Glasgow Victoria Infirmary

BACKGROUND: The eradication of Helicobacter pylori infection is beneficial in patients with gastric or duodenal ulcers. The value of eradicating the infection in patients with dyspepsia and no evidence of ulcer disease is not known. METHODS: We performed a randomized, placebo-controlled trial comparing the efficacy of treatment for two weeks with 20 mg of omeprazole orally twice daily, 500 mg of amoxicillin three times daily (with 500 mg of tetracycline three times daily substituted for amoxicillin in patients allergic to penicillin), and 400 mg of metronidazole three times daily (160 patients) with that of omeprazole alone (158 patients) for resolving symptoms of dyspepsia in patients with H. pylori infection but no evidence of ulcer disease on upper gastrointestinal endoscopy. Symptoms were assessed with the Glasgow Dyspepsia Severity Score, with resolution of symptoms defined as a score of 0 or 1 in the preceding six months (maximal score, 20). One year later the patients were assessed to determine the frequency of the resolution of symptoms. RESULTS: One month after the completion of treatment, 132 of 150 patients (88 percent) in the group assigned to received omeprazole and antibiotics had a negative test for H. pylori, as compared with 7 of 152 (5 percent) in the group assigned to receive omeprazole alone. One year later, dyspepsia had resolved in 33 of 154 patients (21 percent) in the group given omeprazole and antibiotics, as compared with 11 of 154 (7 percent) in the group given omeprazole alone (95 percent confidence interval for the difference, 7 to 22 percent; P<0.001). Among the patients in the group given omeprazole and antibiotics, the symptoms resolved in 26 of the 98 patients (27 percent) who had had symptoms for five years or less, as compared with 7 of the 56 patients (12 percent) who had had symptoms for more than five years (P=0.03). CONCLUSIONS: In patients with H. pylori infection and nonulcer, or functional, dyspepsia, treatment with omeprazole and antibiotics to eradicate the infection is more likely to resolve symptoms than treatment with omeprazole alone.

AIMS: To assess mortality in patients with diabetes incident under the age of 30 years. METHODS: A cohort of 23 752 diabetic patients diagnosed under the age of 30 years from throughout the United Kingdom was identified during 1972-93 and followed up to February 1997. Following notification of deaths during this period, age- and sex-specific mortality rates, attributable risks and standardized mortality rates were calculated. RESULTS: The 23 752 patients contributed a total of 317 522 person-years of follow-up, an average of 13.4 years per subject. During follow-up 949 deaths occurred in patients between the ages of 1 and 84 years, 566 in males and 383 in females. All-cause mortality rates in the patients with diabetes exceeded those in the general population at all ages and within the cohort were higher for males than females at all ages except between 5 and 15 years. The relative risk of death (standardized mortality ratio, SMR), was higher for females than males at all ages, being 4.0 (95% CI 3.6-4.4) for females and 2.7 (2.5-2.9) for males overall, but reaching a peak of 5.7 (4.7-7.0) in females aged 20-29, and of 4.0 (3.1-5.0) in males aged 40-49. Attributable risks, or the excess deaths in persons with diabetes compared with the general population, increased with age in both sexes. CONCLUSIONS: This is the first study from the UK of young patients diagnosed with diabetes that is large enough to calculate detailed age-specific mortality rates. This study provides a baseline for further studies of mortality and change in mortality within the United Kingdom.

