Biomedical subjects
Publications and source records attributed to S M Allen.
1. The case is described of a 28-year old male with a diagnosis of Lesch-Nyhan syndrome. 2. Chronic treatment with the atypical neuroleptic risperidone at 4 mg daily has maintained a significant reduction in occurrence of self-mutilation.
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In the early days of cervical cytology there was a general assumption that mistakes would be a rare occurrence. These expectations were unrealistic given the fatiguing nature of the work and its dependence on human judgement. Media attention and the introduction of quality control have highlighted inadequacies in the service. The reasons for both sampling and screening errors which give rise to the issuing of false negative smear results need to be understood before measures can be taken to minimise them. An acceptable error rate should be recognised and, if possible, improved upon. Further investigations into the role of human papilloma virus (HPV) in the development of cervical cancer, and evaluation of automated screening, should lead to improvements in the cervical screening programme.
We recently have used retrograde cerebral perfusion via the superior vena cava in association with hypothermic circulatory arrest as an adjunct to cerebral protection during aortic arch operations. Between April 1993 and March 1994, 23 patients (14 male; 9 female; median age, 64 years; age range, 25 to 76 years; 14 emergency, 9 elective) underwent operation on the ascending aorta, aortic arch, or both for acute dissection (11) or aneurysm (12). Aortic root replacement was performed in 13 patients (7 with arch replacement), ascending aortic replacement in 7 (4 with arch replacement), isolated aortic arch replacement in 2, and repair of sinus of Valsalva aneurysm in 1. Coronary artery bypass grafting was performed in 4 patients. Hypothermic circulatory arrest (15 degrees C) and retrograde cerebral perfusion were implemented in all cases (median circulatory arrest time, 21 minutes; range, 13 to 51 minutes; median retrograde cerebral perfusion time, 20 minutes; range, 12 to 50 minutes). Three hospital deaths occurred (atheromatous embolic stroke, sepsis, rupture of infrarenal aortic aneurysm). The remaining patients had no neurologic damage (median intensive therapy unit stay, 1 day; range, 1 to 5 days). Retrograde cerebral perfusion is easy to establish and safe, and may improve brain protection during hypothermic circulatory arrest.
Seventeen patients with severe ischaemic heart failure without angina were studied prospectively to determine the effects of surgical revascularization on exercise tolerance, peak oxygen consumption and left ventricular function at rest and during inotropic stimulation at 3 months after surgery. Suitability for surgery was assessed by the presence of ischaemia identified by thallium scintigraphy and stress electrocardiographic (ECG) testing and the left ventricular response to dobutamine measured by radionuclide ventriculography. One patient died awaiting surgery and one required cardiac transplantation. Fifteen patients underwent coronary artery surgery with two perioperative deaths. Thirteen patients were restudied 3 months after surgery. Mean treadmill exercise time (362 +/- 204 s to 562 +/- 303 s, P < 0.05) and peak oxygen consumption (14.9 +/- 3.5 ml/kg per min to 20.8 ml/kg per min, P < 0.01) increased significantly. Resting ejection fraction was not changed after surgery (20 +/- 5% to 21 +/- 6%) but ejection fraction during derived from thermodilution Swan-Ganz catheter data both at rest during dobutamine stimulation were unchanged after surgery. At 13 +/- 3 months after surgery there had been three sudden deaths and one patient had undergone successful cardiac transplantation. Of the remaining nine patients, three had improved to NYHA symptomatic class I, three were in NYHA class II and three in NYHA class III. Repeat treadmill exercise testing in seven patients showed that the improvement in exercise capacity evident in the first follow-up visit was maintained during long-term follow-up.
A microtitre plate format enzyme linked immunosorbent assay (ELISA), employing commercially available PASE/4LJ mouse monoclonal hybridoma antibody is described. The technique is a solid phase indirect ELISA for prostatic acid phosphatase, applicable to specific detection of semen. Maximal detectability was found to be one hundred thousand fold dilution of pooled seminal plasma. No cross reactivities with human vaginal fluid, blood, saliva, female urine, nasal discharge, earwax, sweat or faeces have been found.
