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Biomedical subjects

N Black

Publications and source records attributed to N Black.

At least 73 records · Page 4Linked to original sources
PubMed1996

The effect of prostatectomy on symptom severity and quality of life.

OBJECTIVE: To determine the effectiveness of prostatectomy in reducing symptom severity and bother and in improving disease-specific and general quality of life. PATIENTS AND METHODS: A prospective, cohort study was performed in National Health Service and private hospitals in the Northern, Wessex, Mersey, and South-West Thames Health Regions which comprised 5276 men undergoing prostatectomy recruited by 101 of the 106 (96%) surgeons (specialist and non-specialist) performing prostatectomy during a 6-month period. Patients were assessed using the American Urological Association (AUA) Symptom Index Score, the AUA symptom bother score, disease-specific and generic quality-of-life scores, the occurrence of adverse events (urinary incontinence, erectile impotence and retrograde ejaculation) and three global (general) questions on the results of their treatment. The outcome was assessed 3 months after surgery. RESULTS: Prostatectomy was effective in reducing both symptoms (initial mean score 20.1 reduced to 7.4, P < 0.001) and symptom bother (initial mean score 14.4 reduced to 4.3, P < 0.001). Not all men experienced a good reduction in symptoms; 121 (3.9%) were worse, 301 (9.6%) were the same, and 721 (23%) experienced only slight improvement. The type of operation, grade of principal operator and use of pre-operative investigations were not associated with the extent of symptomatic improvement. Changes in symptom severity were highly correlated with changes in bothersomeness++ and disease-specific quality of life but not with generic quality of life. A third of men who were continent before surgery reported some incontinence 3 months later, although only 6% found it a problem. Two-thirds of men experienced retrograde ejaculation and 31% experienced some erectile impotence following surgery. CONCLUSIONS: Prostatectomy is effective in reducing symptoms in most men. Men who experience a substantial reduction in symptoms were more likely to report a favourable outcome. The study confirmed that approximately one-third of men reported an unfavourable result 3 months after their operation.

Aged↗
PubMed1996

Impact of the 1991 NHS reforms on the availability and use of coronary revascularisation in the UK (1987-1995)

OBJECTIVE: To describe changes in the availability, utilisation, and waiting times for coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA) between 1987/88 and 1994/95 and to review commissioning of these services. DESIGN: A series of cross sectional surveys and interviews with purchasers and providers. SETTING: Four health regions in the United Kingdom. PATIENTS: All residents aged 25 years or more who underwent coronary revascularisation. RESULTS: There has been little change in the availability of consultants in cardiology in specialist centres, while the number of non-consultant cardiologists has risen significantly. The availability of consultant surgeons more than doubled in some regions, while non-consultant surgical staff increased by 40-90%. The NHS rate of use of both CABG and PTCA has increased steadily since 1987/88. In 1994/95, only two districts had CABG rates of less than 300 per million population. The additional contribution of privately funded cases varied between 14-23% for CABG and 7-30% for PTCA. Regional rates varied 1.3-fold for CABG and threefold for PTCA in 1994/95, while district rates of CABG varied 3.6-fold and PTCA 18-fold. Revascularisation rates were higher in districts with least need in 1991/92 and this persisted over the following three years. The overall waiting time for CABG (214 days) was largely unchanged from 1992/93 (234 days). The overall waiting time for PTCA (138 days) was 25% shorter than in 1992/93 (185 days). Prioritisation of patients waiting over a year had not yet adversely affected the waiting time of more urgent patients. Commissioning has faced a complex web of interconnected problems which, in general, caused more problems for purchasers than providers initially but which appear to be of increasing concern to providers. CONCLUSIONS: The 1991 NHS reforms had had no observable impact on the availability and use of coronary revascularisation by 1995. Continued monitoring is necessary to detect any delayed effect.

Adult↗
PubMed1996

Does a shorter length of hospital stay affect the outcome and costs of hysterectomy in southern England?

