1
|
Mowat A, Balbirsingh V, Sandhar P, Parekh M, Amlani A, Young B, Giblett N. Rigid bronchoscopy: a consultant survey. Ann R Coll Surg Engl 2024; 106:377-384. [PMID: 37843132 PMCID: PMC10981987 DOI: 10.1308/rcsann.2023.0067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2023] [Indexed: 10/17/2023] Open
Abstract
INTRODUCTION Inhalation of foreign bodies represents a potentially fatal emergency in both adults and children. Chest x-ray, in isolation, is neither sensitive nor specific. Rigid bronchoscopy represents the gold standard to diagnose and retrieve paediatric foreign bodies. Cases are encountered infrequently, creating anxieties about their management. Little is known about the confidence in, and maintenance of, rigid bronchoscopy skills by ear, nose and throat teams. METHODS A 15-question survey was completed by 50 practising otolaryngology consultants in England. RESULTS Results show that almost 40% of otolaryngology consultants covering rigid bronchoscopy have not performed bronchoscopy in more than 5 years. Consultants raised concerns about the anaesthetic support and the speed of equipment assembly. Questions on clinical practice showed disparities in practice in the same scenario. CONCLUSIONS The authors advocate addressing many of the issues raised by the study with a greater availability of simulation courses and regular scheduled intradepartmental teaching days for all professionals involved. National guidelines on criteria for transfer to tertiary centres would improve the consistency of practice.
Collapse
Affiliation(s)
- A Mowat
- The Royal Wolverhampton NHS Trust, UK
| | | | - P Sandhar
- The Royal Wolverhampton NHS Trust, UK
| | - M Parekh
- The Royal Wolverhampton NHS Trust, UK
| | - A Amlani
- The Royal Wolverhampton NHS Trust, UK
| | - B Young
- Maidstone and Tunbridge Wells NHS Trust, UK
| | - N Giblett
- The Royal Wolverhampton NHS Trust, UK
| |
Collapse
|
2
|
Mowat A, Meakin P, Anastasiadou S, Bidaye R, Anari S. The management of posterior epistaxis in the United Kingdom, a national survey. RHINOL 2022. [DOI: 10.4193/rhinol/21.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Background: Posterior bleeds account for 5% of epistaxis. The patient cohort is often elderly and has significant co-morbidities. Such cases have been managed historically with urinary catheters, held in place with umbilical clips. Recently bespoke, double balloon, posterior packs have been utilised. The treatments remain in clinical equipoise with no gold standard or clear national guideline. Methodology: A ten question survey was sent out through www.surveymonkey.com. Attempts were made to contact all Trusts in the United Kingdom via the ENT on call service. A comparison of treatment costs was made. Results: 112 responses have been received. 54% of respondents reported a preference for bespoke posterior pack insertion, only 12% preferred catheters. Twice as many respondents have seen complications from urinary catheters: 14% vs 29%. The availability of posterior packs is inconsistent: 30% of respondents were not aware of the packs or reported them unavailable in their hospital. Conclusions: This survey provides the first comparison of the techniques in the United Kingdom. Bespoke packs have a lower complication rate and are preferred by ENT clinicians on the front line of patient care. We recommend that all UK trusts should stock posterior packs which should be used as first line treatment for cases of posterior epistaxis.
Collapse
|
3
|
Mowat A, Mistry S, Ward V. What is the Role of the Senior House Officer in the ENT Casualty Clinic? Int J Surg 2017. [DOI: 10.1016/j.ijsu.2017.08.235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
4
|
Mowat C, Arnott I, Cahill A, Smith M, Ahmad T, Subramanian S, Travis S, Morris J, Hamlin J, Dhar A, Nwokolo C, Edwards C, Creed T, Bloom S, Yousif M, Thomas L, Campbell S, Lewis SJ, Sebastian S, Sen S, Lal S, Hawkey C, Murray C, Cummings F, Goh J, Lindsay JO, Arebi N, Potts L, McKinley AJ, Thomson JM, Todd JA, Collie M, Dunlop MG, Mowat A, Gaya DR, Winter J, Naismith GD, Ennis H, Keerie C, Lewis S, Prescott RJ, Kennedy NA, Satsangi J. Mercaptopurine versus placebo to prevent recurrence of Crohn's disease after surgical resection (TOPPIC): a multicentre, double-blind, randomised controlled trial. Lancet Gastroenterol Hepatol 2016; 1:273-282. [PMID: 28404197 PMCID: PMC6358144 DOI: 10.1016/s2468-1253(16)30078-4] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Revised: 08/02/2016] [Accepted: 08/04/2016] [Indexed: 12/24/2022]
Abstract
BACKGROUND Up to 60% of patients with Crohn's disease need intestinal resection within the first 10 years of diagnosis, and postoperative recurrence is common. We investigated whether mercaptopurine can prevent or delay postoperative clinical recurrence of Crohn's disease. METHODS We did a randomised, placebo-controlled, double-blind trial at 29 UK secondary and tertiary hospitals of patients (aged >16 years in Scotland or >18 years in England and Wales) who had a confirmed diagnosis of Crohn's disease and had undergone intestinal resection. Patients were randomly assigned (1:1) by a computer-generated web-based randomisation system to oral daily mercaptopurine at a dose of 1 mg/kg bodyweight rounded to the nearest 25 mg or placebo; patients with low thiopurine methyltransferase activity received half the normal dose. Patients and their carers and physicians were masked to the treatment allocation. Patients were followed up for 3 years. The primary endpoint was clinical recurrence of Crohn's disease (Crohn's Disease Activity Index >150 plus 100-point increase in score) and the need for anti-inflammatory rescue treatment or primary surgical intervention. Primary and safety analyses were by intention to treat. Subgroup analyses by smoking status, previous thiopurines, previous infliximab or methotrexate, previous surgery, duration of disease, or age at diagnosis were also done. This trial is registered with the International Standard Randomised Controlled Trial Register (ISRCTN89489788) and the European Clinical Trials Database (EudraCT number 2006-005800-15). FINDINGS Between June 6, 2008, and April 23, 2012, 240 patients with Crohn's disease were randomly assigned: 128 to mercaptopurine and 112 to placebo. All patients received at least one dose of study drug, and no randomly assigned patients were excluded from the analysis. 16 (13%) of patients in the mercaptopurine group versus 26 (23%) patients in the placebo group had a clinical recurrence of Crohn's disease and needed anti-inflammatory rescue treatment or primary surgical intervention (adjusted hazard ratio [HR] 0·54, 95% CI 0·27-1·06; p=0·07; unadjusted HR 0·53, 95% CI 0·28-0·99; p=0·046). In a subgroup analysis, three (10%) of 29 smokers in the mercaptopurine group and 12 (46%) of 26 in the placebo group had a clinical recurrence that needed treatment (HR 0·13, 95% CI 0·04-0·46), compared with 13 (13%) of 99 non-smokers in the mercaptopurine group and 14 (16%) of 86 in the placebo group (0·90, 0·42-1·94; pinteraction=0·018). The effect of mercaptopurine did not significantly differ from placebo for any of the other planned subgroup analyses (previous thiopurines, previous infliximab or methotrexate, previous surgery, duration of disease, or age at diagnosis). The incidence and types of adverse events were similar in the mercaptopurine and placebo groups. One patient on placebo died of ischaemic heart disease. Adverse events caused discontinuation of treatment in 39 (30%) of 128 patients in the mercaptopurine group versus 41 (37%) of 112 in the placebo group. INTERPRETATION Mercaptopurine is effective in preventing postoperative clinical recurrence of Crohn's disease, but only in patients who are smokers. Thus, in smokers, thiopurine treatment seems to be justified in the postoperative period, although smoking cessation should be strongly encouraged given that smoking increases the risk of recurrence. FUNDING Medical Research Council.
