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P McCulloch

Publications and source records attributed to P McCulloch.

At least 19 recordsLinked to original sources
PubMed2006

Impact of socio-economic deprivation on death rates after surgery for upper gastrointestinal tract cancer.

We hypothesised that socio-economic deprivation in England may be a prognostic factor for death after oesophagectomy or gastrectomy for cancer of the upper gastrointestinal tract. We analysed statistical data from hospital records linked to death records for patients who underwent operations for oesophageal and gastric cancer in England from April 1998 to March 2002. The patients were stratified into quintiles according to the index of multiple deprivation (IMD) (2000) for their place (ward) of residence. Age and sex standardised death rates at 30 and 90 days for each deprivation quintile were calculated. Following oesophagectomy, death rates showed a significant association with IMD. They increased with increasing levels of deprivation: the odds ratio for death, comparing highest with lowest quintile for deprivation, was 1.37 (95% confidence interval 1.03-1.85) at 30 days and 1.30 (1.04-1.64) at 90 days. Following gastrectomy, the death rates showed smaller and nonsignificant associations with IMD with odds ratios of 1.16 (0.84-1.62) and 1.10 (0.86-1.41), respectively. There is a significant association between social deprivation and death after oesophagectomy, but less of an association, if any, after gastrectomy in current UK practice.

Digestive System Surgical Procedures↗
PubMed2005

Gastrectomy with extended lymphadenectomy for primary treatment of gastric cancer.

BACKGROUND: The appropriate extent of lymph node clearance during gastrectomy for cancer remains controversial. METHODS: Medline, Embase, the Cochrane register and other databases were searched for studies reporting node dissection technique, 5 year survival and mortality after gastrectomy. Comparisons with systematic bias in treatment allocation and patients who received perioperative chemotherapy were excluded. Meta-analysis was performed separately for randomized and non-randomized comparisons. RESULTS: Two randomized and two non-randomized comparisons of limited (D1) versus extended (D2) node dissection and 11 reports of one dissection type were analysed. For D2 the randomised trials showed no overall survival benefit (Risk ratio (RR) = 0.95, 95 per cent c.i. 0.83-1.09) and an increased postoperative mortality (RR = 2.23, c.i. 1.45-3.45), apparently related to pancreatico-splenectomy and surgical inexperience. A trend towards survival benefit for D2 was observed for T3+ tumours (RR = 0.68, c.i. 0.42-1.10). Non-randomized comparisons found no survival benefit for D2 (RR = 0.92, c.i. 0.83-1.02), but decreased postoperative mortality (RR = 0.65, c.i. 0.45-0.93). Nine observational studies of D2 reported better results than two studies of D1 surgery, but in very different settings. CONCLUSIONS: Evidence for D2 dissection is inconclusive. No overall survival advantage has emerged, but some patients with intermediate stage disease may benefit. Excess operative mortality appears to be associated with pancreatico-splenectomy, low case volume and lack of specialist training.

Clinical Trials as Topic↗
PubMed2005

Tolerance of uncertainty, extroversion, neuroticism and attitudes to randomized controlled trials among surgeons and physicians.

BACKGROUND: Surgeons have a reputation for decisiveness and self-confidence, which suggests that they may tolerate uncertainty poorly and therefore be less capable than other doctors of experiencing clinical equipoise. Their 'typical' behaviour is characteristic of the stable extrovert personality and so they may prefer spontaneous clinical judgement over randomized trials. The aim of this study was to compare personality dimensions and tolerance of uncertainty among surgeons and hospital physicians, to determine whether differences in either property might help to explain the apparently poor performance of surgeons in conducting randomized controlled trials. METHODS: This was a postal questionnaire study of 1000 consultant general surgeons and 1000 consultant physicians. Respondents completed a short self-assessment of Eysenck personality dimensions, Budner's Intolerance of Ambiguity scale and a short questionnaire about attitudes to randomized trials. Correlation and multiple regression analyses were performed. RESULTS: The response rate was 36.5 per cent. Physicians were more likely to be women (P < 0.001) and had spent 1 more year in academic posts than surgeons (P < 0.030). Surgeons were significantly more extrovert (P < 0.001) and less neurotic (P < 0.001) than physicians. Surgeons were significantly more intolerant of uncertainty than physicians (P = 0.007). Multivariate analysis identified age (P < 0.030) and sex (P = 0.015) as independent predictors of intolerance of uncertainty. The attitudes of surgeons and physicians to randomized trials were no different. CONCLUSION: Surgeons are not prejudiced against randomized trials, but their intolerance of uncertainty may inhibit them from deciding that an individual patient is suitable for trial entry. If more surgeons were female, this difference between surgeons and physicians might disappear.