STUDY OBJECTIVE: To see whether a shorter postoperative length of stay (LOS) for a major procedure, abdominal hysterectomy for benign conditions, was associated with health outcome, the use of formal and lay care after discharge, cost, and satisfaction. DESIGN: Prospective cohort study. SETTING: Three hospitals in London and three in Hertfordshire and Bedfordshire. PATIENTS: A total of 363 women undergoing total abdominal hysterectomy with or without oophorectomy: 112 with a short postoperative LOS (five days or less) and 251 with a standard LOS (six days or more). MAIN OUTCOME MEASURES: Wound infection within 10 days and six weeks; change in general health status (Nottingham health profile) after six weeks; general health and change in social activity (lifestyle index) three months after surgery. Mean cost difference for hospitals, use of formal and lay care after discharge, and patient satisfaction. RESULTS: Short LOS was associated with benefits: a lower risk of wound infection in the first 10 days (odds ratio 0.44; p = 0.03) and no deterioration in physical mobility (measured using the NHP) after six weeks- and with adverse outcomes: constipation six weeks later (OR 0.48; p < 0.001) and moderate or severe urinary symptoms six weeks (OR 0.69; p < 0.004) and three months (OR 0.65; p < 0.008) later. On multivariate analysis, the only outcome to remain significantly associated with LOS was physical mobility after six weeks (p = 0.024). There was no significant difference between short and standard stay women as regards their use of formal or lay care after discharge from hospital. The mean cost of hospital care was Pounds251 (in 1992) less for short than for standard stay patients. Most women (73% at six weeks) felt their LOS was appropriate. Short stay women were more likely to feel it was too short, though the difference was not statistically significant. CONCLUSIONS: Short postoperative stays do not seem to be associated with any adverse outcomes and result in modest financial saving to the health service. There is potential for greater use of early discharge.

Adult↗
PubMed1996

Appropriateness of total hip replacement in the United Kingdom.

The paper discusses the use of consensus models in determining the application of Total Hip Replacement surgery. The paper notes the wide national and international variation in use of this procedure but considers it in the broader context of reaching consensus on other surgical interventions.

Decision Making↗
PubMed1995

Computer-assisted three-dimensional reconstruction of epithelial cells attached to percutaneous implants.

It is generally accepted that cell shape plays a pivotal role in many aspects of cell behavior including proliferation, differentiation, and gene expression. Although previous reports have shown that implant-surface topography can alter cell shape in vitro, in vivo evidence for such an effect is largely based on intuitive interpretation of two-dimensional histological sections. The objective of this in vivo study was to develop a method to reconstruct in three dimensions the shape of epithelial cells attached to smooth and micromachined implant surfaces. Titanium-coated epoxy replicas of smooth and 10-microns-deep micromachined grooved surfaces were implanted percutaneously in the parietal region of rats. After 7 days the implants and attached tissue were removed and processed for light and electron microscopy. One-micrometer-thick serial histological sections were used to trace and digitize cells and their nuclei into a Hewlett Packard computer. Three-dimensional images were reconstructed and rotated to measure length, width, height, area, orientation index and the angle cells or nuclei formed with the long axis of the grooves (XY angle), and the angle cells or nuclei formed with the long axis of the implant (XZ angle). Epithelial cells attached to the smooth surfaces were found to be significantly (P < .05) flatter and more spread than were the cells attached to the grooved surfaces. Cells on the smooth surfaces were aligned parallel with the long axis of the implant, whereas on the grooved surfaces cells were oriented obliquely with the implant.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1995

Recollected versus contemporary patient reports of pre-operative symptoms in men undergoing transurethral prostatic resection for benign disease.

The objective of the study was to investigate the reliability of patients' recollected pre-intervention symptom status and the impact of those symptoms compared with contemporary pre-operative reports, and to test the stability of recollected views. In design (A) a self-completed symptom questionnaire was administered before (contemporary) and 3 months after (recollected) surgery. In design (B) a self-completed symptom questionnaire on recollected pre-operative symptoms was administered 12 and 14 weeks after surgery. Setting (A) comprised the twin consultant urological unit in the Chesterfield and North Derbyshire Royal Hospital NHS Trust, and setting (B) a sample from the National Prostatectomy Audit of 5281 patients. The subjects were 77 consecutive patients scheduled for transurethral resection of the prostate (TURP), and 170 consecutive respondents undergoing TURP. The main outcome measures were the difference in group mean scores for The American Urological Association (AUA) Symptom Index, Impact Index (a score of symptom impact), and 14 constituent questions; association assessed using Pearson's correlation coefficient; agreement assessed using weighted Kappa statistics. Complete paired data sets were available for 58 (75%) men for the Symptom Index, and for 61 (79%) men for the Impact Index. Pre-operative mean Symptom Index scores for contemporary and recollected were similar, as were mean scores for the Impact Index. However, only poor to fair levels of association and agreement were obtained for the Symptom Index (r = 0.6, kappa (w) = 0.3) and Impact Index (r = 0.6, kappa (w) = 0.3). Results for the constituent questions were similar.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1995

International variation in intervention rates. What are the implications for patient selection?

While international variations in intervention rates are well recognized, little is known about their implications for patient selection. This paper describes an exploratory study in which the probability of undergoing an elective intervention (surgery for benign prostatic hyperplasia) in an area in the United Kingdom was compared with an area in the United States. It found that the area with high intervention rates was associated with higher levels of surgery in men with low levels of need who are unlikely to gain much benefit.

