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Biomedical subjects

T S O'Brien

Publications and source records attributed to T S O'Brien.

At least 19 recordsLinked to original sources
PubMed2003

Identifying under-performing surgeons.

OBJECTIVE: To estimate the likelihood of poor surgical results being explained by chance rather than under-performance. METHODS: The 30-day mortality rates after radical cystectomy for bladder cancer were analysed theoretically. Surgical competence was defined as a mortality rate of 4%, excellence as 2% and under-performance as 8%, 12%, 20% or 40%. Four scenarios were explored for surgeons of different competence: first, the sample size required to show that a given level of under-performance is very unlikely to be due to chance; second, the likelihood of two or more consecutive deaths in a series of cases; third, the likelihood of clustering of deaths, defined as two deaths in five or in 10 cases; and last, the likelihood of outstanding surgical results (i.e. no deaths) being achieved in small cohorts by surgeons of differing competence. RESULTS: For surgeons with a mortality rate of 8%, 12%, 20% or 40%, the sample sizes needed to prove under-performance are 211, 65, 21 and seven, respectively. For consecutive deaths, 0.4% of excellent, 1.4% of competent and 21% of surgeons with a mortality rate of 12% will experience two or more consecutive deaths in the next 10 cases. For clustered deaths, 1% of excellent, 5% of competent and 23% of seriously under-performing surgeons (mortality rates > or = 12%) will experience two deaths in their next 10 cases. Lastly, for the likelihood of outstanding results, only 3.6% of surgeons with an 8% mortality rate and < 1% of surgeons with a mortality rate > or = 12% will experience no deaths over 40 consecutive cases. CONCLUSIONS: Very large cohorts are needed to confirm even significant under-performance. Consecutive deaths are very unlikely events for competent surgeons. Clustered deaths (two deaths in 10 cases) are very unlikely events for excellent surgeons but plausible for competent ones. Analysis of consecutive/clustered deaths is limited by low statistical sensitivity; only up to a quarter of seriously under-performing surgeons are identified. No deaths in 40 consecutive cases implies competence.

Clinical Competence↗
PubMed1999

Open versus arthroscopic ankle arthrodesis: a comparative study.

A retrospective review was undertaken for 36 patients who underwent ankle arthrodesis. Nineteen patients underwent an arthroscopic ankle arthrodesis, and 17 patients underwent an open arthrodesis. Only patients with limited angular deformities were suitable candidates for an arthroscopic arthrodesis. The open arthrodesis group inclusion criteria were defined by the maximum coronal and sagittal plane deformity in the arthroscopic group. Perioperative parameters were compared and analyzed. Arthroscopic ankle arthrodesis yielded comparable fusion rates to open ankle arthrodesis, with significantly less morbidity, shorter operative times, shorter tourniquet times, less blood loss, and shorter hospital stays. Arthroscopic ankle arthrodesis is a valid alternative to traditional open arthrodesis of the ankle for selected patients with ankle arthritis.

Adolescent↗
PubMed1999

Fibular nonunion and equinovarus deformity secondary to posterior tibial tendon incarceration in the syndesmosis: a case report after a bimalleolar fracture-dislocation.

A 39-year-old woman sustained a grade II open bimalleolar fracture-dislocation of the left ankle. Six months after an ORIF of these fractures was performed, she presented with a nonunion of the distal fibula fracture and with a fixed hindfoot equinovarus and forefoot adduction deformity. At surgery for repair of the fibular nonunion, the posterior tibial tendon (PTT) was found to be entrapped in the posterior tibiotalar joint, with a portion of the tendon interposed between the tibia and the fibula in the area of the posterior syndesmosis. After extrication of the PTT, the hindfoot varus and forefoot adduction deformity were corrected. To our knowledge, this is the first case report in the English literature of a missed PTT syndesmotic entrapment that resulted in a fibular nonunion and in a fixed foot deformity after an open bimalleolar ankle fracture dislocation.

Adult↗
PubMed1997

Extraosseous manifestations of rheumatoid arthritis in the foot and ankle.

The immune mediated pathologic effects of rheumatoid arthritis on osteoarticular tissues are well delineated in the orthopaedic and medical literature. Less well explored are the extraosseous manifestations of rheumatoid arthritis. The rheumatoid disease process can affect virtually any organ system or tissue in the human body; from scleritis, arteritis, and splenomegaly to neuropathy, bursitis, and tendinopathy. The scope of this treatise is to define better for the clinician the extraosseous presentation of rheumatoid arthritis in the foot and ankle.