Collapse
Affiliation(s)
- Craig Mowat
- Gastrointestinal Unit, Ninewells Hospital, Dundee, UK
| | - Ian Arnott
- Gastrointestinal Unit, Western General Hospital, Edinburgh, UK
| | - Aiden Cahill
- Gastrointestinal Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - Malcolm Smith
- Gastrointestinal Unit, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Tariq Ahmad
- Department of Gastroenterology, Royal Devon and Exeter Hospital NHS Foundation Trust, Exeter, UK; IBD Pharmacogenetics Unit, University of Exeter, Exeter, UK
| | - Sreedhar Subramanian
- Department of Gastroenterology, Royal Liverpool University Hospital, Liverpool, UK
| | - Simon Travis
- Translational Gastroenterology Unit, Nuffield Department of Experimental Medicine, University of Oxford, Oxford, UK
| | - John Morris
- Gastrointestinal Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - John Hamlin
- Department of Gastroenterology, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Anjan Dhar
- Department of Gastroenterology, Darlington Memorial Hospital, Darlington, UK
| | - Chuka Nwokolo
- Department of Gastroenterology, University Hospital Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Cathryn Edwards
- Department of Gastroenterology, Torbay Hospital, South Devon Healthcare NHS Foundation Trust, Torbay, Devon, UK
| | - Tom Creed
- Department of Gastroenterology, Bristol Royal Infirmary, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Stuart Bloom
- Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mohamed Yousif
- Department of Gastroenterology, Rotherham NHS Foundation Trust Hospital, Rotherham, UK
| | - Linzi Thomas
- Department of Gastroenterology, Singleton Hospital, Abertawe Bro Morgannwg University Health Board, Swansea, UK
| | - Simon Campbell
- Department of Gastroenterology, Manchester Royal Infirmary, Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Stephen J Lewis
- Department of Gastroenterology, Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - Shaji Sebastian
- Department of Gastroenterology, Hull Royal Infirmary, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | - Sandip Sen
- Department of Gastroenterology, Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Simon Lal
- Department of Gastroenterology, Salford Royal NHS Foundation Trust Hospital, Salford, UK
| | - Chris Hawkey
- Department of Gastroenterology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Charles Murray
- Department of Gastroenterology, Royal Free London NHS Foundation Trust Hospital, London, UK
| | - Fraser Cummings
- Department of Gastroenterology, Southampton General Hospital, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Jason Goh
- Department of Gastroenterology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - James O Lindsay
- Department of Gastroenterology, Barts Health NHS Trust, Barts and the London School of Medicine, London, UK
| | - Naila Arebi
- Inflammatory Bowel Disease Unit, St Mark's Hospital, North West London Hospitals NHS Trust, London, UK
| | - Lindsay Potts
- Gastrointestinal Unit, Raigmore Hospital, Inverness, UK
| | | | - John M Thomson
- Gastrointestinal Unit, Aberdeen Royal Infirmary, Aberdeen, UK
| | - John A Todd
- Gastrointestinal Unit, Ninewells Hospital, Dundee, UK
| | - Mhairi Collie
- Colorectal Surgery, Western General Hospital, Edinburgh, UK
| | | | - Ashley Mowat
- Gastrointestinal Unit, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Daniel R Gaya
- Gastrointestinal Unit, Glasgow Royal Infirmary, Glasgow, UK
| | - Jack Winter
- Gastrointestinal Unit, Glasgow Royal Infirmary, Glasgow, UK
| | | | - Holly Ennis
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Catriona Keerie
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Steff Lewis
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | | | - Nicholas A Kennedy
- Gastrointestinal Unit, Western General Hospital, Edinburgh, UK; IBD Pharmacogenetics Unit, University of Exeter, Exeter, UK
| | - Jack Satsangi
- Gastrointestinal Unit, Western General Hospital, Edinburgh, UK.
| |
Collapse
|
5
|
Mowat A. SP0086 Tissue Specific Differentiation of Intestinal Macrophages. Ann Rheum Dis 2016. [DOI: 10.1136/annrheumdis-2016-eular.6339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
6
|
Pankhania M, Mowat A, Snowden C, England J. Post-thyroidectomy haemorrhage in a tertiary centre: analysis of 1280 operations and comparison with the BAETS audit 2012. Clin Otolaryngol 2016; 42:484-487. [PMID: 26939787 DOI: 10.1111/coa.12643] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2016] [Indexed: 12/01/2022]
Affiliation(s)
- M Pankhania
- Department of ENT, Head and Neck Surgery, Castle Hill Hospital, Cottingham, UK
| | - A Mowat
- Department of ENT, Head and Neck Surgery, Castle Hill Hospital, Cottingham, UK
| | - C Snowden
- Department of Anaesthetics, Castle Hill Hospital, Cottingham, UK
| | - J England
- Department of ENT, Head and Neck Surgery, Castle Hill Hospital, Cottingham, UK
| |
Collapse
|
7
|
Martin JCJ, Bériou G, Heslan M, Chauvin C, Utriainen L, Aumeunier A, Scott CL, Mowat A, Cerovic V, Houston SA, Leboeuf M, Hubert FX, Hémont C, Merad M, Milling S, Josien R. Interleukin-22 binding protein (IL-22BP) is constitutively expressed by a subset of conventional dendritic cells and is strongly induced by retinoic acid. Mucosal Immunol 2014; 7:101-13. [PMID: 23653115 PMCID: PMC4291114 DOI: 10.1038/mi.2013.28] [Citation(s) in RCA: 114] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Accepted: 04/08/2013] [Indexed: 02/04/2023]
Abstract
Interleukin-22 (IL-22) is mainly produced at barrier surfaces by T cells and innate lymphoid cells and is crucial to maintain epithelial integrity. However, dysregulated IL-22 action leads to deleterious inflammation and is involved in diseases such as psoriasis, intestinal inflammation, and cancer. IL-22 binding protein (IL-22BP) is a soluble inhibitory IL-22 receptor and may represent a crucial regulator of IL-22. We show both in rats and mice that, in the steady state, the main source of IL-22BP is constituted by a subset of conventional dendritic cells (DCs) in lymphoid and non-lymphoid tissues. In mouse intestine, IL-22BP was specifically expressed in lamina propria CD103(+)CD11b(+) DC. In humans, IL-22BP was expressed in immature monocyte-derived DC and strongly induced by retinoic acid but dramatically reduced upon maturation. Our data suggest that a subset of immature DCs may actively participate in the regulation of IL-22 activity in the gut by producing high levels of IL-22BP.