Aged↗
PubMed1995

Impact of non-response and of late-response by patients in a multi-centre surgical outcome audit.

OBJECTIVE: To determine the impact of non-responders on the results of a multi-centre surgical outcome audit, factors associated with failure to respond and to assess the benefits of pursuing non-responders beyond two reminders. DESIGN: A multi-centre prospective cohort study. SETTING: English health regions of Wessex, Mersey and Northern and South-West Thames. SUBJECTS: Five thousand two hundred and eighty-one (5281) consecutive cases undergoing surgery for prostate disease for a 6-month period. MAIN OUTCOME MEASURES: Socio-demographic and clinical factors associated with response (both early and late) and associations of these factors with outcomes (change in symptom severity, overall outcome, and occurrence of complications) three months after surgery. RESULTS: An overall response rate of 82.4% was achieved. Non-responders were likely to be older and in poorer physical health than responders. Although non-response would lead to the results of an audit overestimating the benefit and underestimating the adverse effects of surgery, the size of these errors is small. Pursuit of a random sample of non-responders beyond two reminders led to 45% responding, potentially boosting the overall response rate by 8% to a total of 90.4%. However, there were few significant differences between these late responders and those who responded earlier suggesting that effort and resources expended in obtaining their response would not be justified in the routine practice of audit. CONCLUSIONS: The results show that in a large multi-centre audit of post-operative patient perceived outcome, a response rate in excess of 80% will provide sufficiently accurate data for assessing the overall outcome of the service.

Aged↗
PubMed1995

The National Prostatectomy Audit: the clinical management of patients during hospital admission.

OBJECTIVE: To determine everyday practice in the hospital management of men undergoing prostatectomy and the extent of its variation. PATIENTS AND METHODS: A total of 5361 patients, who represented 89% of all those undergoing prostatic procedures in four health regions (Mersey, Wessex, Northern and South West Thames) and one test site (within Trent) were recruited by 103 (97%) surgeons. Clinical information was collected on a pre-coded data collection form which was completed during the hospital stay by the principal operator. Patient identification occurred at the time of surgery. RESULTS: Important findings included: (i) both older men and those of higher social class were more likely to undergo prostatectomy with fewer symptoms; (ii) men who waited longer for surgery had worse symptoms by the time of their operation; (iii) there were unexplained differences in routine pre- and post-operative investigation and treatment. Half the men had their flow rate or residual urine measured as part of their pre-operative assessment. About half the men received prophylactic antibiotics; (iv) when large groups were analysed, a consistent proportion of men throughout the study (12%) were undergoing the operation for a second time. The clinical course of men having a repeat operation differed in many ways from those having a first time procedure; (v) the larger proportion of men (62%) had surgery for strong indications as opposed to symptoms alone; (vi) although most operations were performed by consultants, emergency admissions, though symptomatically more severe and sicker, were more likely to be operated on by trainee surgeons; (vii) significant variation in mean pre-operative symptom severity and bother scores were seen between surgeons. CONCLUSION: The clinical management of prostatectomy has been defined in a large and representative UK sample. In some circumstances consistent variations have been identified. It is not yet clear whether these variations influence outcome. These data can be used by surgeons wishing to compare their own patient management with that described here.

Age Factors↗
PubMed1995

Indications for and outcome of total abdominal hysterectomy for benign disease: a prospective cohort study.

OBJECTIVE: To describe the indications for total abdominal hysterectomy for women with nonmalignant disease and to determine the immediate (initial ten days) and medium term outcome. DESIGN: A prospective cohort study. SETTING: Three district general hospitals in shire counties, two in outer London and one London teaching hospital. SUBJECTS: Three hundred and sixty-six women undergoing total abdominal hysterectomy (with or without other procedures) for nonmalignant disease. INTERVENTIONS: Self-completed patient questionnaires before and ten days, six weeks and three months after surgery. Data extracted from patients' hospital case notes. MAIN OUTCOME MEASURES: Complications plus change in symptoms, urinary and bowel function, general health status, sexual function, activities of daily living and quality of life. RESULTS: The principal indications were bleeding, pain or both. Symptoms were severe enough to be socially debilitating and have a major impact on lifestyle. Otherwise, the women were in good health. During the first ten post-operative days the women suffered more pain, urinary discomfort, constipation and a reduction in their ability to perform activities of daily living. Urinary (25%) and wound (25%) infections were the commonest complications. At the same time, significant improvements in psychological health occurred. By six weeks, the principal symptoms had resolved for 95% of the women and early adverse effects on urinary and bowel function had settled. This was reflected in improvements in health status and quality of life including sexual activity. Despite this, these changes did not meet the pre-operative expectations of some women. CONCLUSIONS: Most women reported substantial benefits from hysterectomy. However, women should be warned about early, transient adverse effects. These findings can serve as a benchmark for nonexperimental evaluations of the effectiveness of new treatment modalities.

