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Biomedical subjects

C Royston

Publications and source records attributed to C Royston.

17 recordsLinked to original sources
PubMed2005

Reflux rising! An essay on witnessing a disease in evolution.

BACKGROUND AND AIM: The prevalence of gastro-oesophageal reflux disease is thought to be rising but supporting evidence is sparse. We assessed trends from data prospectively collected over 25 years at our centre which serves Rotherham's 250000 population. PATIENTS AND METHODS: Detailed computerised records have been kept of all patients investigated for upper gastrointestinal symptoms. DEFINITION: Erosive oesophagitis=endoscopy-verified erosive changes. Non-erosive reflux=heartburn+/-regurgitation but normal endoscopy. Gastro-oesophageal reflux disease=erosive oesophagitis+non-erosive reflux, i.e. total. RESULTS: The data, presented in 5-year time periods spanning 1977-2001, showed four major changing trends. (1) The numbers with newly diagnosed gastro-oesophageal reflux disease rose markedly, affecting both erosive oesophagitis and non-erosive reflux. Gastro-oesophageal reflux disease: n=714; 1587; 2381; 3812; 3880. (2) The proportion of women affected rose from 0.36 to 0.82. (3) Gastro-oesophageal reflux disease patients were older than the general population; the mean age at presentation rose from 48.0 to 53.5 years. (4) Presentation with haemorrhage (percentage of erosive oesophagitis) rose from 5.2% to 10.9% but, as with stricture (around 4%), remained uncommon. Throughout, few (4.4%) changed from non-erosive reflux to erosive oesophagitis. CONCLUSION: The marked increase in gastro-oesophageal reflux disease cannot be accounted for by greater awareness alone for the demographic profile has changed, or by misclassification as erosive oesophagitis was diagnosed on endoscopic appearances. The dramatic five-fold increase in gastro-oesophageal reflux disease is a new phenomenon, perhaps an example of a disease in evolution.

Aged↗
PubMed2004

Admission rates for peptic ulcer in the trent region, UK, 1972--2000. changing pattern, a changing disease?

BACKGROUND AND AIM: Peptic ulcer disease is believed to be less common and less severe as a result of modern medical treatment. We therefore examined changes in the admission rates for patients with duodenal ulcer and gastric ulcer, both emergency (for haemorrhage, perforation or severe pain) and for elective surgery, before and since the introduction of the new advances in therapy. These admission indices reflect disease prevalence and severity. PATIENTS AND METHODS: We identified admission rates during 1972--2000 within the Trent Regional Health Authority, UK (population 4.7 million), from computerised patient information using diagnostic search codes ICD8-10 and expressed as rates per million resident population. Drug expenditure details were obtained from the Department of Health. RESULTS: Emergency admission rates as a whole changed little, a decline in the young being offset by an increase in the elderly. Haemorrhage was the most common reason (approximately 115 per million for duodenal ulcer and 87 for gastric ulcer) throughout [compared with perforation (80 and 21) and pain (90 and 68)]. In contrast, elective surgery has almost disappeared; this reduction began before the introduction of modern treatment. CONCLUSION: Emergency admission rates for duodenal and gastric ulcer for complications or severe pain have fluctuated over the last three decades but with little overall change. In contrast, elective surgery has declined dramatically, as a result of advances in treatment but also from changes in the natural history.

Adult↗
PubMed2003

Oesophageal acid-peptic strictures in the histamine H2 receptor antagonist and proton pump inhibitor era.

BACKGROUND AND AIM: We present a survey on the incidence, demography and natural history (re-dilatation rates) of patients with oesophageal acid-peptic stricture seen between 1977 and 1995. PATIENTS AND METHODS: Prospective, cohort observational study. Stricture severity was graded mild, moderate or severe (needing forcible dilatation with bougies). Most were treated with histamine H2 receptor antagonists or proton pump inhibitors, and were followed up by serial check endoscopy. RESULTS: A total of 156 of 7429 (2%) reflux patients had stricture: mild, n=56; moderate, n=25; severe, n=75. The prevalence of reflux disease is rising, paralleled by an increase in the number of patients with stricture; hence the incidence of stricture is unchanged: 1977-1982, 1.8% (18/986); 1983-1989, 2.4% (61/2595); 1990-1995, 2% (77/3848). Demography: mean age 68 years; mean length of reflux history 6.4 years; 15% on non-steroidal anti-inflammatory drugs/aspirin; 18% with Barrett's metaplasia. Mean follow-up: 5.6 years. OUTCOME: of the 75 with severe stricture, 36 (48%) needed forcible dilatation only once, and 39 more often (13 twice, nine three times), most within 2 years. Only six of these patients need > or = 6 re-dilatations. CONCLUSION: The incidence of stricture is low and remains unchanged, despite the increased prevalence of reflux disease. Most patients have a good prognosis, only half needing further forcible dilatation, mainly within the first 2 years.