Collapse
Affiliation(s)
- JCJ Martin
- INSERM Center of Research in Transplantation and Immunology, UMR1064, Nantes, F - 44000, France,CHU Nantes, Institut de Transplantation Urologie Néphrologie (ITUN), Nantes, F-44000, France,CHU Nantes, Laboratoire d’immunologie, Nantes, F-44000, France,Université de Nantes, Faculté de Médecine, Nantes, F-44000, France
| | - G Bériou
- INSERM Center of Research in Transplantation and Immunology, UMR1064, Nantes, F - 44000, France,CHU Nantes, Institut de Transplantation Urologie Néphrologie (ITUN), Nantes, F-44000, France
| | - M Heslan
- INSERM Center of Research in Transplantation and Immunology, UMR1064, Nantes, F - 44000, France,CHU Nantes, Institut de Transplantation Urologie Néphrologie (ITUN), Nantes, F-44000, France
| | - C Chauvin
- INSERM Center of Research in Transplantation and Immunology, UMR1064, Nantes, F - 44000, France,CHU Nantes, Institut de Transplantation Urologie Néphrologie (ITUN), Nantes, F-44000, France
| | - L Utriainen
- Centre for Immunobiology, Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, G12 8TA, UK
| | - A Aumeunier
- Centre for Immunobiology, Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, G12 8TA, UK
| | - CL Scott
- Centre for Immunobiology, Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, G12 8TA, UK
| | - A Mowat
- Centre for Immunobiology, Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, G12 8TA, UK
| | - V Cerovic
- Centre for Immunobiology, Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, G12 8TA, UK
| | - SA Houston
- Centre for Immunobiology, Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, G12 8TA, UK
| | - M Leboeuf
- Department of Gene and Cell medicine and the Department of Medicine, Mount Sinai School of Medicine, New York 10029, USA
| | - FX Hubert
- INSERM Center of Research in Transplantation and Immunology, UMR1064, Nantes, F - 44000, France,CHU Nantes, Institut de Transplantation Urologie Néphrologie (ITUN), Nantes, F-44000, France,Université de Nantes, Faculté de Médecine, Nantes, F-44000, France
| | - C Hémont
- INSERM Center of Research in Transplantation and Immunology, UMR1064, Nantes, F - 44000, France,CHU Nantes, Institut de Transplantation Urologie Néphrologie (ITUN), Nantes, F-44000, France,CHU Nantes, Laboratoire d’immunologie, Nantes, F-44000, France,Université de Nantes, Faculté de Médecine, Nantes, F-44000, France
| | - M Merad
- Department of Gene and Cell medicine and the Department of Medicine, Mount Sinai School of Medicine, New York 10029, USA
| | - S Milling
- Centre for Immunobiology, Institute of Infection, Immunity and Inflammation, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, G12 8TA, UK
| | - R Josien
- INSERM Center of Research in Transplantation and Immunology, UMR1064, Nantes, F - 44000, France,CHU Nantes, Institut de Transplantation Urologie Néphrologie (ITUN), Nantes, F-44000, France,CHU Nantes, Laboratoire d’immunologie, Nantes, F-44000, France,Université de Nantes, Faculté de Médecine, Nantes, F-44000, France
| |
Collapse
|
8
|
Abstract
The surgeon frequently encounters renal and biliary stones but rarely may also encounter enteric stones or enteroliths. An enterolith is a stony foreign body that is formed in the gastrointestinal tract. We present a rare case of multiple, large enteroliths found associated with a longstanding incarcerated incisional hernia.
Collapse
|
9
|
Ho GT, Mowat A, Potts L, Cahill A, Mowat C, Lees CW, Hare NC, Wilson JA, Boulton-Jones R, Priest M, Watts DA, Shand AG, Arnott ID, Russell RK, Wilson DC, Morris AJ, Satsangi J. Efficacy and complications of adalimumab treatment for medically-refractory Crohn's disease: analysis of nationwide experience in Scotland (2004-2008). Aliment Pharmacol Ther 2009. [PMID: 19183339 DOI: 10.111/j.1365-2036.2008.03919.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Adalimumab is a second generation humanized anti-tumour necrosis factor (TNF) monoclonal antibody with established efficacy in Crohn's disease (CD). AIMS To evaluate the efficacy and safety of adalimumab on a nationwide clinical setting. METHODS We used the Scottish Society of Gastroenterology network to identify and follow up the clinical outcomes of patients with CD treated with adalimumab over a 4-year period (2004-2008). RESULTS A total of 98 patients received adalimumab - 100.5 patient follow-up years were recorded (64.3% females; median age at diagnosis of 20.7 years; 88.8% treated with 80/40 mg induction regimen. Eighty eight (89.8%) had previous infliximab with 29 (32.9%) primary nonresponders; 32 (32.6%) were corticosteroid-dependent; 47 (47.9%) were intolerant/resistant to most immunosuppressive therapies (two or more). In all, 60% of patients were in clinical remission at 1-year follow-up, with 30% and 55% requiring dose escalation to weekly therapy at 1-and 2-year follow-up respectively. Overall, 29 (29.6%) patients developed complications with eight nonfatal serious (8.2%) adverse events and 2 (2.0%) case fatalities (sepsis following perforation and disseminated colorectal cancer, respectively). CONCLUSIONS Adalimumab is efficacious in severe and refractory CD in the clinical setting, although there remain significant therapy- and disease-related risks of serious complications.
Collapse
Affiliation(s)
- G T Ho
- Scottish Society of Gastroenterology, Edinburgh, UK.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
10
|
Ho GT, Mowat A, Potts L, Cahill A, Mowat C, Lees CW, Hare NC, Wilson JA, Boulton-Jones R, Priest M, Watts DA, Shand AG, Arnott ID, Russell RK, Wilson DC, Morris AJ, Satsangi J. Efficacy and complications of adalimumab treatment for medically-refractory Crohn's disease: analysis of nationwide experience in Scotland (2004-2008). Aliment Pharmacol Ther 2009; 29:527-34. [PMID: 19183339 DOI: 10.1111/j.1365-2036.2008.03919.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Adalimumab is a second generation humanized anti-tumour necrosis factor (TNF) monoclonal antibody with established efficacy in Crohn's disease (CD). AIMS To evaluate the efficacy and safety of adalimumab on a nationwide clinical setting. METHODS We used the Scottish Society of Gastroenterology network to identify and follow up the clinical outcomes of patients with CD treated with adalimumab over a 4-year period (2004-2008). RESULTS A total of 98 patients received adalimumab - 100.5 patient follow-up years were recorded (64.3% females; median age at diagnosis of 20.7 years; 88.8% treated with 80/40 mg induction regimen. Eighty eight (89.8%) had previous infliximab with 29 (32.9%) primary nonresponders; 32 (32.6%) were corticosteroid-dependent; 47 (47.9%) were intolerant/resistant to most immunosuppressive therapies (two or more). In all, 60% of patients were in clinical remission at 1-year follow-up, with 30% and 55% requiring dose escalation to weekly therapy at 1-and 2-year follow-up respectively. Overall, 29 (29.6%) patients developed complications with eight nonfatal serious (8.2%) adverse events and 2 (2.0%) case fatalities (sepsis following perforation and disseminated colorectal cancer, respectively). CONCLUSIONS Adalimumab is efficacious in severe and refractory CD in the clinical setting, although there remain significant therapy- and disease-related risks of serious complications.