Activities of Daily Living↗
PubMed1995

Surgery for glue ear: the English epidemic wanes.

OBJECTIVES: To describe the progress of the epidemic of surgery for glue ear since 1983 and trends in the use of different operative procedures. DESIGN: Analysis of routine hospital data. SETTING: Thirteen health districts in the Oxford and East Anglian regions. MAIN MEASURES: Annual rates of surgery in children under 10 years of age. RESULTS: The rate of surgery for glue ear reached a peak in 1986 since when it has declined by 12.6%. The rate peaked in all 13 districts but at different times over a six year period (1984-1989/90). Following the peak, district rates plateaued in eight districts and declined in five. These changes have been accompanied by: an increase in the proportion of operations confined to the tympanic membrane since 1983 (from 40% to 60%); an increase in the use of grommets after myringotomy (from 50% to 94% since 1980); and an increased use of day surgery for ear-only operations (from about 10% in the late 1970s to 50% in 1987/88). CONCLUSIONS: The previously reported epidemic of surgery for glue ear is waning. This seems to be a result of changes in the clinical judgment of general practitioners and surgeons as to its use and possibly of a reduced demand from parents.

Ambulatory Surgical Procedures↗
PubMed1995

Coronary revascularisation: why do rates vary geographically in the UK?

OBJECTIVE: To explain the reasons for geographical variation in the use of coronary revascularisation in the United Kingdom. DESIGN: This was a cross sectional ecological study. SETTING: NHS and independent hospitals performing coronary revascularisation for the 11.6 million residents of the south east Thames, East Anglian and north western health regions in England plus Greater Glasgow, Lanarkshire, Ayr and Arran health boards in Scotland were included. SUBJECTS: All residents aged > or = 25 years in 1992-93 who underwent coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA) in either the public or private sector were included. MAIN MEASURES: Crude and age-sex standardised intervention rates for residents of the 42 constituent districts and boards were determined. Variation was measured using the systematic component of variation. RESULTS: Considerable systematic variations in district rates of CABG and PTCA existed. These variations mostly arose from differences in supply factors. Higher rate districts were characterised by being close to a regional revascularisation centre and having a local cardiologist. Demand factors such as the level of need in the population (measured by coronary heart disease mortality) and the lack of use of alternative treatments not only failed to explain the observed variation but were inversely associated with the rate of intervention--an example of the inverse care law. The finding that the residents of more socially deprived districts experienced higher intervention rates was probably subject to confounding due to their close proximity to specialist centres. CONCLUSIONS: If greater geographical equity of use for the same level of need is to be achieved, attention must be paid to the supply factors that determine levels of utilisation. As responsibility for purchasing these procedures is decentralised, utilisation might become even more unequal.

Adult↗
PubMed1995

The feasibility and cost of a large multicentre audit of process and outcome of prostatectomy.

Objective--To determine the feasibility of performing multicentre process and outcome audits of common interventions taking prostatic procedures as an example. Design--Prospective, cohort study. Setting--All National Health Service and independent hospitals in Northern, Wessex, Mersey, and South West Thames health regions. Patients--5361 men undergoing prostatectomy identified by 103 of the 107 urologists and general surgeons performing prostatectomy in the study regions. Main measures-- Rates of participation by surgeons and patients; completeness of clinical data provided by surgeons; patient response rate and completeness of patient derived data; and cost. Results--Most surgeons (103,96%) agreed to participate. Overall, the proportion of eligible patients invited to take part was high (89%), although this was only measured in South West Thames, where dedicated data collectors were employed. Few men (80, 1.5%) declined to participate. Of those surviving for three months after surgery, 82.4% (4226) completed and returned the postal questionnaire. The response rate was higher in South West Thames (86.7%) than in the other regions (80.6%-80.8%). The audit was well received: 91% of patients found the questionnaire easy to complete and only 2.3% of them disapproved. Completeness of data was high with both the hospital and patient questionnaires. Missing data occurred in less than 5% of responses to most questions. The attributable cost was 34.50 pounds per patient identified or 44 pounds for patients in whom either the treatment outcome or vital status was known three months after their prostatectomy. Conclusions--This multicentre audit of process and outcome of prostatectomy proved feasible in terms of surgeon participation, patient identification, and the quantity and quality of data collection. Whether the cost was warranted will depend on how surgeons use the audit data to modify their practice.

Aged↗