Attitude of Health Personnel↗
PubMed2005

Extending pedicle length in free jejunal loop grafts.

By mobilisation of the jejunal marginal artery with reverse flow, the authors present a novel way of increasing artery length available for anastomosis in free jejunal loop transfer for reconstruction in head and neck cancer surgery.

Anastomosis, Surgical↗
PubMed2004

Extended versus limited lymph nodes dissection technique for adenocarcinoma of the stomach.

BACKGROUND: Surgeons disagree about the merits and risks of radical lymph node clearance during gastrectomy for cancer. OBJECTIVES: To evaluate survival and peri-operative mortality after limited or extended lymph node removal during gastrectomy for cancer. SEARCH STRATEGY: We searched MEDLINE, EMBASE, CancerLit, LILACS, Central Medical Journal Japanese Database and the Cochrane register, references from relevant articles and conference proceedings. We contacted known workers in the field. SELECTION CRITERIA: Studies published after 1970 which reported 5 year survival or postoperative mortality rates, and clearly defined the node dissection performed, were considered. We excluded studies which overtly included patients receiving perioperative chemotherapy, and comparisons with clear systematic treatment allocation bias. Randomised controlled trials (RCTs), non-randomised comparisons and observational studies were considered separately. DATA COLLECTION AND ANALYSIS: Three reviewers selected trials for inclusion. Quality assessment and data extraction were performed independently by two reviewers. Results of trials of similar design were pooled. Meta-analysis was performed separately for randomised and non-randomised comparisons. MAIN RESULTS: Two randomised and two non-randomised comparisons of limited (D1) versus extended (D2) node dissection and 11 cohort studies of either D1 or D2 resection were analysed. Meta-analysis of randomised trials did not reveal any survival benefit for extended lymph node dissection (Risk ratio = 0.95 (95% CI 0.83 - 1.09), but showed increased postoperative mortality (RR 2.23, 95% CI 1.45 - 3.45). Pre-specified subgroup analysis suggested a possible benefit in stage T3+ tumours (RR = 0.68, 95% CI 0.42-1.10). Non-randomised comparisons showed no significant survival benefit for extended dissection (RR 0.92, 95% CI 0.83 -1.02), but decreased mortality (RR 0.65, 95% CI 0.45-0.93). Subgroup analysis showed apparent benefit in UICC stage II and IIIa. Observational studies of D2 resection reported much better mortality and survival than those of D1 surgery, but the settings were strikingly different. REVIEWERS' CONCLUSIONS: D2 dissection carries increased mortality risks associated with spleen and pancreas resection, and probably with inexperience and low case volumes. Randomised studies show no evidence of overall survival benefit, but possible benefit in T3+ tumours. These results may be confounded by surgical learning curves and poor surgeon compliance. Non-randomised comparisons suggest a possible survival benefit for D2 in intermediate UICC stages. Observational studies show high 5 year survival and low operative mortality after D2 dissection in experienced units, and poor results after D1 dissection in non-specialist units. Further studies, with precautions to eliminate learning curve effects, contamination and non-compliance, are needed to evaluate D2 dissection in intermediate stage gastric cancer.

Adenocarcinoma↗
PubMed2004

Risk-adjusted prediction of operative mortality in oesophagogastric surgery with O-POSSUM.