Collapse
Affiliation(s)
- G T Ho
- Scottish Society of Gastroenterology, Edinburgh, UK.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Grant A, Wileman S, Ramsay C, Bojke L, Epstein D, Sculpher M, Macran S, Kilonzo M, Vale L, Francis J, Mowat A, Krukowski Z, Heading R, Thursz M, Russell I, Campbell M. The effectiveness and cost-effectiveness of minimal access surgery amongst people with gastro-oesophageal reflux disease - a UK collaborative study. The REFLUX trial. Health Technol Assess 2008; 12:1-181, iii-iv. [PMID: 18796263 DOI: 10.3310/hta12310] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES To evaluate the clinical effectiveness, cost-effectiveness and safety of a policy of relatively early laparoscopic surgery compared with continued medical management amongst people with gastro-oesophageal reflux disease (GORD) judged suitable for both policies. DESIGN Relative clinical effectiveness was assessed by a randomised trial (with parallel non-randomised preference groups) comparing a laparoscopic surgery-based policy with a continued medical management policy. The economic evaluation compared the cost-effectiveness of the two management policies in order to identify the most efficient provision of future care and describe the resource impact that various policies for fundoplication would have on the NHS. SETTING A total of 21 hospitals throughout the UK with a local partnership between surgeon(s) and gastroenterologist(s) who shared the secondary care of patients with GORD. PARTICIPANTS The 810 participants, who were identified retrospectively or prospectively via their participating clinicians, had both documented evidence of GORD (endoscopy and/or manometry/24-hour pH monitoring) and symptoms for longer than 12 months. In addition, the recruiting clinician(s) was clinically uncertain about which management policy was best. INTERVENTION Of the 810 eligible patients who consented to participate, 357 were recruited to the randomised arm of the trial (178 allocated to surgical management, 179 allocated to continued, but optimised, medical management) and 453 recruited to the parallel non-randomised preference arm (261 chose surgical management, 192 chose to continue with best medical management). The type of fundoplication was left to the discretion of the surgeon. MAIN OUTCOME MEASURES Participants completed a baseline REFLUX questionnaire, developed specifically for this study, containing a disease-specific outcome measure, the Short Form with 36 Items (SF-36), the EuroQol-5 Dimensions (EQ-5D) and the Beliefs about Medicines and Surgery questionnaires (BMQ/BSQ). Postal questionnaires were completed at participant-specific time intervals after joining the trial (equivalent to approximately 3 and 12 months after surgery). Intraoperative data were recorded by the surgeons and all other in-hospital data were collected by the research nurse. At the end of the study period, participants completed a discrete choice experiment questionnaire. RESULTS The randomised groups were well balanced at entry. Participants had been taking GORD medication for a median of 32 months; the mean age of participants was 46 years and 66% were men. Of 178 randomised to surgery, 111 (62%) actually had fundoplication. There was a mixture of clinical and personal reasons why some patients did not have surgery, sometimes related to long waiting times. A total or partial wrap procedure was performed depending on surgeon preference. Complications were uncommon and there were no deaths associated with surgery. By the equivalent of 12 months after surgery, 38% in the randomised surgical group (14% amongst those who had surgery) were taking reflux medication compared with 90% in the randomised medical group. There were substantial differences (one-third to one-half standard deviation) favouring the randomised surgical group across the health status measures, the size depending on assumptions about the proportion that actually had fundoplication. These differences were the same or somewhat smaller than differences observed at 3 months. The lower the REFLUX score, the worse the symptoms at trial entry and the larger the benefit observed after surgery. The preference surgical group had the lowest REFLUX scores at baseline. These scores improved substantially after surgery, and by 12 months they were better than those in the preference medical group. The BMQ/BSQ and discrete choice experiment did distinguish the preference groups from each other and from the randomised groups. The latter indicated that the risk of serious complications was the most important single attribute of a treatment option. A within-trial cost-effectiveness analysis suggested that the surgery policy was more costly (mean 2049 pounds) but also more effective [+0.088 quality-adjusted life-years (QALYs)]. The estimated incremental cost per QALY was 19,000-23,000 pounds, with a probability between 46% (when 62% received surgery) and 19% (when all received surgery) of cost-effectiveness at a threshold of 20,000 pounds per QALY. Modelling plausible longer-term scenarios (such as lifetime benefit after surgery) indicated a greater likelihood (74%) of cost-effectiveness at a threshold of 20,000 pounds, but applying a range of alternative scenarios indicated wide uncertainty. The expected value of perfect information was greatest for longer-term quality of life and proportions of surgical patients requiring medication. CONCLUSIONS Amongst patients requiring long-term medication to control symptoms of GORD, surgical management significantly increases general and reflux-specific health-related quality of life measures, at least up to 12 months after surgery. Complications of surgery were rare. A surgical policy is, however, more costly than continued medical management. At a threshold of 20,000 pounds per QALY it may well be cost-effective, especially when putative longer-term benefits are taken into account, but this is uncertain. The more troublesome the symptoms, the greater the potential benefit from surgery. Uncertainty about cost-effectiveness would be greatly reduced by more reliable information about relative longer-term costs and benefits of surgical and medical policies. This could be through extended follow-up of the REFLUX trial cohorts or of other cohorts of fundoplication patients. TRIAL REGISTRATION Current Controlled Trials ISRCTN15517081.
Collapse
Affiliation(s)
- A Grant
- Health Services Research Unit, University of Aberdeen, UK
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
12
|
Abstract
OBJECTIVE Surgery can prevent extensor tendon rupture in the rheumatoid wrist but it is difficult to identify patients at risk. Extensor digiti minimi (EDM) usually ruptures first, but rupture may pass unnoticed because extensor digitorum communis (EDC) extends all four fingers simultaneously. We assessed the value of screening for EDM rupture by examining for absent independent extension of the little finger in a hospital rheumatoid arthritis population. METHODS The EDM test was performed in 550 previously unoperated wrists. Disease activity, joint damage, wrist swelling, tenderness and crepitus were recorded. RESULTS Unsuspected EDM loss was found in nine of the 550 wrists (1.6%); dorsal synovitis was absent or minimal in eight and ulnar tenderness was absent in six. EDM loss was not associated with activity, severity or duration of disease. CONCLUSIONS The EDM test is simple and cheap. It may identify patients at risk and permit prophylactic surgery before hand function is lost.
Collapse
Affiliation(s)
- L Williamson
- Department of Rheumatology, Nuffield Orthopaedic Centre, Oxford OX3 7LD, UK
| | | | | |
Collapse
|
13
|
Williamson L, Illingworth H, Smith D, Mowat A. Oral quinine in ankylosing spondylitis: a randomized placebo controlled double blind crossover trial. J Rheumatol 2000; 27:2054-5. [PMID: 10955360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
|
14
|
Abstract
Three hundred and forty-one salivary gland fine-needle aspiration (FNA) cytology specimens taken over a 6-yr period were reviewed and correlated with clinical and/or histological findings. The aspirates were derived from parotid gland (212 cases), submandibular gland (124 cases), and minor salivary gland (5 cases). The major diagnostic categories were unsatisfactory (10 cases), normal (100 cases), sialadenitis (74 cases), cyst (34 cases), lipoma (5 cases), pleomorphic adenoma (55 cases), Warthin's tumor (36 cases), and malignancy (27 cases). The latter included 14 primary salivary neoplasms (4 lymphomas of mucosa-associated lymphoid tissue (MALT) type, 3 adenocarcinomas, 2 squamous carcinomas, 2 adenoid cystic cacinomas, and one case each of carcinoma ex pleomorphic adenoma, undifferentiated carcinoma, and high-grade mucoepidermoid carcinoma), and 13 metastases, 9 of which were derived from squamous carcinomas of head and neck origin. Clinicopathological review showed that 88 of 91 (97%) benign epithelial tumors and 27 of 31 (87%) malignant neoplasms with adequate FNA sampling were accurately diagnosed cytologically. False-negative results were caused by sampling error (7 cases), most notably in cystic tumors, or were due to misinterpretation of uncommon neoplasms (3 cases). The overall sensitivity, specificity, and accuracy were 92%, 100%, and 98%, respectively. FNA cytology provides accurate diagnosis of most salivary gland lesions and contributes to conservative management in many patients with nonneoplastic conditions.
