PubMed Health⌕ Search

Biomedical subjects

D Churchill

Publications and source records attributed to D Churchill.

At least 19 recordsLinked to original sources
PubMed2007

Management of advanced HIV disease with no other complications in women and in Africans.

The number of patients who present with advanced human immunodeficiency virus (HIV) disease [defined as a helper lymphocyte (CD4) count <50 cells/mm3 or the presence of an acquired immunodeficiency syndrome (AIDS)-defining illness] is increasing. In the USA during 1994-1999, a relatively stable proportion of 43% of people diagnosed with HIV infection were tested late in the infection (had AIDS diagnosed within 1 year of diagnosis). A recent review of newly diagnosed infections in 2003 found that 301/977 (31%) of patients in the UK and Ireland presented late (<200 CD4 cells/mm3). Before a diagnosis is made, patients with advanced disease do not benefit from antiretroviral therapy and may continue to transmit the infection to others. Furthermore, when antiretroviral therapy is initiated in patients with CD4 counts of 201-350 cells/mm(3), the risk of death is lower than when treatment is started at lower CD4 cell counts. With the increasing prevalence of HIV in women and African immigrants, some doctors are concerned that different management approaches need to be used in these groups. This article reviews the evidence and some clinical scenarios for patients with advanced disease without complications and women and Africans who may present with advanced HIV disease. The aim is to offer practical advice on therapeutic options for treatment-naïve patients who present with advanced HIV disease on the basis of available clinical evidence.

Africa↗
PubMed2005

Antenatal diagnosis of fetal renal calculus.

Pediatric urolithiasis is commonly associated with structural renal tract anomalies and metabolic disorders. Antenatal diagnosis of renal calculi is extremely rare, with only one report in the literature. We present a case of renal stone formation diagnosed at 34 weeks' gestation on ultrasound examination.

Adult↗
PubMed2003

A further case of confined placental mosaicism for trisomy 2 associated with adverse pregnancy outcome.

OBJECTIVES: To add to the knowledge base concerning confined placental mosaicism for trisomy 2. METHODS: Cytogenetic study of a late CVS referred for hyperechogenic bowel and raised AFP, and cytogenetic and molecular genetic study of a follow-up amniocentesis. Ultrasound monitoring at regular intervals following the CVS result. RESULTS: All cells examined from direct and cultured CVS showed a 47,XY,+2 karyotype. Amniocentesis showed a mosaic 47,XY,+2[8]/46,XY[81] karyotype. Uniparental disomy (UPD) studies on the amniotic fluid showed normal biparental inheritance. The pregnancy developed oligohydramnios and IUGR and resulted in a 26-week liveborn male infant with a 46,XY karyotype, which died after 3 days because of complications of severe prematurity. Placental villi post delivery showed only the 47,XY,+2 cell line. CONCLUSIONS: This case represents a further example of confined placental mosaicism (CPM) for trisomy 2 associated with oligohydramnios, IUGR and poor pregnancy outcome.

Adult↗
PubMed2003

Pharmacological treatment of hypertension in pregnancy.

The hypertensive disorders of pregnancy complicate 5-10% of pregnancies. Of these disorders 70% are pregnancy related (preeclampsia-eclampsia and gestation hypertension) and 30 % are a pre-existing hypertensive condition (chronic hypertension). These disorders are associated with maternal and fetal complications and have a substantial economic impact. This review examined the pharmacological treatment of the hypertensive disorders of pregnancy. There is a general consensus that anti-hypertensive should be given with severe hypertension and this should be in the hospital. The value of antihypertensive drugs in pregnant women with mild hypertension continues to be an area of debate that the evidence is too scanty to securely evaluate the clinical benefits of treating mild hypertension during pregnancy. The choice of the antihypertensive agents depends on individual clinician preference, the specified maternal and foetal benefits and the reproductive complications (teratogenisity, fetotoxicity and neonatal toxicity) of each particular agent. There are unequivocal evidences that Magnesium sulphate is superior to other agents in reducing recurrent eclamptic seizures. There is a strong recent evidence recommended that magnesium sulphate should be considered for women with pre-eclampsia for whom there is concern about the risk of eclampsia.

Antihypertensive Agents↗
PubMed2002

Interventionist versus expectant care for severe pre-eclampsia before term.

