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Biomedical subjects

J W Fielding

Publications and source records attributed to J W Fielding.

At least 37 records · Page 2Linked to original sources
PubMed1993

A randomised trial of selective or routine on-table cholangiography.

To assess the value of pre- and peroperative indicators of common bile duct (CBD) stones, 167 patients undergoing cholecystectomy were randomised to receive either routine (R) or selective (S) on-table cholangiography (OTC). In all, 81/84 patients in the R group and 22/78 in the S group had OTCs (P < 0.0001). In the R group 11/81 were positive (one false-positive) and in the S group 7/22 were positive (P < 0.05). CBD stones were present in 10/81 in the R group and 7/78 in the S group (P = NS). In the R group 8/10 and in the S group 5/7 had CBD stones diagnosed preoperatively by ultrasound scanning (USS), giving USS a positive predictive value (PPV) of 100% and a sensitivity of 71.4% in the S group. A raised preoperative alkaline phosphatase (ALP) was found in 1/10 in the R group and 1/7 in the S group (PPV = 33.3%, sensitivity = 14.3%). In the R group 1/10 and in the S group 1/7 (PPV = 25%, sensitivity = 14.3%) were found to have a dilated CBD during operation suggesting CBD stones. There have been no cases of symptomatic unsuspected retained CBD stones during follow-up to date. Our study has demonstrated that selective use of OTCs can be safely employed in open cholecystectomies. Over 85% (6/7 in the S group and 15/17 overall) of CBD stones can be diagnosed preoperatively by USS and liver function tests, with USS having the greatest PPV and sensitivity.

Adult↗
PubMed1992

Acceptability of opportunistic screening for occult gastrointestinal blood loss.

OBJECTIVE: To test patient compliance for faecal occult blood testing in suburban and inner city general practice. DESIGN: Prospective opportunistic trial using the Haemoccult test kit. Tests were offered during routine surgery attendance. SETTING: Three group general practices in Birmingham. SUBJECTS: All patients aged 40 years or older on the start date who routinely attended surgery during two years. MAIN OUTCOME MEASURES: Numbers of patients approached for testing and the numbers refusing, accepting, and returning the test kits. RESULTS: Only 26.3% (1230/4677) of the potential target population had been screened within the two years, although 988 (39.3%) of the suburban practice target were screened. However, 55.7% (1230/2207) of patients actually offered a test returned completed kits, with only 6% (133) refusing the kit. 683 (61.6%) patients aged 50-69 returned kits, compared with 343 (54.3%) aged 70 or over and 204 (43.8%) aged 40-49. These differences were significant (p less than 0.001). Patients from the inner city practice were significantly less likely to be offered the test than those in suburban practice (242 (11.2%) v 988 (39.9%), p less than 0.001) and return the samples (242 (38.8%) v 988 (62.4%), p less than 0.001). Patients from the inner city practice were also more likely to refuse the test (78 (12.5%) v 55 (3.5%), p less than 0.001). CONCLUSIONS: Opportunistic testing for occult faecal blood in asymptomatic patients was reasonably acceptable to patients, especially those in a suburban practice. If the test is shown to reduce mortality from colorectal cancer then formal screening would probably achieve acceptable target rates, especially among patients aged 50-69, who represent the prime risk group.

Adult↗
PubMed1992

The selection of cases for randomised trials: a registry survey of concurrent trial and non-trial patients. The British Stomach Cancer Group.

A randomised trial of adjuvant chemotherapy vs placebo in operable stomach cancer recruited 249 patients from the West Midlands Region between 1976-1980. A Cancer Registry survey identified a further 1261 suitable concurrent cases. Trial patients were compared with the 960 non-trial cases from participating Districts. Only 493 (51%) non-trial cases passed all of the prospective trial selection criteria for entry. Stage and fitness caused the majority of exclusions and were also highly prognostic. A univariate analysis comparing eligible patients with the trial showed the two groups to be balanced for the significant independent prognostic factors of the trial. However, differences in patient age and the surgery performed indicate that recruitment may have been influenced by unknown selection factors. This survey highlights the difficulty of retrospective selection and confirms the need for randomised controls. Data available from specialist Registries may be used to help develop new protocols and to verify and extend trial results.

Adolescent↗
PubMed1992

Complications of anterior cervical disk removal and fusion.

Surgeons favoring fusion believe that removal of the disk alone can result in painful spondylosis, eventually requiring fusion. Surgeons not favoring fusion eliminate painful neuralgia from damage to the anterior femoral cutaneous nerve as well as painful donor site scars. Also eliminated are painful pseudarthrosis and degenerative problems. Graft collapse and displacement are uncommon if three-sided iliac grafts are used. Rarely, if ever, is it necessary to fix the graft in place with wire silk sutures. Fortunately, complications of cervical spine surgery are uncommon.

Cervical Vertebrae↗
PubMed1992

Onlay technique for occipitocervical fusion.