BACKGROUND AND PURPOSE: The modified Rankin Scale (mRS) is widely used to assess global outcome after stroke. The aim of the study was to examine rater variability in assessing functional outcomes using the conventional mRS, and to investigate whether use of a structured interview (mRS-SI) reduced this variability. METHODS: Inter-rater agreement was studied among raters from 3 stroke centers. Fifteen raters were recruited who were experienced in stroke care but came from a variety of professional backgrounds. Patients at least 6 months after stroke were first assessed using conventional mRS definitions. After completion of initial mRS assessments, raters underwent training in the use of a structured interview, and patients were re-assessed. In a separate component of the study, intrarater variability was studied using 2 raters who performed repeat assessments using the mRS and the mRS-SI. The design of the latter part of the study also allowed investigation of possible improvement in rater agreement caused by repetition of the assessments. Agreement was measured using the kappa statistic (unweighted and weighted using quadratic weights). RESULTS: Inter-rater reliability: Pairs of raters assessed a total of 113 patients on the mRS and mRS-SI. For the mRS, overall agreement between raters was 43% (kappa=0.25, kappa(w)=0.71), and for the structured interview overall agreement was 81% (kappa=0.74, kappa(w)=0.91). Agreement between raters was significantly greater on the mRS-SI than the mRS (P<0.001). Intrarater reliability: Repeatability of both the mRS and mRS-SI was excellent (kappa=0.81, kappa(w) > or =0.94). CONCLUSIONS: Although individual raters are consistent in their use of the mRS, inter-rater variability is nonetheless substantial. Rater variability on the mRS is thus particularly problematic for studies involving multiple raters. There was no evidence that improvement in inter-rater agreement occurred simply with repetition of the assessment. Use of a structured interview improves agreement between raters in the assessment of global outcome after stroke.

This account concerns Alfred Ernest Maylard, 1855-1947, a surgeon of exceptional ability and a man with extraordinary energy and drive. He was appointed to the Victoria Infirmary, Glasgow, when it opened in 1890 and made an outstanding clinical and academic contribution, particularly in abdominal surgery. His organisational talents were remarkable and manifest in his influence not just upon the hospital's developments but also upon Glasgow's medical life in general. In his spare time he was a keen mountaineer and was the driving force behind the formation of the Scottish Mountaineering Club in 1889 and its first secretary and later president. He was a prolific writer in all these fields, his eminence as scientific surgeon being recognised by election to the Fellowship of the Royal Society of Edinburgh and his contribution to mountaineering by the vice-presidency of the Royal Scottish Geographical Society.

A study of 60 patients with oro-facial granulomatosis has been conducted and the clinical presentation of this disorder defined. It encompasses the previously recognised clinical entities of Melkersson—Rosenthal syndrome and cheilitis granulomatosa. The pathological features of the disease are lymphoedema and the presence of multiple non-caseating giant cell granulomata. These granulomata are histologically indistinguishable from those found in both gastrointestinal Crohn's disease and systemic sarcoidosis. Within this series of patients, nine had evidence suggestive of gastrointestinal Crohn's disease, and in six this was confirmed. A diagnosis of sarcoidosis was made in a further two patients. The relationship of oro-facial granulomatosis to these systemic granulomatous diseases is not yet clear. Patients with oro-facial granulomatosis who have gastrointestinal symptoms should be investigated for the presence of gastrointestinal Crohn's disease. Those without symptoms should be investigated for evidence of malabsorption or serological evidence of Crohn's disease. Within the present study, the erythrocyte sedimentation rate, full blood count, corrected whole blood folate, serum albumin and calcium were the most sensitive markers of gastrointestinal involvement. Sarcoidosis should be considered in all patients with oro-facial granulomatosis. The absence of clinical signs suggestive of sarcoidosis, a normal chest radiograph and normal levels of serum angiotensin-converting enzyme makes sarcoidosis unlikely.

Primary biliary cirrhosis (PBC) is a classical autoimmune liver disease for which effective immunomodulatory therapy is lacking. Here we perform meta-analyses of discovery data sets from genome-wide association studies of European subjects (n=2,764 cases and 10,475 controls) followed by validation genotyping in an independent cohort (n=3,716 cases and 4,261 controls). We discover and validate six previously unknown risk loci for PBC (Pcombined<5 × 10(-8)) and used pathway analysis to identify JAK-STAT/IL12/IL27 signalling and cytokine-cytokine pathways, for which relevant therapies exist.

Summary Aims To measure cause‐specific mortality, by age, in patients with insulin‐treated diabetes incident at a young age. Methods A cohort of 23 752 patients with insulin‐treated diabetes diagnosed under the age of 30 years, from throughout the United Kingdom, was identified during 1972–93 and followed to February 1997. Death certificates have been obtained for deaths during the follow‐up period and cause‐specific mortality rates and standardized mortality ratios by age and sex are reported. Results During the follow‐up period 949 deaths occurred and at all ages mortality rates were considerably higher than in the general population. Acute metabolic complications of diabetes were the greatest single cause of excess death under the age of 30 years. Cardiovascular disease was responsible for the greatest proportion of the deaths from the age of 30 years onwards. Conclusions Deaths in patients with diabetes diagnosed under the age of 30 have been reported and comparisons drawn with mortality in the general population. To reduce these deaths attention must be paid both to the prevention of acute metabolic deaths and the early detection and treatment of cardiovascular disease and associated risk factors.