BACKGROUND: Severe pre-eclampsia can cause significant mortality and morbidity for both mother and child, particularly when it occurs well before term. The only known cure for this disease is delivery. Some obstetricians advocate early delivery to prevent the development of serious maternal complications, such as eclampsia (fits) and kidney failure. Others prefer a more expectant approach in an attempt to delay delivery and, hopefully, reduce the mortality and morbidity for the child associated with being born too early. OBJECTIVES: The objective of the review was to compare the effects of a policy of interventionist care and early delivery with a policy of expectant care and delayed delivery for women with early onset severe pre-eclampsia. SEARCH STRATEGY: We search the register of trials maintained by the Cochrane Pregnancy and Childbirth Group (April 2002) and the Cochrane Controlled Trials Register (The Cochrane Library, Issue 2, 2002). SELECTION CRITERIA: Randomised trials comparing the two intervention strategies for women with early onset severe pre-eclampsia. DATA COLLECTION AND ANALYSIS: Trial quality was assessed using the criteria set out in the Cochrane Reviewers' Handbook. Data were extracted and checked independently by both reviewers. MAIN RESULTS: Two trials (133 women) are included in this review. There are insufficient data for reliable conclusions about the comparative effects on outcome for the mother. For the baby, there is insufficient evidence for reliable conclusions about the effects on stillbirth or death after delivery (relative risk (RR) 1.50, 95% confidence interval (CI) 0.42 to 5.41). Babies whose mothers had been allocated to the interventionist group had more hyaline membrane disease (RR 2.3, 95% CI 1.39 to 3.81), more necrotising enterocolitis (RR 5.5, 95% CI 1.04 to 29.56) and were more likely to need admission to neonatal intensive care (RR 1.32, 95% CI 1.13 to 1.55) than those allocated an expectant policy. Nevertheless, babies allocated to the interventionist policy were less likely to be small for gestational age (RR 0.36, 95% CI 0.14 to 0.90). There were no statistically significant differences between the two strategies for any other outcomes. REVIEWER'S CONCLUSIONS: There are insufficient data for any reliable recommendation about which policy of care should be used for women with severe early onset pre-eclampsia. Further large trials are needed.

Delivery, Obstetric↗
PubMed2002

The 'Severe Hypertensive Illness in Pregnancy' (SHIP) audit: promoting quality care using a high risk monitoring chart and eclampsia treatment pack.

We set out to measure the standards of care in a regional cohort of women with severe hypertensive illness of pregnancy and to subsequently improve the quality of care using a series of interventions. This was a multi centre cyclical criterion audit involving 21 maternity units in the West Midlands Region. Prospective data collection involved named co-ordinators in each unit using customised proformas. Intervention comprised feedback of baseline results to each hospital, a monitoring chart and eclampsia treatment pack. The first audit period (n = 183) was for a 4-month period between 1/9/96 and 31/12/96 and the second audit period (n = 111) was during the same 4-month period 1 year later. Although compliance with the audit standards set increased in all but one standard, there is clearly a need to make further improvements in the quality of care administered.

Adult↗
PubMed2002

Anti-hypertensive drugs in pregnancy and fetal growth: evidence for "pharmacological programming" in the first trimester?

OBJECTIVES: To determine the timing and exact nature of the effect of the drug atenolol upon fetal growth. Also to discover if the reduction in fetal growth is due to superimposed pre-eclampsia or any other confounding variable. DESIGN: A retrospective cohort study of prospectively collected data in a hypertensive pregnancy database. SETTING: Two district general hospitals in the midlands of England. Both hospitals have specialised medical antenatal clinics for pregnant women with chronic hypertension. PARTICIPANTS: 491 pregnancies in 380 women with essential or secondary hypertension. OUTCOME MEASURES: The outcome measures used were the infant birth weight, birth weight standardized for gestational age, and the ponderal index at birth, a surrogate measure for in utero growth restriction. RESULTS: The babies of women taking atenolol at conception or during the first trimester had significantly lower birth weights (by 139-512 g, p<0.01) than women on calcium channel blockers or no medication. Likewise the ponderal index was also significantly reduced, p<0.01. In addition most of these babies were small for gestational age (SGA) with 70% on or below the 10th centile and 40% below the third centile. No such independent association was seen with anti-hypertensives taken in the second trimester. CONCLUSIONS: Atenolol taken at the time of conception and/or during the first trimester of pregnancy was associated with low birth weight. This finding was independent of the development of superimposed pre-eclampsia. Other anti-hypertensives were not found to be associated with low birth weight. Use of atenolol in the second trimester of pregnancy did not produce the same effect and was not materially different in its effects from the other anti-hypertensive drugs. In the second trimester, the development of superimposed pre-eclampsia is the over-riding effect in the reduction of infant birth weight. Atenolol used in the first trimester could be pharmacologically programming these infants to restricted growth patterns.