Collapse
Affiliation(s)
- C J Stewart
- Department of Pathology, Glasgow Royal Infirmary, Glasgow, UK
| | | | | | | |
Collapse
|
15
|
Williamson L, Bowness P, Mowat A, Ostman-Smith I. Lesson of the week: difficulties in diagnosing acute rheumatic fever-arthritis may be short lived and carditis silent. BMJ 2000; 320:362-5. [PMID: 10657336 PMCID: PMC1127146 DOI: 10.1136/bmj.320.7231.362] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/25/1999] [Indexed: 11/03/2022]
Affiliation(s)
- L Williamson
- Department of Rheumatology, Nuffield Orthopaedic Centre, Oxford OX3 7LD.
| | | | | | | |
Collapse
|
16
|
|
17
|
|
18
|
Grdic D, Smith R, Donachie A, Kjerrulf M, Hörnquist E, Mowat A, Lycke N. The mucosal adjuvant effects of cholera toxin and immune-stimulating complexes differ in their requirement for IL-12, indicating different pathways of action. Eur J Immunol 1999; 29:1774-84. [PMID: 10382739 DOI: 10.1002/(sici)1521-4141(199906)29:06<1774::aid-immu1774>3.0.co;2-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Adjuvants that can improve mucosal vaccine efficacy are much warranted. In this comparative study between cholera toxin (CT) and immune-stimulating complexes (ISCOM) we found that, contrary to CT, ovalbumin (OVA)-ISCOM were poor inducers of mucosal anti-OVA IgA responses, but induced similar or better systemic immunity following oral immunizations. The addition of CT to the oral OVA-ISCOM protocol did not stimulate local anti-OVA IgA immunity, nor did it change the quality or magnitude of the systemic responses. Both vectors recruited strong innate immunity, but only OVA-ISCOM could directly induce IL-12, demonstrable at the protein and mRNA levels. CT had no inhibitory effects on lipopolysaccharide/IFN-gamma-induced IL-12 mRNA expression or IL-12 production. Furthermore, adjuvanticity of CT was unaffected in IL-12-deficient mice, while OVA-ISCOM showed partly impaired adjuvant effects by the lack of IL-12. CT abrogated the induction of oral tolerance stimulated by antigen feeding in these mice. In addition, CT did not alter TGF-beta levels, suggesting that the immunomodulating effect of CT was independent of IL-12 as well as TGF-beta production. Taken together, these findings indicate that mucosal adjuvanticity of CT and ISCOM are differently dependent on IL-12, suggesting that separate and distinct antigen-processing pathways are involved.
Collapse
Affiliation(s)
- D Grdic
- Department of Medical Microbiology and Immunology, University of Göteborg, Sweden
| | | | | | | | | | | | | |
Collapse
|
19
|
Melendez HV, Dhawan A, Mieli-Vergani G, Rela M, Heaton ND, Pritchard J, Mowat A. Liver transplantation for Langerhans' cell histiocytosis--a case report and literature review. Transplantation 1996; 62:1167-71. [PMID: 8900319 DOI: 10.1097/00007890-199610270-00023] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Langerhans' cell histiocytosis (LCH) is a rare disorder of unknown etiology and pathogenesis. End-stage chronic liver disease is one presentation and orthotopic liver transplantation (OLT) has been reported in 17 cases, with variable resolution of LCH lesions postoperatively. We report a case of multisystem LCH with end-stage liver disease treated by OLT and review the overall results of OLT for children with LCH.
Collapse
Affiliation(s)
- H V Melendez
- Liver Transplant Surgical Service and Department of Child Health, King's College Hospital, London, United Kingdom
| | | | | | | | | | | | | |
Collapse
|
20
|
Clark BJ, Mowat A, Fallowfield ME, Lee FD. Papular mucinosis: is the inflammatory cell infiltrate neoplastic? The presence of a monotypic plasma cell population demonstrated by in situ hybridization. Br J Dermatol 1996; 135:467-70. [PMID: 8949447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Papular mucinosis is a condition reported to be associated with abnormal serum paraproteins and plasma cell dyscrasias. We report a patient with papular mucinosis, without a serum paraprotein or bone marrow plasmacytosis, in whom the affected skin contained a prominent perivascular plasma cell infiltrate. Using in situ hybridization, for kappa and lambda light chain mRNA, these plasma cells were demonstrably monotypic for lambda light chain and, therefore, presumably monoclonal and putatively neoplastic. We suggest that the absence of a serum paraprotein and marrow plasmacytosis does not exclude the existence of a plasma cell neoplasm in patients with papular mucinosis. Such plasma cell populations may exist in the affected skin, although their true nature and behaviour remains to be determined.
Collapse
Affiliation(s)
- B J Clark
- University Department of Pathology, Royal Infirmary, Glasgow
| | | | | | | |
Collapse
|
21
|
Abstract
A study was carried out to examine the possible relationship between levels of copper in drinking water and the incidence of specified childhood liver complaints presenting at a major UK paediatric liver unit. Public drinking water supplies were generally found to have levels of copper which were well below the EC standard of 3,000 micrograms/l. In private supplies, a slightly greater number of samples were found to exceed the prescribed concentration; in one instance a value of 26,000 micrograms/l was recorded. Data describing infant patients reporting to Kings College Hospital, London with specified liver complaints were examined. Where the address of patients could be determined (220 out of 240 cases), all patients were found to live in areas served by public drinking water supplies and were, thus, unlikely to have experienced elevated drinking water copper concentrations.
Collapse
Affiliation(s)
- L Fewtrell
- Centre for Research into Environment and Health, Crewe, Cheshire, UK
| | | | | | | | | |
Collapse
|
22
|
Garratt AM, Ruta DA, Russell I, Macleod K, Brunt P, McKinlay A, Mowat A, Sinclair T. Developing a condition-specific measure of health for patients with dyspepsia and ulcer-related symptoms. J Clin Epidemiol 1996; 49:565-71. [PMID: 8636730 DOI: 10.1016/0895-4356(95)00584-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
A patient-administered instrument for dyspepsia and symptoms suggestive of duodenal or gastric ulcer, based on the type of questions asked when taking a patient's history, was developed and tested using the following steps: literature reviews, devising the questions, testing the responses to the questions using factor analysis and internal consistency, assessing test-retest reliability, and validating the questionnaire by comparing patient responses to the SF-36 health survey questionnaire. The main sample consisted of 135 patients referred to an outpatient clinic with dyspepsia, and 152 patients in general practice who were not referred to a specialist. The final instrument produced a Cronbach's alpha of 0.72 and an intraclass correlation coefficient of 0.69. Patient scores on the dyspepsia questionnaire had small to moderate correlations with the SF-36 health survey, the largest correlation being with the SF-36 scale of pain. Patient scores were significantly related to general practitioner perceptions of symptom severity, family history of gastric ulcer disease, and whether the patient was referred. The questions asked in taking a clinical history from a patient with dyspepsia and other symptoms suggestive of ulcer disease can be used to construct a valid and reliable measure of the effect of dyspepsia on health.
Collapse
Affiliation(s)
- A M Garratt
- Department of Public Health, University of Aberdeen, Foresterhill, United Kingdom
| | | | | | | | | | | | | | | |
Collapse
|
23
|
Banerjee S, El-Omar E, Mowat A, Ardill JE, Park RH, Watson W, Beattie AD, McColl KE. Sucralfate suppresses Helicobacter pylori infection and reduces gastric acid secretion by 50% in patients with duodenal ulcer. Gastroenterology 1996; 110:717-24. [PMID: 8608880 DOI: 10.1053/gast.1996.v110.pm8608880] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND & AIMS The mechanism(s) by which sucralfate heals duodenal ulcers remains unclear. The aim of this study was to determine the effect of sucralfate on Helicobacter pylori infection and on the accompanying hypersecretion of gastric acid the infection induces in patients with duodenal ulcer. METHODS Basal and gastrin-releasing peptide (GRP) stimulated gastrin release and acid secretion. H. pylori density, gastric urease activity, and severity of gastritis were studied in patients with duodenal ulcer who were positive for H. pylori before, during, and after 4 weeks' treatment with sucralfate (2 g twice daily). RESULTS The density of H. pylori decreased by 70% during sucralfate treatment and returned to the pretreatment level after discontinuation of therapy. This suppression of H. pylori infection was accompanied by an 80% decrease in gastric urease activity. GRP-stimulated plasma gastrin concentrations, GRP-stimulated acid output, and basal acid output all decreased by approximately 50% during sucralfate therapy and returned to pretreatment levels after treatment was discontinued. CONCLUSIONS These findings indicate that sucralfate markedly suppresses H. pylori infection and the accompanying hypersecretion of acid the infection induces in patients with duodenal ulcer. These effects are likely to be important mechanisms by which the drug promotes duodenal ulcer healing.