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Ten male patients with a mean age of 57.5 years (range 27-75 years) underwent homograft aortic valve or root replacement for destructive aortic valve endocarditis. Six patients had native valve endocarditis (one with associated native mitral valve endocarditis) and four had prosthetic valve endocarditis (one with associated prosthetic mitral endocarditis). Causative organisms were Streptococci in six patients, Staphylococci in one, Q fever in one and no organisms were isolated in the remaining two patients. All the patients were operated while on antibiotics (mean lengths of treatment 13 days; range 2-42). The main indication for surgery was cardiogenic shock in five patients, progressive cardiac failure in four patients and uncontrolled sepsis in one patient. Operative procedures involved homograft aortic root replacement with coronary reimplantation (seven patients; associated prosthetic mitral valve replacement in one patient), infracoronary homograft aortic valve replacement (three patients) and a number of other procedures were performed to reconstruct the disrupted cardiac anatomy. Patients were followed up for a mean of 13.2 months (range 2-21). One patient died 4 months postoperatively of an unrelated cause; all the others are asymptomatic with no evidence of recurrent endocarditis. We conclude that homograft aortic valve or root replacement is an effective method of managing destructive aortic valve endocarditis.
We have evaluated the effect of mitomycin 6 mg/m2, ifosfamide 3 g/m2, and cisplatin 50 mg/m2 (MIC) in two groups of patients with squamous or undifferentiated carcinoma of the oesophagus, as either preoperative or primary treatment. Response was assessed by barium swallow, CT scan, and measurement of metastases where present. Toxicity was acceptable and there were no chemotherapy related deaths. In the operated group, five of 23 patients (22%) showed a complete response (three confirmed histologically) and nine (39%) showed a partial response following two courses of MIC. Resection was completed in 21 patients, with three hospital deaths (14%). Of the 18 patients who were discharged from hospital, eight have died at 4-24 months (median 13) from the start of treatment and 10 are alive at 5-35 months, with known recurrence in one. In the non-operated group, five of 20 patients (25%) showed a response, one complete, following one to four (mean 2.6) courses of MIC. Nineteen patients have died (at median 5 months), and one, who had a complete response, is alive and free from disease at 29 months. Neo-adjuvant therapy with MIC in squamous carcinoma of the oesophagus has shown encouraging early results, with acceptable toxicity.
This study investigated gender differences in spousal caregiving in a sample of 353 currently married people with cancer who were undergoing outpatient treatment. Results indicate that husbands were less likely than wives to help their sick spouses with household tasks, and husbands who helped were more likely to have other helpers, whereas wives tended to be sole caregivers. Wives provided approximately twice the hours of care that husbands provided. Women undergoing treatment who experienced high levels of morbidity received more hours of help with household tasks from nonspousal sources than men with comparable levels of morbidity, thus compensating for the deficit in hours of care provided by their husbands. At lower levels of morbidity, however, compensatory help to women was not sufficient to fill the gap in care. Women were more likely than men to report unmet need for assistance with household tasks, although not with personal care.
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Since 1984 we have identified 14 patients under the age of 45 years with severe, unexplained loss of oesophageal motility. The ages at presentation ranged from 20 to 42 years and nine were female. Barium swallow was normal in eight patients and showed minor abnormalities in six. Twenty-four hour pH studies were normal in all patients and the only endoscopic abnormality was minimal oesophagitis in three. Upper oesophageal sphincter resting pressures and cervical motility were normal except in one patient. Motility in the body of the oesophagus was severely reduced in all patients with a mean peristaltic amplitude of 10 mmHg. Lower oesophageal sphincter resting pressures were reduced in 11 patients and normal in three, with incomplete sphincter relaxation in three. All patients have been followed up for a minimum of 3 years without progression of their symptoms or the development of a secondary cause. Six patients have undergone repeat manometry and pH studies with no changes. We conclude that there is a group of young patients who appear to undergo severe primary loss of oesophageal motility for reasons that have not yet been identified. It is important to identify these patients so that inappropriate surgery can be avoided.
Fourteen patients with shortening of the oesophagus due to chronic reflux oesophagitis have been treated by a combination of an oesophageal lengthening procedure with a standard anti-reflux repair. Their ages ranged from 18 to 78 years and eight were male. Thirteen patients had a reflux stricture (with additional penetrating ulcer in six) and one had a columnar-lined oesophagus. A complete circular myotomy was performed just below the level of the aortic arch, in combination with a Belsey Mark IV anti-reflux repair. There were no deaths post-operatively but one patient required re-operation for haemorrhage and one underwent oesophageal dilatation before discharge. All patients have now been followed up for over 5 years. Nine patients have required no further treatment for their oesophageal problems, two required two early dilatations each, two required multiple dilatations and one required oesophageal resection for stricture. We suggest that this combination merits further evaluation in the management of patients with short oesophagus due to reflux.