Antihypertensive Agents↗
PubMed2001

Impact of baseline polymorphisms in RT and protease on outcome of highly active antiretroviral therapy in HIV-1-infected African patients.

OBJECTIVE: To assess the therapeutic response and investigate the significance of polymorphic codons in African patients receiving highly-active antiretroviral therapy (HAART). DESIGN AND METHODS: African patients were identified from the St Mary's Hospital HIV-1 database. Clinical outcome was assessed by viral load and CD4 cell count. Pre- and post-therapy sequences of RT and protease were analysed. The impact of subtype and individual polymorphic codons on therapeutic outcome was assessed statistically (Fishers exact and chi2 tests) and phylogenetically (Jukes and Cantor). RESULTS: Of 79 drug-naive African patients who were prescribed HAART, 60 remained undetectable for 1 year, with no differences detected in the clinical response to non-nucleoside reverse transcriptase inhibitor (NNRTI)- or protease inhibitor (PI)-containing regimes. Country of origin, sex and viral subtype had no impact on outcome of HAART. A total of 133 polymorphisms were identified in pol (37 in protease and 96 in RT), with a mean of 9.0 in protease and 22.3 in RT per patient. There was no significant difference in the overall numbers of polymorphisms per patient, and no single polymorphism had any impact on clinical outcome. Sequences from 'failing' patients experiencing viral rebound produced few mutations known to be associated with drug resistance, suggesting minimal drug pressure. CONCLUSIONS: The response of patients infected with African subtypes of HIV-1 to HAART appears to be independent of regime, HIV-1 clade and baseline polymorphisms. Non-B subtypes are fully sensitive to HAART and, accordingly, therapy should not be withheld from African patients for reasons of viral diversity.

Africa↗
PubMed2001

Long-term follow-up of antiretroviral-naive HIV-positive patients treated with nevirapine.

This article reports on the extended follow-up of 125 antiretroviral (ARV)-naive patients treated with nevirapine (NVP) in the United Kingdom. The patients have been observed for a median of 1.8 years after starting NVP (range, 4 days-2.7 years). Baseline CD4 counts and HIV RNA levels were 210 (interquartile range, 130 - 335) cells/mm3 and 4.86 (range, 4.52-5.26) log10 copies/ml, respectively. Eleven patients (9.0%) developed a rash thought to be related to NVP, of whom 4 permanently discontinued NVP. Twenty-four months after starting NVP, RNA levels had dropped by a median of 2.32 log10 copies/ml and CD4 counts increased by a median of 143 cells/mm3. In all, 96 patients had at least one viral load measured <500 copies/ml, a median of 2.8 months after starting NVP. RNA levels rebounded >500 copies/ml in 37 of these patients, on average 2 years after initial response. In conclusion, in ARV-naive patients, NVP is generally well tolerated and long-term response rates are good.

Adult↗
PubMed2001

The West Midlands "Severe Hypertensive Illness in Pregnancy" (SHIP) audit.

OBJECTIVE: To study the management of a series of women presenting with acute-onset hypertension in the 21 maternity units in the West Midlands region, in order to measure the standard of care and the outcomes of these patients and their babies. DESIGN: Multicenter audit. SETTING: Twenty-one Maternity Units in the West Midlands region with 85,658 births during the audit period. METHODS: Prospective data collection by named coordinators (multidisciplinary) in each unit using customized proformas. The proformas were then forwarded to the Research Coordinator for input onto a database and observational analyses. RESULTS: The total number of cases was 516. Eighty-one percent were diagnosed as having severe preeclampsia, 14% HELLP syndrome, and 5% eclampsia. Seven percent were admitted to the intensive therapy unit. Seventy percent of births were preterm, 62% of babies were low birth weight (< 2.5 kg), 57% of babies were admitted to the neonatal unit, and the perinatal mortality rate was 5%. The commonest antihypertensive agents were hydralazine and nifedipine. In terms of compliance with audit standards, 61% had both oxygen saturation and noninvasive blood pressure monitoring, 47% had good fluid balance documentation, and 79% had no fluid mismanagement. Seventy-four percent were seen by a consultant obstetrician, 62% were seen by a member of an "expert team," 83% adhered to local guidelines, and 71% of eclamptics received magnesium sulfate (MgSO4). CONCLUSION: Our study shows that severe hypertensive illness of pregnancy remains an important cause of maternal mortality and perinatal mortality. This audit highlights areas in which standards of care can be improved.