Adult↗
PubMed2003

History in our lifetime: the changing nature of refractory duodenal ulcer in the era of histamine H2 receptor antagonists.

BACKGROUND AND AIM: This prospective cohort observational study, set in a district hospital, presents our experience (1976-1993) of duodenal ulcer refractory to histamine H2 receptor antagonists (defined as not healed after 3 months' treatment) and comments on onset, outcome and spontaneous decline. METHODS: Patients were treated mainly with cimetidine, the dose being titrated (up to 3.2 g daily) according to response, and followed by serial check endoscopy and clinical assessment. RESULTS: A total of 782 of the 4032 duodenal ulcer patients seen (19%) were refractory; the incidence declined over time: 1976-1978: 124/379 (33%); 1979-1983: 390/1240 (31%); 1984-1988: 190/1295 (15%); 1989-1993: 78/1118 (7%). A total of 344 were refractory for the first time on their first healing course and 174 on their second. Healing was achieved in two-thirds after a mean of 7 months' treatment with cimetidine 1 g; treatment for 12-18 months with higher doses was needed in the remainder. Relapse occurred in up to three-quarters of patients despite maintenance cimetidine up to 3 g daily. Eventually 47 patients were operated upon but good results (i.e., no ulcer, no symptoms) were achieved in only 11. CONCLUSION: Refractoriness was common until recently. Its incidence has declined dramatically, the fall preceding the newer more powerful treatment with proton pump inhibitors and with Helicobacter pylori eradication. We suggest this phenomenon is a modern example of a spontaneous change in the natural history of the disease.

Adult↗
PubMed2001

Pseudomembranous esophagitis.

BACKGROUND: Little is known of pseudomembranous esophagitis, a condition of striking endoscopic appearance. Presented here is a description of its nature and outcome. METHOD: Information on all patients with upper GI disease seen in our unit are held in a computerized database that includes presentation, diagnosis (including pseudomembranous esophagitis), treatment, and outcome. RESULTS: Forty-eight patients (mean age 70 years) with pseudomembranous esophagitis were seen over 15 years; 42 were in-patients with various illnesses. At endoscopy, a thin, concentric membrane and/or thick slough covered the distal half and occasionally the entire esophagus. This layer, yellow or blackened, could be peeled away to reveal underlying friable esophageal submucosa. The membrane was composed of fibrinous exudate and inflammatory cells; there was no basement membrane, hence the term pseudomembrane. Patients were treated with histamine H2 receptor antagonists or proton pump inhibitors for about 3 months and followed by endoscopy or clinical observation. All became asymptomatic; the pseudomembrane had disappeared in 32 who underwent follow-up endoscopy. It recurred in 3 of 38 being followed (mean 3.2 years), again associated with another illness requiring hospitalization. The long-term outcome was poor, determined by age and general condition and independent of pseudomembranous esophagitis. Seven patients died within 3 months and 17 during follow-up (mean 42 months, range 5-140 months). CONCLUSION: Pseudomembranous esophagitis is an unusual condition of unknown cause, probably under-reported and associated with systemic illness. It heals rapidly and recurrence is uncommon.

Adolescent↗
PubMed1999

Hepatic artery angiography and embolization for hemobilia following laparoscopic cholecystectomy.

PURPOSE: The effectiveness of angiography and embolization in diagnosis and treatment were assessed in a cohort of patients presenting with upper gastrointestinal hemorrhage secondary to hepatic artery pseudoaneurysm following laparoscopic cholecystectomy. METHODS: Over a 6-year period 1513 laparoscopic cholecystectomies were carried out in our region. Nine of these patients (0.6%) developed significant upper gastrointestinal bleeding, 5-43 days after surgery. All underwent emergency celiac and selective right hepatic artery angiography. All were treated by coil embolization of the right hepatic artery proximal and distal to the bleeding point. RESULTS: Pseudoaneurysms of the hepatic artery adjacent to cholecystectomy clips were demonstrated in all nine patients at selective right hepatic angiography. In three patients celiac axis angiography alone failed to demonstrate the pseudoaneurysm. Embolization controlled hemorrhage in all patients with no further bleeding and no further intervention. One patient developed a candidal liver abscess in the post-procedure period. All patients are alive and well at follow-up. CONCLUSION: Selective right hepatic angiography is vital in the diagnosis of upper gastrointestinal hemorrhage following laparoscopic cholecystectomy. Embolization offers the advantage of minimally invasive treatment in unstable patients, does not disrupt recent biliary reconstruction, allows distal as well as proximal control of the hepatic artery, and is an effective treatment for this potentially life-threatening complication.