Ankle↗
PubMed1996

Expression of the angiogenic factor thymidine phosphorylase/platelet-derived endothelial cell growth factor in primary bladder cancers.

Thymidine phosphorylase (TP), also known as platelet-derived endothelial cell growth factor, has been implicated in bladder cancer angiogenesis. To examine its role more clearly, we have quantified and localized its expression using Western analysis and immunohistochemistry in a series of 105 bladder cancers. We have also assessed the relationship between TP expression and other tumor parameters including quantitative angiogenesis, p53 status, ploidy, and survival. By Western analysis, TP expression was 5-fold higher in tumors than in normal bladder samples (P < 0.02). Expression was 15-fold higher in invasive tumors than in normal bladder (P < 0.001) and 8-fold higher than in superficial tumors (P < 0.005). Immunohistochemistry of the tumors showed TP was present in the neoplastic epithelium in 27% of the tumors, in the inflammatory cells in 72% of the tumors, in stromal cells in 30% of the tumors, and in tumor-associated endothelium in 11% of the tumors. Expression by Western blotting and immunohistochemistry was significantly up-regulated in tumors compared with normal bladder (P < 0.05). Tumor cell TP expression correlated with tumor grade (P < 0.02), but there was no correlation between tumor cell TP expression and tumor stage (P = 0.46), ploidy (P = 0.52), p53 expression (P = 0.9), tumor vascularity (P = 0.8), relapse-free survival (P = 0.57), or overall survival (P = 0.94). TP protein is expressed in bladder cancers, and expression is associated with an aggressive phenotype. Because TP can activate a number of cytotoxic agents, it provides a potential therapeutic target in bladder cancer.

Adult↗
PubMed1996

Surgical skills of pre-registration house surgeons.

As demands on house surgeons increase and junior doctors' hours are reduced, the opportunity for learning surgical skills during the pre-registration period is threatened. An increasing number of medical specialties, including general practice, now require a proficiency in these skills. For many doctors the pre-registration period may be the last occasion when formal training from experienced surgeons is available. Fifteen house surgeons were tested and asked to perform three basic surgical drills on artificial skin and answer 10 questions relevant to minor surgery during the final week of their house surgical post. Four (27 per cent) house surgeons were unable to complete any of the surgical drills, no one could calculate the dose of lignocaine in 10 ml of a 1% solution, and only two (13 per cent) knew the safe maximum dose of subcutaneous plain lignocaine. This study highlights deficiencies in basic surgical skills amongst house surgeons and suggests that this opportunity for training is being missed.

Clinical Competence↗
PubMed1995

Quality of life.

Explore the source record for details and available documents.

Amputation, Surgical↗
PubMed1995

Is follow-up necessary after transurethral resection of the prostate?

OBJECTIVE: To assess the necessity for routine out-patient review following transurethral resection of the prostate (TURP) for benign prostatic hypertrophy. PATIENTS AND METHODS: One-hundred and two patients with histologically proven benign prostatic hypertrophy were prospectively reviewed as out-patients. The views of their general practitioners were established by postal questionnaire. RESULTS: At their first out-patient review 94 of 102 (92%) patients were discharged and only 2% (2/102) patients remained under review after 1 year. Apart from routine urine analysis, only four additional investigations were initiated at the routine clinical assessment. One patient was listed to undergo prostatic surgery again following the post-operative out-patient review. Over the next 16 months only three patients (3%) were re-referred with further urological problems. Confidence in a system without routine hospital out-patient review was expressed by 90% of general practitioners and 78% of patients. CONCLUSION: Follow-up after TURP cannot be justified in terms of the perceived therapeutic benefit to patients. Patients should be discharged to the community and be assessed rapidly in out-patients if and when problems arise.

Aged↗
PubMed1995

Urinary basic fibroblast growth factor in patients with bladder cancer and benign prostatic hypertrophy.