INTRODUCTION: The present study was designed to develop a dedicated oesophagogastric model for the prediction of risk-adjusted postoperative mortality in upper gastrointestinal surgery (O-POSSUM). METHODS: Using 1042 patients undergoing oesophageal (n = 538) or gastric (n = 504) surgery between 1994 and 2000 the Portsmouth predictor equation for mortality (P-POSSUM) scoring system was compared with a standard logistic regression O-POSSUM model and a multilevel O-POSSUM model using the following independent factors: age, physiological status, mode of surgery, type of surgery and histological stage. RESULTS: The overall mortality rate was 12.0 per cent (elective mortality rate 9.4 per cent and emergency mortality rate 26.9 per cent). P-POSSUM overpredicted mortality (14.5 per cent), particularly in the elective group of patients. The multilevel model offered higher discrimination than the single-level O-POSSUM and P-POSSUM models (area under receiver-operator characteristic curve 79.7 versus 74.6 and 74.3 per cent). When observed to expected outcomes were evaluated, the multilevel O-POSSUM model was found to offer better calibration (Hosmer-Lemeshow chi(2) statistic 10.15 versus 10.52 and 28.80). CONCLUSION: The multilevel O-POSSUM model provided an accurate risk-adjusted prediction of death from oesophageal and gastric surgery for individual patients. In conjunction with a multidisciplinary approach to patient management, the model may be used in everyday practice for perioperative counselling of patients and their carers.

Adult↗
PubMed2003

Extended versus limited lymph nodes dissection technique for adenocarcinoma of the stomach.

BACKGROUND: Surgeons disagree about the merits and risks of radical lymph node clearance during gastrectomy for cancer. OBJECTIVES: To evaluate survival and peri-operative mortality after limited or extended lymph node removal during gastrectomy for cancer. SEARCH STRATEGY: We searched MEDLINE, EMBASE, CancerLit, LILACS, Central Medical Journal Japanese Database and the Cochrane register, references from relevant articles and conference proceedings. We contacted known workers in the field. SELECTION CRITERIA: Studies published after 1970 which reported 5 year survival or postoperative mortality rates, and clearly defined the node dissection performed, were considered. We excluded studies which overtly included patients receiving perioperative chemotherapy, and comparisons with clear systematic treatment allocation bias. Randomised controlled trials (RCTs), non-randomised comparisons and observational studies were considered separately. DATA COLLECTION AND ANALYSIS: Three reviewers selected trials for inclusion. Quality assessment and data extraction were performed independently by two reviewers. Results of trials of similar design were pooled. Meta-analysis was performed separately for randomised and non-randomised comparisons. MAIN RESULTS: Two randomised and two non-randomised comparisons of limited (D1) versus extended (D2) node dissection and 11 cohort studies of either D1 or D2 resection were analysed. Meta-analysis of randomised trials did not reveal any survival benefit for extended lymph node dissection (Risk ratio = 0.95 (95% CI 0.83 - 1.09), but showed increased postoperative mortality (RR 2.23, 95% CI 1.45 - 3.45). Pre-specified subgroup analysis suggested a possible benefit in stage T3+ tumours (RR = 0.68, 95% CI 0.42-1.10). Non-randomised comparisons showed no significant survival benefit for extended dissection (RR 0.92, 95% CI 0.83 -1.02), but decreased mortality (RR 0.65, 95% CI 0.45-0.93). Subgroup analysis showed apparent benefit in UICC stage II and IIIa. Observational studies of D2 resection reported much better mortality and survival than those of D1 surgery, but the settings were strikingly different. REVIEWER'S CONCLUSIONS: D2 dissection carries increased mortality risks associated with spleen and pancreas resection, and probably with inexperience and low case volumes. Randomised studies show no evidence of overall survival benefit, but possible benefit in T3+ tumours. These results may be confounded by surgical learning curves and poor surgeon compliance. Non-randomised comparisons suggest a possible survival benefit for D2 in intermediate UICC stages. Observational studies show high 5 year survival and low operative mortality after D2 dissection in experienced units, and poor results after D1 dissection in non-specialist units. Further studies, with precautions to eliminate learning curve effects, contamination and non-compliance, are needed to evaluate D2 dissection in intermediate stage gastric cancer.

Adenocarcinoma↗
PubMed2002

Marimastat as maintenance therapy for patients with advanced gastric cancer: a randomised trial.