Collapse
Affiliation(s)
- S Banerjee
- Gastrointestinal Centre, Southern General Hospital, Glasgow, Scotland
| | | | | | | | | | | | | | | |
Collapse
|
24
|
Bowman S, Mowat A. Cytomegalovirus in methotrexate-treated rheumatoid arthritis patients: comment on the concise communication by Aglas et al. Arthritis Rheum 1995; 38:1861-2. [PMID: 8849362 DOI: 10.1002/art.1780381223] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
|
25
|
Ruta D, Coutts A, Abdalla M, Masson J, Russell E, Brunt P, McKinlay A, Mowat A, Sinclair T. Feasibility of monitoring patient based health outcomes in a routine hospital setting. Qual Health Care 1995; 4:161-5. [PMID: 10153424 PMCID: PMC1055310 DOI: 10.1136/qshc.4.3.161] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess the feasibility of monitoring health outcomes in a routine hospital setting and the value of feedback of outcomes data to clinicians by using the SF 36 health survey questionnaire. DESIGN Administration of the questionnaire at baseline and three months, with analysis and interpretation of health status data after adjustments for sociodemographic variables and in conjunction with clinical data. Exploration of usefulness of outcomes data to clinicians through feedback discussion sessions and by an evaluation questionnaire. SETTING One gastroenterology outpatient department in Aberdeen Royal Hospitals Trust, Scotland. PATIENTS All (573) patients attending the department during one month (April 1993). MAIN MEASURES Ability to obtain patient based outcomes data and requisite clinical information and feed it back to the clinicians in a useful and accessible form. RESULTS Questionnaires were completed by 542 (95%) patients at baseline and 450 (87%) patients at follow up. Baseline health status data and health outcomes data for the eight different aspects of health were analysed for individual patients, key groups of patients, and the total recruited patient population. Significant differences were shown between patients and the general population and between different groups of patients, and in health status over time. After adjustment for differences in sociodemography and main diagnosis patients with particularly poor scores were identified and discussed. Clinicians judged that this type of assessment could be useful for individual patients if the results were available at the time of consultation or for a well defined group of patients if used as part of a clinical trial. CONCLUSIONS Monitoring routine outcomes is feasible and instruments to achieve this, such as the SF 36 questionnaire, have potential value in an outpatient setting. IMPLICATIONS If data on outcomes are to provide a basis for clinical and managerial decision making, information systems will be required to collect, analyse, interpret, and feed it back regularly and in good time.
Collapse
Affiliation(s)
- D Ruta
- Department of Public Health, University of Aberdeen, Scotland
| | | | | | | | | | | | | | | | | |
Collapse
|
26
|
Baker A, Mowat A. Reasons for investigating the jaundiced child. Practitioner 1994; 238:788-790. [PMID: 7991497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Affiliation(s)
- A Baker
- Variety Club Children's Hospital, King's College Hospital, London
| | | |
Collapse
|
27
|
Abstract
Two cases of metastatic balloon cell melanoma are reported. Each tumour was composed of large clear cells which did not contain melanin, glycogen or fat, but showed positive staining for S-100 protein, NK/1-C3 and HMB-45. In each case the primary lesion was a cutaneous melanoma of typical morphology. It is essential to consider balloon cell melanoma in the differential diagnosis of clear cell tumours. These cases emphasize the need for an accurate clinical history.
Collapse
Affiliation(s)
- A Mowat
- University Department of Pathology, Western Infirmary, Glasgow, UK
| | | | | |
Collapse
|
28
|
Abstract
OBJECTIVES To document the variety of liver diseases and the clinical picture of hepatic hypertrophic osteoarthropathy (HOA) complicated by arthritis and to report the effects of successful liver transplantation on this disabling condition. METHODS Seven patients with severe liver disease (two biliary atresia, two primary sclerosing cholangitis, one Wilson's disease, one primary biliary cirrhosis (PBC) and one alcoholic cirrhosis) complicated by radiologically proven hepatic HOA and suffering from arthritis are described. RESULTS In four of the six patients who required hepatic transplantation for inadequate liver function successful grafting was achieved with complete clinical remission of the painful arthritis. This occurred three days to 18 months later. CONCLUSIONS Hepatic HOA with arthritis occurs in a variety of liver diseases. Despite resistance of this arthritis to conventional therapies, successful liver transplantation was associated with complete clinical remission in four of the cases reported.
Collapse
Affiliation(s)
- P Pitt
- Department of Rheumatology, King's College Hospital, London, United Kingdom
| | | | | | | |
Collapse
|
29
|
Abstract
Three patients with stable liver function after Kasai portoenterostomy developed acute liver failure secondary to liver necrosis. Doppler ultrasound at presentation revealed reversed diastolic hepatic arterial blood flow. Two patients survived after urgent liver transplantation. Liver necrosis should be suspected in children with chronic liver disease presenting with fever and rapidly deteriorating liver function.
Collapse
Affiliation(s)
- M T Corbally
- Liver Transplant Surgical Service, King's College Hospital, London
| | | | | | | | | | | | | | | |
Collapse
|
30
|
Abstract
The importance of patient-based assessments of outcomes of care in RA is increasingly recognized. There are a number of methods of gaining such data. One method is to request patients to assess change in health status by means of transition questions. This is considered advantageous to other methods because is directly addresses perceptions of change over time and is short and simple. One hundred patients with RA completed a range of clinical, laboratory and health status assessments on two occasions 3 months apart. On the second occasion they also completed a transition question. Results show the question to be valid and to correlate with a number of different changes obtained from assessments. Psychological mood did not appear to influence transition judgements. A small minority of patients experienced changes for specific dimensions of health status in the opposite direction of the transition item. Transition judgements may have an important role in evaluation studies and audit.
Collapse
Affiliation(s)
- R Fitzpatrick
- Department of Public Health and Primary Care, University of Oxford
| | | | | | | | | |
Collapse
|
31
|
Fitzpatrick R, Ziebland S, Jenkinson C, Mowat A, Mowat A. A comparison of the sensitivity to change of several health status instruments in rheumatoid arthritis. J Rheumatol Suppl 1993; 20:429-36. [PMID: 8478847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
We carried out a study to compare the sensitivity to change of disease specific compared with more generic health status instruments in relation to rheumatoid arthritis (RA). A sample of 102 patients was recruited and assessed by means of 4 health status instruments and standard rheumatological measures on 3 occasions separated by 3 monthly intervals. Sensitivity to change for mobility, activities of daily living, household, pain, emotions and social dimensions were calculated. For some dimensions disease specific health status instruments performed less well. However overall there was no evidence of consistent differences between the 2 approaches. We conclude that generic instruments have a role in the assessment of RA.
Collapse
Affiliation(s)
- R Fitzpatrick
- Department of Rheumatology, Nuffield Orthopaedic Centre, Oxford, UK
| | | | | | | | | |
Collapse
|
32
|
Brett F, Mowat A, Farquharson MA, McGill M, Hind C, Richmond J, Murray D, Khan NU, Foulis AK. The distribution of immunoreactive interferon-gamma-containing cells in normal human tissues. Immunol Suppl 1992; 77:515-9. [PMID: 1493923 PMCID: PMC1421654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
An immunohistochemical technique has been used to study the distribution of lymphocytes expressing interferon-gamma in normal adult tissues. The greatest concentrations of these cells were seen in mucosal sites exposed to a resident microflora. It is proposed that such organisms, by eliciting immune responses, provide the stimulus for the production of 'physiological' interferon-gamma. This in turn may act to preserve the 'tone' or readiness of the immune system.