UNLABELLED: Current therapy for preventing the first variceal bleed includes beta-blocker and variceal band ligation (VBL). VBL has lower bleeding rates, with no differences in survival, whereas beta-blocker therapy can be limited by side effects. Carvedilol, a non-cardioselective vasodilating beta-blocker, is more effective in reducing portal pressure than propranolol; however, there have been no clinical studies assessing the efficacy of carvedilol in primary prophylaxis. The goal of this study was to compare carvedilol and VBL for the prevention of the first variceal bleed in a randomized controlled multicenter trial. One hundred fifty-two cirrhotic patients from five different centers with grade II or larger esophageal varices were randomized to either carvedilol 12.5 mg once daily or VBL performed every 2 weeks until eradication using a multibander device. Seventy-seven patients were randomized to carvedilol and 75 to VBL. Baseline characteristics did not differ between the groups (alcoholic liver disease, 73%; median Child-Pugh score, 8; median age, 54 years; median follow-up, 20 months). On intention-to-treat analysis, carvedilol had lower rates of the first variceal bleed (10% versus 23%; relative hazard 0.41; 95% confidence interval 0.19-0.96 [P = 0.04]), with no significant differences in overall mortality (35% versus 37%, P = 0.71), and bleeding-related mortality (3% versus 1%, P = 0.26). Six patients in the VBL group bled as a result of banding ulcers. Per-protocol analysis revealed no significant differences in the outcomes. CONCLUSION: Carvedilol is effective in preventing the first variceal bleed. Carvedilol is an option for primary prophylaxis in patients with high-risk esophageal varices.

BACKGROUND: Brief interventions involve a time-limited intervention focusing on changing behaviour. They are often motivational in nature using counselling skills to encourage a reduction in alcohol consumption. OBJECTIVES: To determine whether brief interventions reduce alcohol consumption and improve outcomes for heavy alcohol users admitted to general hospital inpatient units. SEARCH STRATEGY: We searched the Cochrane Drug and Alcohol Group Register of Trials (March 2011) the Cochrane Central Register of Controlled Trials (The Cochrane Library March 2011), MEDLINE January 1966-March 2011, CINAHL 1982-March 2011, EMBASE 1980-March 2011 and www.clinicaltrials.gov to April 2011 and performed some relevant handsearching. SELECTION CRITERIA: All prospective randomised controlled trials and controlled clinical trials were eligible for inclusion. Participants were adults and adolescents (16 years or older) admitted to general inpatient hospital care for any reason other than specifically for alcohol treatment and received brief interventions (of up to 3 sessions) compared to no or usual care. DATA COLLECTION AND ANALYSIS: Three reviewers independently selected the studies and extracted data. Where appropriate random effects meta-analysis and sensitivity analysis were performed. MAIN RESULTS: Forteen studies involving 4041 mainly male participants were included. Our results demonstrate that patients receiving brief interventions have a greater reduction in alcohol consumption compared to those in control groups at six month, MD -69.43 (95% CI -128.14 to -10.72) and nine months follow up, MD -182.88 (95% CI -360.00 to -5.76) but this is not maintained at one year. Self reports of reduction of alcohol consumption at 1 year were found in favour of brief interventions, SMD -0.26 (95% CI -0.50 to -0.03). In addition there were significantly fewer deaths in the groups receiving brief interventions than in control groups at 6 months, RR 0.42 (95% CI 0.19 to 0.94) and one year follow up, RR 0.60 (95% CI 0.40 to 0.91). Furthermore screening, asking participants about their drinking patterns, may also have a positive impact on alcohol consumption levels and changes in drinking behaviour. AUTHORS' CONCLUSIONS: The main results of this review indicate that there are benefits to delivering brief interventions to heavy alcohol users admitted to general hospital wards in terms of reduction in alcohol consumption and death rates. However, these findings are based on studies involving mainly male participants. Further research is required determine the optimal content and treatment exposure of brief interventions within general hospital settings and whether they are likely to be more successful in patients with certain characteristics.