Adult↗
PubMed1999

Giant gastric ulcer: its natural history and outcome in the H2RA era.

OBJECTIVE: The aim of this paper is to study the natural history and outcome of medical treatment of giant gastric ulcer in the histamine H2-receptor antagonist era. METHODS: All patients with gastric ulcer were prospectively followed. We assessed the special features (in particular, demography and treatment outcome) in patients with giant gastric ulcer, defined as ulcers large enough to occupy at least one wall. RESULTS: Between 1976 and 1991, 537 patients with gastric ulcer were seen, of whom 129 (24%) had giant gastric ulcer. Giant gastric ulcer patients were significantly older (p < 0.05) than patients with smaller ulcers and had more aggressive disease, reflected by a higher incidence of bleeding, anorexia, weight loss, and emergency admission. More giant gastric ulcers were located in the body of the stomach and a higher proportion looked malignant. Four of 129 patients died immediately (bleed n = 3, unrelated cause n = 1), 15 had urgent surgery (bleed n = 11, perforation n = 2, suspected cancer n = 2) and 110 were treated medically, mainly with cimetidine 1 g daily. Healing occurred in 97 of 110 (88%), including 14 of 15 with refractory disease, i.e., healing took >3 months and/or needed cimetidine 2-3 g daily. Of the remaining 13 patients, six died (from unrelated causes), three had surgery for failed medical treatment, two defaulted, and two were still on treatment (one with refractory ulcer). Refractoriness was more common in patients with associated major medical illness (42% vs 12%, p < 0.01) or with giant gastric ulcers that looked malignant although they were benign (53% vs 21%, p < 0.01). Relapse off treatment was higher (13 of 26) than on maintenance treatment with cimetidine 0.4-2 g daily (14 of 70). Complications occurred in six patients: four off treatment and two on maintenance treatment. Only two giant gastric ulcers finally proved to be malignant. Of the 129 patients, 47 (36%) died, 14 within 3 months (two from bleeding, three postoperatively, nine from unrelated causes) and 33 later (two with gastric cancer and 31 from unrelated causes). CONCLUSIONS: Giant gastric ulcer is uncommon. Patients are more seriously ill than those with smaller ulcers. Most giant gastric ulcers heal with histamine H2-receptor antagonist treatment. The condition is a marker of poor general health, reflected by the high long term mortality.

Adult↗
PubMed1998

The outcome of bleeding duodenal ulcer in the era of H2 receptor antagonist therapy.

We studied 2119 patients presenting with duodenal ulcer as sole lesion, in the period 1976-1993, the era of H2 receptor antagonist (H2RA) therapy, prior to the introduction of Helicobacter pylori eradication. We used clinical assessment and serial check endoscopy to investigate the incidence of bleeding at presentation (group I, n = 286, 13.5%), the long-term outcome in this group and in that presenting with pain alone (group II, n = 1833, 87%) with respect to ulcer recurrence and bleeding, and the effect of H2RA maintenance therapy. Most patients were treated with H2RA, principally cimetidine. In group I, seven patients died early on; 38 had urgent surgery, of whom six died post-operatively. The remainder were treated; five immediately re-bled, of whom three were operated on. On follow-up, 98/227 group I patients relapsed, 21 (21%) of whom rebled. Relapse in group II was 1017/1668, with only 42 (4%) bleeding (p < 0.001). In patients without maintenance treatment, relapse was markedly higher (50/78 group I, 529/742 group II), but group II still bled significantly less (20% group I vs. 3% group II). Relapse on maintenance was: 48/149 with five (10%) rebleeding in group I, and 488/926 with five (1%) bleeding in group II (p < 0.001). Despite the introduction of H2RA therapy, patients presenting with haemorrhage still have a risk of bleeding at ulcer relapse about 7-fold higher than that for those presenting with pain alone.

Abdominal Pain↗
PubMed1996

11 beta-hydroxylase deficiency: management of a difficult case by laparoscopic bilateral adrenalectomy.

A 14-year-old girl presented with short stature and progressive virilization. She had not undergone the menarche. On investigation, she had elevated testosterone, androstenedione, dihydroepiandrosterone sulphate and 17 alpha-hydroxyprogesterone levels, which were all suppressed by overnight dexamethasone to within their normal ranges. An initial diagnosis of 21-hydroxylase deficiency was revised to 11 beta-hydroxylase deficiency after a tetracosactrin stimulation test, which showed only a modest rise in 17 alpha-hydroxyprogesterone level (from 92 nmol/l at baseline to 133 nmol/l at 60 minutes) and measurement of the basal 11-deoxycortisol, which was grossly elevated. Treatment with dexamethasone 0.5 mg nocte resulted in suppression of androgens in the daytime, but not in the evening, particularly androstenedione. Treatment with hydrocortisone 10 mg b.d. failed to suppress testosterone or androstenedione over a 24-hour period. Addition of cyproterone and oestrogen supplements had no effect and significant virilization persisted. Laparoscopic bilateral adrenalectomy was therefore performed as definitive treatment and resulted in remarkable clinical and biochemical improvement. This case illustrates difficulties in correct diagnosis, choice of appropriate steroid regimen and monitoring efficacy of treatment in congenital adrenal hyperplasia due to 11 beta-hydroxylase deficiency. More aggressive management with earlier bilateral adrenalectomy may be appropriate in selected cases.

