorded fields, appears to work moderately well. We suggest that the direct method of data collection used in SMMIS could provide a model for other specialties in the National Health Service.

Data Collection↗
PubMed1994

Comparative hospital databases: value for management and quality.

OBJECTIVES: To establish an accurate and reliable comparative database of discharge abstracts and to appraise its value for assessments of quality of care. DESIGN: Retrospective review of case notes by trained research abstractors and comparison with matched information as routinely collected by the hospitals' own information systems. SETTING: Three district general hospitals and two major London teaching hospitals. PATIENTS: The database included 3905 medical and surgical cases and 2082 obstetric cases from 1990 and 1991. MAIN MEASURES: Accessibility of case notes; measures of reliability between reviewers and of validity of case note content; application of high level quality indicators. RESULTS: The existing hospital systems extracted insufficient detail from case notes to conduct clinical comparative analyses for medical and surgical cases. The research abstractors at least doubled the diagnostic codes extracted. Interabstractor agreement of about 70% was obtained for primary diagnosis and assignment to diagnosis related group. These data were sufficient to create a comparative database and apply high level quality indicators designed to flag topics for further study. For obstetric-specific indicators the rates were comparable for abstractors and the hospital information systems, which in each case was a departmentally based system (SMMIS) producing more detailed and accessible data. CONCLUSIONS: Current methods of extracting and coding diagnostic and procedural data from case notes in this sample of hospitals is unsatisfactory: notes were difficult to access and recording is unacceptably incomplete. IMPLICATIONS: Improvements as piloted in this project, are readily available should the NHS, hospital managers, and clinicians see the value of these data in their clinical and managerial activities.

Data Collection↗