Twenty-eight occipitocervical fusions using the onlay technique were performed in 27 patients ranging in age from 13 to 77 years (average age, 47.6 years). The indications for fusion included neurologic involvement from atlantoaxial instability associated with superior migration of the odontoid and destructive changes at the occiput-C1-C2 articulation, causing pain unrelieved by conservative treatment. Preoperative diagnoses included rheumatoid arthritis, congenital anomalies, posttraumatic, failed C1-C2 fusions, ankylosing spondylitis, and tumor. A standard posterior exposure of occiput-C1-C2 was used, and iliac crest bone graft was placed over the area to be fused. Postoperative immobilization consisted of skull tong traction, minerva jacket, and halo apparatus. There were no neurologic complications, two superficial wound infections, and minor difficulties with halo loosening. There was one perioperative death. Primary fusion was obtained in 89% of patients at an average of 12.8 weeks. Occipitocervical fusion by the onlay technique is safe, requires no internal fixation, and has a high success rate when compared with other methods of obtaining fusion in the occipitocervical region.

Adolescent↗
PubMed1992

Blood transfusion: an overused resource in colorectal cancer surgery.

The use of blood transfusion was examined in 476 patients who underwent curative surgery for large bowel cancer. Of these patients, 128 were not transfused while 348 received a total of 1174 units of blood. A patient was considered over-transfused if the predischarge haemoglobin was more than 12 g/dl. Using this criteria and accepting that single unit transfusions should be avoided, transfusion could have been avoided in 30% of the patients and a total of 377 units were given unnecessarily. Major under-transfusion did not occur; no patient being discharged with a haemoglobin of less than 9 g/dl. This study shows that blood transfusion is overused and the reasons for its use rarely recorded. In view of the morbidity related to transfusion, it is suggested that surgeons and anaesthetists reappraise their transfusion policy and the first step in this must be to record the reason for transfusion.

Aged↗
PubMed1990

Early detection of gastric cancer.

OBJECTIVE: To see whether investigation of dyspeptic patients aged over 40 after their first consultation with the general practitioner would increase the proportions with early and operable gastric cancers. DESIGN: Prospective study of gastric cancer in dyspeptic patients aged over 40 from a defined population. SETTING: 10 General practices (six in central Birmingham, four in Sandwell); the Queen Elizabeth Hospital, Birmingham; and Sandwell District General Hospital. PATIENTS: 2659 Patients aged 40 or over referred with dyspepsia. MAIN OUTCOME MEASURE: Increase in early and operable gastric cancers detected in middle aged patients with dyspepsia. RESULTS: Disease was identified in 1992 patients (75%). Fifty seven were found to have gastric cancer, 36 being treated by potentially curative resection, including 15 with early cancer. CONCLUSIONS: The investigation of dyspeptic patients over 40 at first attendance can increase the proportion of early gastric cancers detected to 26% and the proportion of operable cases to 63%. Such a policy has the potential to reduce mortality from gastric cancer in the population.

Adult↗
PubMed1990

Prognostic factors in acute renal failure following aortic aneurysm surgery.

This study analyses the prognostic factors associated with survival in 70 patients who developed acute renal failure following surgery for an aortic aneurysm. Forty-nine patients (70 per cent) had surgery for a ruptured aortic aneurysm and 21 patients (30 per cent) had an elective procedure. Fifty-nine patients received haemodialysis. Thirty-three patients (47 per cent) survived the episode of acute renal failure. Six of these thirty-three patients died within three months of recovering from acute renal failure, giving an overall survival of 27/70 (39 per cent). A stepwise logistic regression analysis showed that the following factors significantly adversely affected survival: a need for inotropic support, ventilation for more than three days and age over 65 years. A model developed using these variables provided a basis for predicting outcome.

Acute Kidney Injury↗
PubMed1990

Selective salvage surgery in gastrointestinal and gynaecological cancer.

The role of reoperation with intent to excise locally recurrent disease has been evaluated in a selected group of 64 patients originally treated for primary gastrointestinal or gynaecological cancer. In 16 (25%), surgery was successful in eradicating all known sites of disease and was associated with a median survival of 23 months. Patients most suitable for reoperation were those with non-specific gastrointestinal symptoms or asymptomatic local disease. Nevertheless, those with specific symptoms may have treatable local disease or even benign conditions, and thus all with suspected local recurrence should be evaluated with a view to salvage surgery.

Colorectal Neoplasms↗
PubMed1989

Gastric cancer: a 25-year review.

Between 1957 and 1981, 31,716 cases of gastric cancer were registered in the West Midlands, UK. The age-standardized incidence has shown a decrease from 17.42 per 100,000 population during the first quinquennium to 15.30 per 100,000 in the last. There was an apparent increase in the proportion of proximal lesions with a decrease in the proportion of distal, antral cancers. The stage of disease at diagnosis remained constant with 79 per cent of patients having stage IV disease. Less than 1 per cent presented with stage I disease. As a result, the curative resection rate was 21 per cent. The operative mortality rates for curative partial gastrectomy and total gastrectomy were 13 and 29 per cent respectively. Surgeons undertaking more than nine total gastrectomies annually had an overall mean operative mortality rate of 22 per cent. Overall age-adjusted survival at 5 years was 5 per cent. Survival at 5 years for stage I, II and III disease was 72, 32 and 10 per cent respectively. There was a significant increase in survival time for those treated by curative resection between 1972 and 1981 compared with the previous decade. The implications for the management of gastric cancer are discussed.

Age Factors↗