Collapse
Affiliation(s)
- F Brett
- Department of Pathology, Glasgow Royal Infirmary, U.K
| | | | | | | | | | | | | | | | | |
Collapse
|
33
|
Mowat A. Soft tissue injuries. Practitioner 1992; 236:1068-73. [PMID: 1305752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
|
34
|
Ziebland S, Fitzpatrick R, Jenkinson C, Mowat A, Mowat A. Comparison of two approaches to measuring change in health status in rheumatoid arthritis: the Health Assessment Questionnaire (HAQ) and modified HAQ. Ann Rheum Dis 1992; 51:1202-5. [PMID: 1466596 PMCID: PMC1012455 DOI: 10.1136/ard.51.11.1202] [Citation(s) in RCA: 61] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
As an alternative to the calculation of change scores for health status questionnaires used in clinical trials or longitudinal studies, transitional questions have been developed for patients to assess changes directly themselves. Here the original Health Assessment Questionnaire (HAQ) is compared with a modified version of the HAQ (MHAQ) which contains transition questions used at follow up. These, together with a set of standard rheumatological tests, were all completed by 100 patients with rheumatoid arthritis on two occasions, three months apart. Change scores were calculated for the HAQ and for the clinical measures and compared with the MHAQ. The results were strikingly in favour of encouraging patients to assess their own degree of change through the use of transition questions in the MHAQ.
Collapse
Affiliation(s)
- S Ziebland
- Department of Public Health and Primary Care, University of Oxford, Radcliffe Infirmary, U.K
| | | | | | | | | |
Collapse
|
35
|
Sallie R, Katsiyiannakis L, Baldwin D, Davies S, O'Grady J, Mowat A, Mieli-Vergani G, Williams R. Failure of simple biochemical indexes to reliably differentiate fulminant Wilson's disease from other causes of fulminant liver failure. Hepatology 1992. [PMID: 1427659 DOI: 10.1002/hep.1840160517] [Citation(s) in RCA: 62] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Serum, urine and tissue biochemical findings were studied in 21 cases of fulminant Wilson's disease with respect to the value of a recently described biochemical index based on serum alkaline phosphatase and total serum bilirubin levels, and these cases were compared with 193 other cases of fulminant liver failure. Serum bilirubin, alkaline phosphatase and AST levels found in fulminant Wilson's disease were significantly different from those found in other cases of fulminant liver failure, but differentiation from other causes of fulminant liver failure on the basis of these biochemical parameters was not possible. The alkaline phosphatase/bilirubin and aspartate AST/bilirubin ratios derived from the above parameters were also significantly lower in fulminant Wilson's disease than in other categories of fulminant liver failure, but distinction between diagnostic categories on this basis was not possible. When ratios that correctly identified all cases of fulminant Wilson's disease were selected, 59/190 (31%) and 84/190 (44%) cases of non-Wilsonian fulminant liver failure would erroneously be assigned a diagnosis of fulminant Wilson's disease, by alkaline phosphatase/bilirubin and AST/bilirubin ratios, respectively. A low alkaline phosphatase-to-bilirubin ratio (< 0.57) in any category of fulminant liver failure suggested a significantly worse prognosis than in cases with higher ratios (chi 2, Yates' corrected = 5.37, p = 0.02). In the Wilson's disease group, serum and hepatic copper and ceruloplasmin concentrations were normal in 4/21, 2/15 and 2/19, respectively, whereas urinary copper level was elevated in 18/18 and was the most valuable test in diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)
Collapse
Affiliation(s)
- R Sallie
- Institute of Liver Studies, King's College Hospital, Denmark Hill, London
| | | | | | | | | | | | | | | |
Collapse
|
36
|
Fitzpatrick R, Ziebland S, Jenkinson C, Mowat A, Mowat A. Importance of sensitivity to change as a criterion for selecting health status measures. Qual Health Care 1992; 1:89-93. [PMID: 10136848 PMCID: PMC1054970 DOI: 10.1136/qshc.1.2.89] [Citation(s) in RCA: 74] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To assess the sensitivity to change over time of four health status instruments in relation to patients with rheumatoid arthritis. DESIGN Observational three month study of four self assessed instruments (arthritis impact measurement scales (AIMS), health assessment questionnaire (HAQ), Nottingham health profile (NHP), functional limitations profile (FLP)). SETTING One rheumatology unit. PATIENTS 101 patients with definite or classic rheumatoid arthritis. MAIN MEASURES Change scores for dimensions of instruments, as determined by effect size (mean change in score/baseline standard deviation of variable) and conventional rheumatological measures, at baseline and after three months. RESULTS Change scores for comparable dimensions (mobility, activities of daily living, household, pain, mood or emotion, and social scales) of the instruments were compared among 30 patients who considered their health status to have improved over three months. For all dimensions of health status the magnitude of change varied considerably according to the instrument. Maximum range in effect size was for social scales (AIMS 0.06, NHP 0.24, FLP 0.60). No single instrument seemed consistently to show the most change over all dimensions. CONCLUSION Selection of health status instruments for audit or evaluation may have a considerable impact on the pattern of results obtained, and the "responsiveness" of such scales should be as carefully examined as their reliability and acceptability when selecting outcome measures.
Collapse
Affiliation(s)
- R Fitzpatrick
- Department of Public Health and Primary Care, University of Oxford
| | | | | | | | | |
Collapse
|
37
|
Allison MC, Mowat A, McCruden EA, McGregor E, Burt AD, Briggs JD, Junor BJ, Follett EA, MacSween RN, Mills PR. The spectrum of chronic liver disease in renal transplant recipients. Q J Med 1992; 83:355-67. [PMID: 1438671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Chronic liver disease has been reported to be an important cause of late morbidity and mortality in renal transplant recipients. We have examined the prevalence and nature of chronic liver disease among 538 patients with functioning renal allografts managed at the Western Infirmary, Glasgow, between 1980 and 1989. Thirty-seven patients (7 per cent) satisfied biochemical criteria for chronic liver dysfunction. Liver biopsies were obtained from 24 of these, and autopsy tissue was available from three other patients. Chronic hepatitis of variable severity was present in 15 patients, haemosiderosis in 12 patients and nodular regenerative hyperplasia in five patients. Nineteen patients (51 per cent) had serological evidence of infection with the hepatitis C virus, and one of these developed chronic hepatitis B and D infection as well. Although a variety of chronic liver diseases occurred in our transplant population, the frequency of serious sequelae from liver dysfunction was much lower than that reported from transplant centres in other countries.
Collapse
Affiliation(s)
- M C Allison
- Department of Gastroenterology, Western Infirmary, Glasgow
| | | | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Fitzpatrick R, Ziebland S, Jenkinson C, Mowat A, Mowat A. A generic health status instrument in the assessment of rheumatoid arthritis. Br J Rheumatol 1992; 31:87-90. [PMID: 1737237 DOI: 10.1093/rheumatology/31.2.87] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Seventy-three patients with RA were assessed by means of the Nottingham Health Profile (NHP), the Arthritis Impact Measurement Scales (AIMS) and a number of clinical measures. Patients with RA scored higher than controls on the NHP scales for energy, pain, mobility and sleep. Energy, pain, mobility and emotions scales of the NHP correlate significantly with other measures such as clinical assessments, matching scales of the AIMS and the Beck Depression Inventory, indicating satisfactory validity for the instrument with RA. Five of the six scales of the NHP are stable on retesting. The social scale of the NHP on the other hand does not correlate with the matching instrument of the AIMS and is relatively unstable over time. Measurement properties of generic health status instruments such as the NHP will require serious attention as they are increasingly used in evaluation studies.