This randomised, double-blind, placebo-controlled study was designed to evaluate the ability of the orally administered matrix metalloproteinase inhibitor, marimastat, to prolong survival in patients with non-resectable gastric and gastro-oesophageal adenocarcinoma. Three hundred and sixty-nine patients with histological proof of adenocarcinoma, who had received no more than a single regimen of 5-fluorouracil-based chemotherapy, were randomised to receive either marimastat (10 mg b.d.) or placebo. Patients were treated for as long as was tolerable. The primary endpoint was overall survival with secondary endpoints of time to disease progression and quality of life. At the point of protocol-defined study completion (85% mortality in the placebo arm) there was a modest difference in survival in the intention-to-treat population in favour of marimastat (P=0.07 log-rank test, hazard ratio=1.23 (95% confidence interval 0.98-1.55)). This survival benefit was maintained over a further 2 years of follow-up (P=0.024, hazard ratio=1.27 (1.03-1.57)). The median survival was 138 days for placebo and 160 days for marimastat, with 2-year survival of 3% and 9% respectively. A significant survival benefit was identified at study completion in the pre-defined sub-group of 123 patients who had received prior chemotherapy (P=0.045, hazard ratio=1.53 (1.00-2.34)). This benefit increased with 2 years additional follow-up (P=0.006, hazard ratio=1.68 (1.16-2.44)), with 2-year survival of 5% and 18% respectively. Progression-free survival was also significantly longer for patients receiving marimastat compared to placebo (P=0.009, hazard ratio=1.32 (1.07-1.63)). Marimastat treatment was associated with the development of musculoskeletal pain and inflammation. Events of anaemia, abdominal pain, jaundice and weight loss were more common in the placebo arm. This is one of the first demonstrations of a therapeutic benefit for a matrix metalloproteinase inhibitor in cancer patients. The greatest benefit was observed in patients who had previously received chemotherapy. A further randomised study of marimastat in these patients is warranted.

Adenocarcinoma↗
PubMed2002

Muscle UCP-3 mRNA levels are elevated in weight loss associated with gastrointestinal adenocarcinoma in humans.

The mitochondrial uncoupling proteins-2 and -3 are putative mediators of thermogenesis and energy expenditure. We measured the mRNA levels of uncoupling proteins-2 and -3 in skeletal muscle from 12 gastrointestinal adenocarcinoma patients, of whom six had stable weight and six had lost 2-18 kg, and from six healthy controls undergoing elective surgery. Uncoupling proteins-3 mRNA levels were significantly higher in the muscle of the cancer patients with weight loss (2.2 +/- 0.47 arbitrary units) compared both with controls (0.39 +/- 0.20) and with cancer patients who had not lost weight (0.47 +/- 0.23; P<0.02). Uncoupling proteins-2 mRNA levels did not differ significantly between groups. Elevations in muscle uncoupling proteins-3 activity may enhance energy expenditure and this in turn could contribute to tissue catabolism.

Adenocarcinoma↗
PubMed2002

Completeness of data entry in three cancer surgery databases.

AIMS: Clinical databases are regularly used for audit and research purposes. The accuracy of data input is critical to the value of these tools, but little is known about the factors which influence the completeness of data recording. The aim of this study was to evaluate the influences affecting completeness of data recording in computerized clinical databases of cancer treatment. METHODS: Data omission rates in three databases dealing with management of breast, colorectal and gastro-oesophageal cancers were calculated. The effects of (a) type of record; (b) nature of data and (c) training required to interpret data were evaluated by univariate and multivariate analyses. RESULTS: The overall data omission rate was 21.9% (upper GI 27.6%, breast 19.6%, colorectal 32.7%, P=0.13). For different categories of data, omission rates varied from 0% to 55%. Fields requiring a 'text field' or 'numerical' entry, or containing demographic data, data required for the process of care or data which required no interpretation were associated with low omission rates. Clinical data, and fields requiring a 'yes/no' response were associated with high omission rates (45 and 48% respectively). Clinical data and data relating to patient demographic details were independently associated with high and low omission rates respectively (odds ratios for significant missing data 86.9 and 1 respectively). CONCLUSION: Clinical data are poorly captured by current cancer surgery databases. Reasons for the poor completion of fields requiring input by clinical staff, particularly availability of time and training, and prioritization of work, should be addressed. Re-design of databases to ensure that data entry is simple and unambiguous may improve accuracy.

Breast Neoplasms↗
PubMed2001

ASCOT: a comprehensive clinical database for gastro-oesophageal cancer surgery.