We have detected a novel mitochondrial mutation in a maternal pedigree, at least 13 of whose members have sensorineural hearing loss of varying severity, but who exhibit no other pathological features. The mutation, at np 7445, converts the 3' terminal T residue of tRNA-ser(UCN) to a C, and also brings about a silent alteration to the COI stop codon. The mutation destroys an XbaI site, within which a second mutation, at np 7444, has previously been reported in association with Leber's hereditary optic neuropathy. Predominantly mutant mtDNA was found in all 13 family members surveyed, whether or not they are overtly affected by deafness, and some individuals appeared homoplasmic, within the limits of detection. The novel mutation was not found in over 600 normal controls, nor in any of 27 other maternally unrelated individuals with deafness Other mutations found in mitochondrial disorders were also absent from this pedigree.

A randomised, double-blind study of patients after upper abdominal surgery was undertaken to assess the analgesic efficacy of ketorolac tromethamine, a new, parenteral non-steroidal anti-inflammatory agent. Postoperatively, patients received a 24-hour intramuscular infusion of either saline (n = 20), ketorolac 1.5 mg/hour (n = 21) or ketorolac 3.0 mg/hour (n = 20). Cumulative morphine requirements were measured using a patient-controlled analgesia system which delivered intravenous increments of morphine on demand. Pain was assessed by visual analogue scores. Arterial blood gas analyses were performed pre-operatively and on the first postoperative day. Patients who received low and high dose ketorolac infusions required less morphine than the control group (p less than 0.05 and p = 0.06, respectively). This was associated with significantly lower pain scores. Patients who received the higher ketorolac dose had significantly less postoperative increase in arterial carbon dioxide tensions than controls. This study suggests that ketorolac tromethamine is a useful analgesic drug with significant morphine sparing properties.

5671 patients with injuries presenting to a busy eye casualty department were examined prospectively to determine the incidence, aetiology, and severity of the injury. Of these cases 69.9% occurred at work, 18.3% during leisure and domestic activities (excluding recognised sport), 2.3% during sport, and 1.9% were due to assaults; contact lens injury occurred in a further 2.3%, and the cause was unknown in 5.3%. One hundred and two (1.8%) patients required admission to hospital, and of their injuries 13.7% occurred at work, 22.6% during leisure and domestic activities, 42.2% at sport, 18.6% during assault, and 2.9% from an unknown cause. Children under 10 years of age accounted for 4% of the total patients presenting, but for more than 18% of those admitted and 26% of ocular penetrations. 98.3% of all injuries involved periorbital or superficial ocular structures only. The remainder involved intraocular structures. The majority of serious injuries were contusional. There was only one case of intraocular foreign body. This indicates that, while most injuries still occur in the workplace, sport and leisure activities account for the majority of serious injuries. While most injuries do not threaten sight, they do so disproportionately in children.

Abstract Objective : To evaluate the effect of support from a nurse specialising in breast care and a voluntary support organisation on prevalence of psychological morbidity after surgery for breast cancer. Design : Prospective randomised study. Setting : Three teaching hospitals in Glasgow with established breast clinics. Subjects : 272 women aged less than 70 years undergoing surgery for breast cancer. Interventions : Patients were randomly allocated to receive routine care from ward staff, routine care plus support from breast care nurse, routine care plus support from voluntary organisation, or routine care plus support from nurse and organisation. Main outcome measures : Prevalence of psychological morbidity as assessed by self rating scales: 28 item general health questionnaire and its subscales, and hospital anxiety and depression scale. Measurements were made at first postoperative clinic visit and at three, six, and 12 months after surgery. Results : On each self rating scale, psychological morbidity tended to fall over the 12 month period. For each scale, scores were consistently lower in patients offered support from breast care nurse alone compared with the other groups, which were similar to each other. Differences were significant or nearly so: P values were 0.015 (28 item general health questionnaire), 0.027 (anxiety and insomnia), 0.072 (severe depression), 0.053 (somatic symptoms), 0.031 (social dysfunction), 0.093 (hospital anxiety), and 0.003 (hospital depression). Conclusion : Support from breast care nurse can significantly reduce psychological morbidity, as measured by self rating scales, in women undergoing breast cancer surgery. Key messages Key messages The value of different forms of psychological support for breast cancer patients is uncertain We compared effect of four different types of support for patients undergoing surgery for breast cancer: routine care from ward staff, routine care plus support from specialist breast care nurse, routine care plus support from voluntary organisation, or routine care plus support from nurse and organisation Scores of psychological morbidity were consistently lower in patients offered support from breast care nurse alone compared with the other groups, which were similar to each other Psychological support from an experienced breast care nurse can reduce psychological morbidity in patients undergoing surgery for breast cancer