OBJECTIVE: To investigate the role of urinary measurements of an angiogenic factor, basic fibroblast growth factor (bFGF), in the assessment of patients with bladder cancer. PATIENTS AND METHODS: Urine from 83 patients was assayed using a commercially available ELISA for bFGF. Thirty-eight patients had a bladder tumour and 21 had a history of bladder cancer but no disease at the time of testing. Twenty-four patients acted as controls, 16 of whom were about to undergo transurethral resection of the prostate (TURP) for benign prostatic hypertrophy (BPH) and eight who had no urological disease. RESULTS: Median urinary bFGF was higher in patients with active bladder cancer than in those with a clear cystoscopy (5.20 and 2.13 ng/g creatinine, respectively; P < 0.005). Median urinary bFGF was also elevated in patients about to undergo TURP (4.52 ng/g creatinine). Using a threshold value of 6.0 ng/g creatinine, the sensitivity of the test for detecting cancer was 42% and specificity was 88%. At a threshold value of 4.0 ng/g the sensitivity was 62% and the specificity 70%. CONCLUSION: The relationship between urinary basic FGF and the presence of bladder cancer was significant. The test is not sufficiently sensitive or specific to use as a screening test for bladder cancer but may be very useful in monitoring the effectiveness of systemic therapies in bladder cancer. Elevated levels of bFGF in the urine of patients about to undergo TURP suggests a role for bFGF in the pathogenesis of BPH.

Aged↗
PubMed1995

Temporary reappearance of sperm 12 months after vasectomy clearance.

OBJECTIVES: To determine the incidence of positive semen analysis 12 months after vasectomy clearance. SUBJECTS AND METHODS: A prospective study was undertaken, starting in 1990, of men undergoing vasectomy. Azoospermia was confirmed by two successive semen analyses 16 weeks after vasectomy. One year later a further sample was analysed for the presence of sperm. RESULTS: Of 1000 men who provided a sample for analysis, six men (0.6%) have had positive semen analyses 1 year after the initial tests showed azoospermia. In all six the sperm count was <10,000 per mL. Five of the six men produced a repeat sample 1 month later which, in all five cases, showed azoospermia. No pregnancies have been reported to date. CONCLUSION: Transitory reappearance of sperm following successful vasectomy occurs in about 0.6% of men. This incidence is 18 times greater than the reported pregnancy rate following successful vasectomy.

Humans↗
PubMed1995

Efficiency in the outpatient department: the lessons from urology.

To determine the scope for improvements in efficiency in the outpatient management of urological patients, a retrospective analysis was undertaken of outpatient records from one consultant's practice in a regional teaching hospital. Two hundred consecutive patients referred between March and May 1992 were studied for 1 year after referral. Each outpatient visit was judged to be unavoidable or potentially avoidable. Of referrals, 72% were in one of four diagnostic categories (bladder outflow obstruction; haematuria; scrotal disorders; frequency/dysuria syndromes). Of these patients, 90% were seen only once or twice for each episode of illness. Of the visits, 150/347 (42%) were potentially avoidable. Patients with suspected bladder outflow obstruction, haematuria and scrotal disorders should undergo imaging of the relevant anatomy before referral. Patients with haematuria should be referred directly for a flexible cystoscopy after imaging. Urologists need to educate general practitioners more clearly about the indications for the treatment of scrotal swellings in elderly men and mild bladder outflow obstruction in middle-aged men. Patients need not be reviewed routinely after transurethral resection of the prostate for benign prostatic hypertrophy or after investigations for haematuria have revealed no serious abnormality.

Efficiency, Organizational↗
PubMed1993

Calf vessel preservation in peripheral vascular disease--angiography versus pulse generated run-off.

Previous angiographic and radiological studies have suggested that the peroneal artery is the best preserved of the calf vessels in peripheral vascular disease and should be a site of preference for a femorodistal bypass graft. Calf vessel run-off assessed by pulse generated run-off (PGR) provides a more accurate prediction of graft success or failure than angiography and may therefore give a better functional picture of vessel patency than angiography. This study compares the presence and degree of preservation of the three calf vessels in patients with severe peripheral vascular disease using both intra-arterial digital subtraction angiography (IADSA) and PGR. Thirty-four limbs in patients with either ischaemic rest pain, ulceration or gangrene were studied and the results were scored according to the extent and severity of disease in the peroneal, posterior tibial and anterior tibial arteries. On IADSA, the peroneal artery was patent significantly more often (79%) than the posterior tibial artery (47%) or the anterior tibial artery (38%). Conversely, PGR examination showed no difference in patency between the three vessels (peroneal 91%, posterior tibial 88%, anterior tibial 79%). The peroneal artery was also significantly better preserved on IADSA (65%) compared to the posterior tibial artery (38%) and the anterior tibial artery (23%). PGR studies again showed no difference in the best preserved vessel between peroneal (47%), posterior tibial (50%) and anterior tibial (50%) arteries. Thus, the peroneal artery appears the better preserved vessel on angiography but this appearance may be misleading because the more functional PGR studies show no significant difference in the patency or degree of preservation of the three calf vessels.

Angiography, Digital Subtraction↗