We report the development of a multicentre prospective database for gastro-oesophageal cancer surgery. The ASCOT project aims to collect detailed prospective data on co-morbidity, surgery, stage and outcome in a large cohort of patients from a wide variety of hospitals in the UK. We describe the rationale for the initiative, the process of defining the dataset, the database software and structure, the system for data recording and retrieval and the operating rules of the ASCOT co-operative group. Thirty Trusts are currently submitting data, and the first 1000 cases have now been entered. A first annual report has been produced, showing anonymized comparative figures for patient characteristics and outcomes of interest, and a second is due shortly. The collection of detailed comparable data, including co-morbidity evaluation, on a large scale is likely to prove valuable for unit specialist accreditation, surgeon re-validation, audit and research.

Cohort Studies↗
PubMed2000

Gastric cancer.

Explore the source record for details and available documents.

Cause of Death↗
PubMed1998

Laparoscopic staging of gastric cancer is safe and affects treatment strategy.

The accuracy of laparoscopic staging has been documented, but its safety and impact on clinical decision making are less clear. In a prospective series of 64 patients referred to a single consultant, laparoscopy was performed in 49, after exclusion of patients unlikely to derive benefit from laparoscopic staging. The prelaparoscopy treatment plan was altered in 17 (34%). Laparoscopy detected 11 cases of peritoneal and four cases of liver metastasis, of which nine and two, respectively, were not detected by CT scan. Laparoscopy was useful in assessing fitness for major surgery, the planned extent of which was reduced in five cases as a result. Port site metastasis occurred in one case of stage IVB cancer, in conjunction with widespread progressive disease. Laparoscopic staging is recommended in gastric cancer, since it causes important changes to the management plan in one-third of cases, and the risks of port site metastasis appear low.

Adenocarcinoma↗
PubMed1998

Can we improve the uptake of gastroscopy in the population at risk for gastric cancer? The effect of home letter information.

The poor outlook for gastric cancer in Britain is largely due to late diagnosis. Earlier diagnosis will require both easy access to endoscopy and increased public awareness of dyspeptic symptoms. We used information by personal letter to encourage reporting of potentially significant symptoms in patients over 40 years of age. The aim of this study was to measure the acceptability and effect on gastroscopy rates of home letter information. Patients over 40 registered with 12 general practices were used in the study (practice population 80,000). Patients over 40 from another nine practices (practice population 46,500) acted as controls. A letter encouraging consultation for new dyspeptic symptoms was sent to all study subjects. Gastroscopy rates were compared in both study and control populations. Questionnaires on symptoms were sent to 500 study subjects. The principal outcome measure was the gastroscopy rate in people over 40 in both populations, before and during the intervention. The gastroscopy rate was 23% higher in the study than in the control population during the study (3.32 vs. 2.7%, P = 0.00016, chi 2 = 14.25). Gastroscopy uptake increased by 85% from 1991/2 to 1993/4 in the study group and by 34% in the control group (chi 2 = 14.02, P = 0.00018). Thirty-one per cent of questionnaire respondents had dyspeptic symptoms; only 3% had 'significant' symptoms of between 2 and 52 weeks duration. Home letters are an acceptable and efficient method of increasing gastroscopy uptake in dyspeptic patients over 40.

Adult↗
PubMed1997

c-erbB2 and p53 expression are not associated with stage progression of gastric cancer in Britain or Japan.

The results of surgical treatment for gastric cancer are apparently better in Japan than in Western countries. It has been proposed that this is because of a biological difference between the tumours in Japan and in the West. We have previously reported very similar frequencies of positive immunohistochemical staining for the c-erbB2 oncogene and mutant p53 proteins in British and Japanese gastric cancers, findings which do not seem to support the 'biological difference' hypothesis. We realized that these studies did not rule out differences in the mechanism of cancer progression which might show themselves by a different association between p53 and c-erbB2 expression and stage in the two populations. We therefore re-analysed our data to look for differences in the frequency of p53 and c-erbB2 expression in the British and Japanese populations. Comparison of fixed tissue from 88 British and 89 Japanese tumours showed no significant association of c-erbB2 or p53 with stage progression in either population. Logistic regression showed no difference between the two populations in the relationship between stage and oncogene expression. These results do not support the idea of biologically different cancers in Japan and Britain. Other possible explanations for the difference in results such as the stage migration effect, better efficacy of Japanese-style surgery, or a difference in the host resistance to cancer in the two countries should be considered.

Humans↗