This study investigated the reliability of simple bedside free-field voice testing in the detection of hearing impairment in patients admitted to a geriatric unit. Sixty-two consecutive admissions were assessed at four graduated levels of loudness by geriatrician and otolaryngologist independently. Pure tone audiometry was then performed blind. Voice testing by both observers was concordant in 88% of all ears and in 100% of ears able to hear a whispered voice (WV) at 2 ft (approximately 0.6 m). The WV at 2 ft was the most discriminant test with a sensitivity of 100%, a specificity of 84% and a predictive value of 92% for hearing impairment likely to benefit from provision of a hearing aid. Free-field voice testing appears a simple, reliable and reproducible test for detecting hearing impairment in elderly patients.

OBJECTIVES: To determine whether routine oral and enteral nutritional supplementation can improve the weight, anthropometry, and survival of adult patients. DESIGN: Systematic review of randomised controlled trials of oral or enteral protein supplementation in adults. Trials were identified from Medline (Silver Platter 3.11, 1966-96), reference lists of identified studies and review articles, and communication with feed manufacturers. SUBJECTS: Randomised controlled trials comparing oral or enteral protein supplementation with no routine supplementation. All trials of adult subjects were included except those addressing nutrition in pregnancy. MAIN OUTCOME MEASURES: Change in body weight and anthropometry (mid-arm muscle circumference), and all cause case fatality recorded at the end of scheduled follow up. Body weight and anthropometry were analysed as the weighted mean difference and 95% confidence intervals of the percentage change in these variables. Case fatality was analysed with odds ratio and 95% confidence intervals. RESULTS: 32 eligible reports (2286 randomised patients) published between February 1979 and July 1996 were identified, of which 30 (93.8%) (2062 randomised patients) reported outcomes of interest. Case fatality data were available for 1670 (81%) patients, and continuous variable data for up to 1607 (78%) patients. The treatment group receiving routine nutritional supplementation showed consistently improved changes in body weight and anthropometry compared with controls; weighted mean difference 2.06% (95% confidence interval 1.63% to 2.49%) and 3.16% (2.43% to 3.89%) respectively. The pooled odds ratio for death in the treatment group was 0.66 (0.48 to 0.91, 2P<0.01). Apparent benefits were observed in several prespecified subgroups of patients, treatment settings, and interventions, but were not evident if trials with less robust methodology were excluded. CONCLUSIONS: Routine oral or enteral supplementation seems to improve the nutritional indices of adult patients, but there are insufficient data in trials which meet strict methodological criteria to be certain if mortality is reduced. Benefits were not restricted to particular patient groups. Further large pragmatic randomised controlled trials of routine nutritional supplementation are justified.

Raised risks of several cancers have been found in patients with type II diabetes, but there are few data on cancer risk in type I diabetes. We conducted a cohort study of 28 900 UK patients with insulin-treated diabetes followed for 520 517 person-years, and compared their cancer incidence and mortality with national expectations. To analyse by diabetes type, we examined risks separately in 23 834 patients diagnosed with diabetes under the age of 30 years, who will almost all have had type I diabetes, and 5066 patients diagnosed at ages 30-49 years, who probably mainly had type II. Relative risks of cancer overall were close to unity, but ovarian cancer risk was highly significantly raised in patients with diabetes diagnosed under age 30 years (standardised incidence ratio (SIR)=2.14; 95% confidence interval (CI) 1.22-3.48; standardised mortality ratio (SMR)=2.90; 95% CI 1.45-5.19), with greatest risks for those with diabetes diagnosed at ages 10-19 years. Risks of cancer at other major sites were not substantially raised for type I patients. The excesses of obesity- and alcohol-related cancers in type II diabetes may be due to confounding rather than diabetes per se.