Adolescent↗
PubMed1996

The management of refractory gastric ulcer using H2-receptor antagonists.

BACKGROUND: There is little information on the natural history of refractory gastric ulcer, defined as non-healing on cimetidine > or = 1 g daily given for at least 3 months. SETTING: A district general hospital serving an industrial population. METHODS: Patients with refractory gastric ulcer had their treatment extended and/or the dose increased, and upon healing the majority were put on maintenance treatment with cimetidine 400 mg nightly or 1 g daily and their progress was followed. RESULTS: Of 536 patients with gastric ulcer, 74 (14%) were refractory. Fifty of the 74 (68%) refractory gastric ulcer patients were refractory on their very first course of cimetidine. They had no distinguishing demographic features. Healing occurred in 62 patients (84%) after a mean treatment period of 11.1 months; 28 patients required cimetidine > or = 2 g daily. Eleven of 23 (48%) patients relapsed on maintenance with cimetidine 400 mg compared with seven of 24 (29%) on 1 g daily. A total of 22 out of 62 (35%) relapsed; nine had a second refractory recurrence but none thereafter. Eleven patients were operated upon, seven for failed medical treatment. Only two patients eventually proved to have malignant disease. CONCLUSIONS: Refractory gastric ulcer is uncommon, transient and rarely malignant. Most patients can be satisfactorily managed medically.

Adult↗
PubMed1995

Quantitative study of synaptophysin immunoreactivity of cerebral cortex and spinal cord in motor neuron disease.

Synaptophysin immunoreactivity can be quantified by image analysis to evaluate loss of presynaptic terminals in human neurodegenerative diseases. The extent and regional distribution of such loss is reported in motor neuron disease (MND). Autopsy samples of spinal cord and cerebral cortex were examined from 28 cases of MND and 28 age and sex matched controls. The MND group included individuals with amyotrophic lateral sclerosis (17[ALS]), and progressive muscular atrophy (11[PMA]). In the spinal cord, there was significant reduction of presynaptic terminals in the lateral ventral horn (15%) in both the ALS (p < 0.01) and PMA (p < 0.05) groups. Perisomatic synaptophysin profiles on lower motor neurons are preserved late in the disease and are not related to corticospinal innervation. Less marked presynaptic loss was demonstrable more widely in the medial ventral, intermediate and dorsal spinal grey matter (10%) in both ALS (p = 0.03) and PMA (p = 0.05). In the cerebral cortex no synaptic loss was demonstrated in motor or anterior cingulate regions in any of the MND cases. Spinal degeneration in MND is associated with loss of presynaptic terminals in all grey matter regions. It is most marked in the limb motor neuron area and is independent of corticospinal tract degeneration. The cerebral pathology of ALS is not associated with significant loss of presynaptic terminals in the cortical areas studied.

Adult↗
PubMed1987

Sodium dependent D-[3H]aspartate binding in cerebral cortex in patients with Alzheimer's and Parkinson's diseases.

The sodium dependent binding of D-[3H]aspartate to the high-affinity glutamate uptake system was used as a marker of glutamate-releasing terminals in the cerebral cortex of brains from patients with Alzheimer-type dementia (ATD) and Parkinson's disease (PD). Sodium-dependent D-[3H]aspartate binding was reduced in the ATD patients but not in the PD patients. Within the PD patients no association was observed between sodium-dependent D-[3H]aspartate binding and the presence of dementia. In contrast choline acetyltransferase activity was reduced in both the ATD and the PD patients. The present results suggest that changes in the cortical cholinergic system can occur independently of the cortical glutamate system. The glutamatergic deficit in ATD may contribute to some of the clinical differences between the dementia of ATD and PD.

Aged↗
PubMed1985

A follow-up study of accident neurosis.

Thirty five claimants with accident neurosis, in which there were gross perplexing somatic symptoms without demonstrable organic pathology were traced and followed-up in their homes, from one to seven years after compensation was received. Few claimants recovered and such recovery as did take place was unrelated to the time of compensation. Family processes leading to over-protection by relatives were examined and appeared to be vitally important in the prolongation of symptoms. The legal process and the delays involved caused great distress.

Accidents↗