Adult↗
PubMed2000

Association between teenage pregnancy rates and the age and sex of general practitioners: cross sectional survey in Trent 1994-7.

OBJECTIVE: To examine variations in teenage pregnancy rates in Trent region and to determine possible associations with local general practice characteristics such as the age and sex of the doctors. DESIGN: Cross sectional survey. SETTING: All 826 general practices in Trent region in existence between 1994 and 1997. SUBJECTS: All pregnancies of teenagers aged 13 to 19 between 1994 and 1997 that resulted in an admission to an NHS hospital. MAIN OUTCOME MEASURES: Pregnancy rates for teenagers aged 13 to 19 and general practice characteristics: presence of a female or young doctor (under 36 years old), number of whole time equivalent practice nurses, Townsend score, vocational training status, list size per whole time equivalent doctor, fund-holding status, and partnership size. RESULTS: On multivariate analysis, lower teenage pregnancy rates were associated with the presence of a female or young doctor and more nurse time. Practices in deprived areas had higher teenage pregnancy rates. CONCLUSION: General practices with female doctors, young doctors, or more nurse time had lower teenage pregnancy rates. The findings may have implications for the mix of health professionals within primary care.

Abortion, Therapeutic↗
PubMed2000

Reduced thrombus burden with abciximab delivered locally before percutaneous intervention in saphenous vein grafts.

BACKGROUND: Existing thrombus can complicate percutaneous saphenous vein graft (SVG) intervention. Local delivery of thrombolytics has been used to reduce the thrombus burden often associated with these interventions. We sought to determine whether local delivery of a platelet glycoprotein IIb/IIIa inhibitor is feasible and can reduce thrombus burden before percutaneous SVG intervention. METHODS: We performed a multicenter pilot study of abciximab (0.25 mg/kg) given by local delivery catheter before percutaneous intervention for de novo SVG stenoses followed by intravenous infusion. All patients (n = 58) had >/=60% stenosis and Thrombolysis In Myocardial Infarction (TIMI) grade >0 flow in an SVG of 3 to 4 mm in diameter. Percent diameter stenosis, TIMI thrombus grade, and TIMI flow grade were measured before and after delivery of abciximab and after intervention. RESULTS: Median percent diameter stenosis improved from 69% to 45% (P =.0001) after local delivery, and TIMI thrombus grade >/=1 incidence reduced from 68% to 34% (P =.0001). TIMI flow grade was not significantly affected (P =.12). All patients had a successful intervention (</=50% residual stenosis). CONCLUSIONS: Local abciximab delivery before percutaneous SVG intervention is associated with significantly reduced thrombus burden, significantly improved percent diameter stenosis, and excellent acute procedural results. Further studies of this approach are warranted to define its clinical utility.

Abciximab↗
PubMed2000

HIV associated culture proved tuberculosis has increased in north central London from 1990 to 1996.

OBJECTIVES: To examine rates of culture proved tuberculosis in HIV infected patients in three specialist centres in north central London. METHODS: Cases of tuberculosis in patients with previously documented HIV infection from 1990 to 1996 were identified retrospectively from microbiological/clinical records at Chelsea and Westminster, St Mary's, and University College London Hospitals. RESULTS: Between 1990 and 1996 202 cases of culture proved tuberculosis were identified at the three centres. Of these, 132/202 (65.3%) occurred in homosexual/bisexual men, 41/202 (20.3%) were in patients with heterosexual contact in sub-Saharan Africa, and 29/202 (14.4%) were in "others." Overall 148/202 (73.3%) had pulmonary tuberculosis. The total number of HIV infected individuals seen at the three centres increased from 4298 in 1990 to 5048 in 1996. Rates of tuberculosis in the three centres increased from 0.46% in 1990 to 0.83% in 1996. Part of this increase was due to an increase in tuberculosis among Africans from 1993 to 1996. CONCLUSIONS: Rates of HIV associated tuberculosis increased in these three centres in north central London between 1990 and 1996. In part this was due to an increase in the number of African patients with HIV infection attending the three centres. In addition, there was circumstantial evidence of recent transmission among homosexual men with HIV infection. Prospective "real time" surveillance of tuberculosis in HIV infected patients is needed in order to detect case clustering and to improve tuberculosis control.

Africa↗