AIMS: To compare the sensitivity and specificity of percutaneous fine needle aspiration (FNA) cytology and needle core biopsy (NCB) in the diagnosis of suspected intra-abdominal tumours. METHODS: One hundred and forty one consecutive patients who underwent radiologically guided combined FNA/NCB of abdominal lesions over a four year period were reviewed. The diagnostic accuracy of both techniques and the value of rapid staining and assessment of cytological preparations were assessed. RESULTS: FNA cytology and NCB identified 111 of 129 (86%) and 104 of 129 (80.6%) malignant lesions, respectively; in combination, the sensitivity increased to 90.7%. The diagnostic specificity was 100% for both methods, although one case of phaeochromocytoma was misinterpreted as undifferentiated carcinoma on biopsy. More accurate tumour subtying was possible in two cases with FNA and four cases on NCB. The series included 12 benign lesions, of which 11 and nine were accurately identified on FNA and NCB, respectively. Two specific benign diagnoses (Budd-Chiari syndrome and hepatic infarct) were made only on biopsy. The use of rapid assessment cytology preparations ensured that appropriate samples were submitted for microbiology in three liver abscesses, and provided an accurate cytological diagnosis at the time of the procedure in 103 of 141 (73%) cases. None of the patients suffered biopsy related complications. CONCLUSIONS: FNA cytology is more sensitive and accurate than NCB in the diagnosis of abdominal lesions, and also offers more rapid diagnosis. However, the combination of these sampling techniques increases diagnostic sensitivity and occasionally provides more accurate classification of tumours and benign lesions. The techniques should be considered complementary in the investigation of abdominal lesions.

Abstract Excessive gambling is recognized with dopamine agonist therapy, but the prevalence is unknown. We assessed the prevalence of excess gambling by specific prospective enquiry in Parkinson's disease patients attending six West Scotland movement disorder clinics. Of 388 patients taking anti‐Parkinson medication, 17 (4.4%) developed pathological gambling, all of whom were prescribed dopamine agonists. Thus, 8% of patients taking dopamine agonists had pathological gambling. Pathological gambling is not uncommon, and patients should be made aware of this potential adverse effect. © 2006 Movement Disorder Society

Undernutrition of long-stay hospital patients and those in surgical units is well documented. This study was designed to determine the extent of the problem in elderly people admitted to hospital with acute medical problems and to assess the relationship between nutritional status and course of hospital stay. Sixty-nine patients underwent a nutritional assessment on admission and at intervals throughout their hospital stay and episodes of sepsis were documented. Severely malnourished patients were identified using body mass index, BMI (22%) and corrected arm muscle area, CAMA (26%). Episodes of sepsis occurred significantly more often in the severely undernourished group (p < 0.04). The median length of stay of the group was 16 days (range 2-113): during this time there was no significant change in markers of nutritional status apart from actual muscle circumference (AMC), which showed a reduction in measurement between admission and discharge which was statistically significant (p < 0.0003). This study indicated that severe malnutrition is common in elderly medical admissions, and that it is associated with an increased risk of sepsis. Additional nutritional depletion may occur during hospital stay, and is not easily recognized unless anthropometry is undertaken.

Journal Article The mobile micro-architecture of dermal collagen: A bio-engineering study Get access T Gibson, T Gibson Department of Surgery, Western Infirmary, Glasgow Search for other works by this author on: Oxford Academic Google Scholar R M Kenedi, R M Kenedi Department of Bio-Engineering, University of Strathclyde, Glasgow Search for other works by this author on: Oxford Academic Google Scholar J E Craik J E Craik Department of Pathology, Victoria Infirmary, Glasgow Search for other works by this author on: Oxford Academic Google Scholar British Journal of Surgery, Volume 52, Issue 10, October 1965, Pages 764–770, https://doi.org/10.1002/bjs.1800521017 Published: 08 December 2005