This research quantified the contribution of traditional gender roles to patient-reported receipt of assistance with personal care activities, housework, cooking, shopping, transportation, and administrative activities among a sample of 629 cancer patients with advanced disease who were undergoing outpatient treatment. Approximately 80 percent of male patients and 30 percent of female patients attributed help received with household tasks to longstanding division of labor. This response was particularly common among married men and did not differ by age or educational status. However, available morbidity indicators suggest that approximately one-third of these patients actually were functionally impaired, despite attribution to gender role expectations. We adjusted estimates of need for assistance to avoid overestimation due to role-related help, and a second time to avoid underestimation due to underreporting of physical inability to perform a task alone. After making these adjustments, male patients' level of need for assistance with traditionally female-associated tasks was reduced by approximately 50 percent.
AIMS: To investigate the pathological effects of preoperative chemotherapy on oesophageal carcinoma. METHODS: Qualitative and quantitative changes in oesophageal carcinoma after preoperative chemotherapy were assessed by examination of biopsy specimens before treatment and resected specimens. RESULTS: Of 13 patients with adenocarcinoma treated with 5-fluorouracil, adriamycin, and mitomycin (FAM), nine showed minor histological changes compared with 14 control cases. All 12 patients with squamous carcinoma treated with preoperative mitomycin, ifosfamide, and cisplatin (MIC) showed noticeable histological changes when compared with the 13 control cases. Changes included complete ablation (n = 1) and partial regression (n = 5) of the tumour. A quantitative estimate of the proportion of tumour to stroma showed no difference between control adenocarcinomas and those treated with chemotherapy. There was, however, a significant reduction (p < 0.01) in the proportion of tumour to stroma in the treated squamous group compared with the controls. There was no relation between the degree of response in squamous carcinomas and the degree of differentiation of the tumour. Patients in which squamous carcinomas responded well, as assessed quantitatively, showed a tendency to better survival at one year. CONCLUSIONS: Histopathological changes attributable to chemotherapy can be observed in oesophageal carcinoma. The response of squamous carcinoma to MIC is histologically more evident than that of adenocarcinoma to FAM. A quantitative technique may be useful in assessing the effect of chemotherapy in oesophageal squamous carcinoma.
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This paper discusses the problems encountered in delivering home health services to persons with AIDS (PWAs), based on telephone interviews conducted with administrators of 68 home care agencies located in 10 high AIDS prevalence areas nationwide. Lack of adequate insurance mechanisms was cited as a major barrier to serving PWAs. Some respondents indicated a greater potential for stress among staff treating PWAs, given the youth of this population, the intensity of illness manifestations, and the complexity of treatment regimens. Other difficulties that are especially prevalent among PWAs include the absence of informal caregivers, residence in unsafe areas, and patient and family drug abuse. Although many of the reported patient problems are not unique to PWAs, the frequency with which they occur in this population suggests a need for expanded public and private insurance coverage for custodial care, and for expanded availability of AIDS-specific housing, if excessive hospitalization is to be avoided.
De-hospitalization of cancer treatment, particularly for those with advanced disease, can complicate adjustment and strain the capacity of caregiver networks to meet patients' daily needs. Outpatient staff should be able to recognize patients who need help to meet their daily needs as well as those who are not getting enough help. This study describes the physiological and social determinants of need and unmet need for assistance among 629 cancer patients with advanced disease initiating a course of outpatient chemotherapy and/or radiation therapy. Areas of needs examined through telephone interviews with participating patients were: personal care, instrumental tasks (housework, shopping, and cooking), and transportation. Physiological factors (metastases, disease stage, and functional status) were associated with need for assistance in all three areas. Also, older age (over 65) and low income predicted need for help with personal care, and women were more likely than men to report illness-related need for assistance with instrumental tasks and transportation. Unmet need was primarily associated with patients' social support system (e.g., children living nearby and perceived resiliency of network helpers). These findings highlight the need for outpatient staff to evaluate patients' informal care resources as well as patients' symptoms and impairments in deciding who should be referred for home care services.