Collapse
Affiliation(s)
- R Fitzpatrick
- Department of Public Health and Primary Care, University of Oxford
| | | | | | | | | |
Collapse
|
39
|
Abstract
We report the association of erythema elevatum diutinum (EED) with ulcerative colitis (UC). The patient, whose history included rheumatoid disease, diabetes mellitus (type I) and hypothyroidism developed EED during a severe acute exacerbation of UC which resolved following colectomy. To our knowledge this is the first report of such an association. Also of interest was the observation of Köebner phenomenon occurring at the sites where blood vessels were damaged.
Collapse
Affiliation(s)
- K Buahene
- Department of Dermatology, Aberdeen Royal Infirmary, UK
| | | | | | | | | |
Collapse
|
40
|
Abstract
Fifty-six patients with rheumatoid arthritis (RA) were assessed on two occasions three months apart. They completed two health status instruments--the Arthritis Impact Measurement Scales (AIMS) and the Nottingham Health Profile (NHP)--and the Beck Depression Inventory. In addition, clinical and serological data were gathered in order to calculate severity of disease according to the Mallya and Mace index. Health status instruments and the severity of disease index showed agreement in the assessment of mobility; similar agreement was found for different assessments of emotions. However, the two instruments provided social interaction scores with little agreement either cross-sectionally or in terms of change over time. It is argued that the generic NHP may be a valid instrument as an outcome measure in RA but the NHP and AIMS assess different aspects of social interaction. Care is needed in the selection of outcome measures to evaluate interventions.
Collapse
Affiliation(s)
- R Fitzpatrick
- Nuffield College and Rheumatology Unit, Nuffield Orthopaedic Centre, Oxford, UK
| | | | | | | | | |
Collapse
|
41
|
Abstract
We have studied 23 patients receiving penicillamine for the treatment of rheumatoid arthritis to determine the prevalence of penicillamine-induced elastosis. One female patient had pseudoxanthoma elasticum-like skin changes and bramble-bush elastosis without calcification in the involved skin. Penicillamine elastosis was present in the joint capsule in 62% of eight patients or 64% of II joints examined and was detected in joint capsules after as little as I year of treatment.
Collapse
Affiliation(s)
- K L Dalziel
- Department of Dermatology, Slade Hospital, Oxford, U.K
| | | | | | | | | |
Collapse
|
42
|
Fagan E, Yousef G, Brahm J, Garelick H, Mann G, Wolstenholme A, Portmann B, Harrison T, Mowbray JF, Mowat A. Persistence of hepatitis A virus in fulminant hepatitis and after liver transplantation. J Med Virol 1990; 30:131-6. [PMID: 2156006 DOI: 10.1002/jmv.1890300210] [Citation(s) in RCA: 61] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
A peroxidase-labelled, specific mouse monoclonal antibody to hepatitis A virus (HAV) and an in situ hybridization technique (streptavidin-biotin-horseradish peroxidase reaction) with an HAV-specific cDNA probe (recombinant plasmid pAWHA comprising 1.8 kb of the HAV-specific cDNA, located toward the 3' end of the genome) were used to detect HAV in liver tissues in two patients with fulminant viral hepatitis type A treated by liver transplantation after a protracted (day 40: case 1) and relapsing (day 60: case 2) clinical course. HAV antigens and HAV-specific genomic sequences were detected in the hepatectomy tissues and in serial biopsies of the liver grafts through to final follow-up at 2 months (case 2) or death at 7 months after re-grafting for chronic rejection (case 1). In the fulminant liver parenchyma, numerous degenerating and some surviving hepatocytes were positive and randomly scattered. The immunoperoxidase staining was predominantly cytoplasmic and often granular. The localization of the cDNA probe was predominantly nuclear/perinuclear but was occasionally cytoplasmic. High-titre IgM-anti-HAV antibodies persisted until death (case 1) or resolution (5 months) of an acute hepatitis (case 2), which occurred at 2 months, accompanied by HAV antigen (ELISA), in stool. Intact replicating virus particles must have been present in one or more sites in each case, including extrahepatic locations, with a viraemia as the most likely explanation for subsequent reinfection of the grafts.
Collapse
Affiliation(s)
- E Fagan
- Liver Unit, King's College Hospital, London, England
| | | | | | | | | | | | | | | | | | | |
Collapse
|
43
|
Abstract
Hilus cell abnormalities are uncommon causes of hirsutism with virilization. Although hilus cell tumours have been well described, hilus cell hyperplasia is rare and is poorly defined clinically. We describe three cases of hilus cell hyperplasia and compare them with a case of hilus cell tumour. Both pathologies were associated with increased testosterone and oestradiol secretion. Suppression of testosterone to the 'normal range' in response to exogenous oestrogen was seen only in the cases with hyperplasia; only partial responsiveness was seen in the case with hilus cell tumour. Bilateral oophorectomy offers the potential for cure for both hilus cell hyperplasia and tumour.
Collapse
Affiliation(s)
- A R McLellan
- Department of Pathology, Western Infirmary, Glasgow, UK
| | | | | | | | | | | | | |
Collapse
|
44
|
Abstract
Liver transplantation for metabolic disorders continues to be an expanding field, both in the range of indications and patient numbers. In most large series it accounts for approximately 7% of all adult transplants and 29% of all childhood transplants. As the results of medical therapy are improved so too are the results of liver transplantation, and hence more patients are being considered for the latter therapy. The benefits of this treatment are not only the prolongation of and improvement in the quality of life for the patient, it has also given insight into the basic metabolic defects of many disorders.
Collapse
|
45
|
Burge S, Dalziel K, Mowat A, Ryan T. (15) Elastic fibre damage with low dose pencillamine—a review of 18 patients with rheumatoid arthritis. Br J Dermatol 1988. [DOI: 10.1111/j.1365-2133.1988.tb05389.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
46
|
Abstract
Functional residual capacity was measured in 20 children (aged 3.1-11.2 years) with liver disease. Children with severe liver disease, regardless of diagnosis, had reduced functional residual capacities (less than 80% of expected). Children with alpha-1 antitrypsin deficiency had higher functional residual capacities than those with other hepatic diagnoses. Three children had a functional residual capacity greater than 120% of expected, all had alpha-1 antitrypsin deficiency.
Collapse
Affiliation(s)
- A Greenough
- Department of Child Health, King's College Hospital, London
| | | | | | | | | |
Collapse
|
47
|
Abstract
Bilateral posterior interosseous nerve palsy in a rheumatoid patient is described. Six previous case reports and our experience indicate that steroid injection into the elbow may not produce lasting recovery and may lead to unacceptable delay before surgical decompression. An anterolateral approach for division of the arcade of Frohse is effective in cases with diffuse synovitis; where there is a local cystic swelling a posterolateral approach provides better access. Good recovery of nerve function can be expected after early operation.
Collapse
Affiliation(s)
- S H White
- Nuffield Orthopaedic Centre, Headington, Oxford, England
| | | | | |
Collapse
|
48
|
Abbott CM, McMahon CJ, Kelsey GD, Parkar M, Whitehouse DB, Corney G, Povey S, Hopkinson DA, Mieli-Vergani G, Mowat A. Alpha 1-antitrypsin-related gene (ATR) for prenatal diagnosis. Lancet 1987; 1:1425-6. [PMID: 2884507 DOI: 10.1016/s0140-6736(87)90607-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
|
49
|
Mowat A. NK cell lineage and target specificity: a unifying concept. Immunol Today 1986; 7:191. [PMID: 25290393 DOI: 10.1016/0167-5699(86)90098-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- A Mowat
- Department of Bacteriology and Immunology, Western Infirmary, Glasgow G11 6NT, UK
| |
Collapse
|
50
|
Mowat A. The management of metabolic disorders of the liver. Pediatr Ann 1985; 14:501-4, 506-7. [PMID: 3875072 DOI: 10.3928/0090-4481-19850701-09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
|