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Judy M Simpson

Publications and source records attributed to Judy M Simpson.

At least 19 recordsLinked to original sources
PubMed2006

Intrapartum epidural analgesia and breastfeeding: a prospective cohort study.

BACKGROUND: Anecdotal reports suggest that the addition of fentanyl (an opioid) to epidural analgesia for women during childbirth results in difficulty establishing breastfeeding. The aim of this paper is to determine any association between epidural analgesia and 1) breastfeeding in the first week postpartum and 2) breastfeeding cessation during the first 24 weeks postpartum. METHODS: A prospective cohort study of 1280 women aged > or = 16 years, who gave birth to a single live infant in the Australian Capital Territory in 1997 was conducted. Women completed questionnaires at weeks 1, 8, 16 and 24 postpartum. Breastfeeding information was collected in each of the four surveys and women were categorised as either fully breastfeeding, partially breastfeeding or not breastfeeding at all. Women who had stopped breastfeeding since the previous survey were asked when they stopped. RESULTS: In the first week postpartum, 93% of women were either fully or partially breastfeeding their baby and 60% were continuing to breastfeed at 24 weeks. Intrapartum analgesia and type of birth were associated with partial breastfeeding and breastfeeding difficulties in the first postpartum week (p < 0.0001). Analgesia, maternal age and education were associated with breastfeeding cessation in the first 24 weeks (p < 0.0001), with women who had epidurals being more likely to stop breastfeeding than women who used non-pharmacological methods of pain relief (adjusted hazard ratio 2.02, 95% CI 1.53, 2.67). CONCLUSION: Women in this cohort who had epidurals were less likely to fully breastfeed their infant in the few days after birth and more likely to stop breastfeeding in the first 24 weeks. Although this relationship may not be causal, it is important that women at higher risk of breastfeeding cessation are provided with adequate breastfeeding assistance and support.

Journal Article↗
PubMed2006

Progressive resistance training and stretching following surgery for breast cancer: study protocol for a randomised controlled trial.

BACKGROUND: Currently 1 in 11 women over the age of 60 in Australia are diagnosed with breast cancer. Following treatment, most breast cancer patients are left with shoulder and arm impairments which can impact significantly on quality of life and interfere substantially with activities of daily living. The primary aim of the proposed study is to determine whether upper limb impairments can be prevented by undertaking an exercise program of prolonged stretching and resistance training, commencing soon after surgery. METHODS/DESIGN: We will recruit 180 women who have had surgery for early stage breast cancer to a multicenter single-blind randomized controlled trial. At 4 weeks post surgery, women will be randomly assigned to either an exercise group or a usual care (control) group. Women allocated to the exercise group will perform exercises daily, and will be supervised once a week for 8 weeks. At the end of the 8 weeks, women will be given a home-based training program to continue indefinitely. Women in the usual care group will receive the same care as is now typically provided, i.e. a visit by the physiotherapist and occupational therapist while an inpatient, and receipt of pamphlets. All subjects will be assessed at baseline, 8 weeks, and 6 months later. The primary measure is arm symptoms, derived from a breast cancer specific questionnaire (BR23). In addition, range of motion, strength, swelling, pain and quality of life will be assessed. DISCUSSION: This study will determine whether exercise commencing soon after surgery can prevent secondary problems associated with treatment of breast cancer, and will thus provide the basis for successful rehabilitation and reduction in ongoing problems and health care use. Additionally, it will identify whether strengthening exercises reduce the incidence of arm swelling. TRIAL REGISTRATION: The protocol for this study is registered with the Australian Clinical Trials Registry (ACTRN012606000050550).

Arm↗
PubMed2006

Intravitreal triamcinolone for refractory diabetic macular edema: two-year results of a double-masked, placebo-controlled, randomized clinical trial.

OBJECTIVE: To report 2-year safety and efficacy outcomes from a trial of intravitreal triamcinolone acetonide (TA) injections (4 mg) in eyes with diabetic macular edema and impaired vision that persisted or recurred after laser treatment. DESIGN: Prospective, double-masked, placebo-controlled, randomized clinical trial. PARTICIPANTS AND CONTROLS: Sixty-nine eyes of 43 patients were entered into the study, with 34 eyes randomized to receive active treatment and 35 placebo. Two-year data were available for 60 of 69 (87%) eyes of 35 of 41 (85%) patients; 9 eyes of 6 patients were lost to follow-up, of which 6 received a placebo and 3 received intravitreal TA. INTERVENTION: Triamcinolone acetonide (0.1 ml) was injected through the pars plana using a 27-gauge needle. Eyes randomized to placebo received a subconjunctival injection of saline. MAIN OUTCOME MEASURES: Improvement of best-corrected logarithm of the minimum angle of resolution visual acuity (VA) by > or =5 letters after 2 years and incidence of moderate or severe adverse events. RESULTS: Improvement of > or =5 letters' best-corrected VA was found in 19 of 34 (56%) eyes treated with intravitreal TA, compared with 9 of 35 (26%) eyes treated with the placebo (z(generalized estimating equation) = 2.73, P = 0.006). The mean improvement in VA was 5.7 letters (95% confidence interval, 1.4-9.9) more in the intravitreal TA-treated eyes than in those treated with the placebo. An increase of intraocular pressure (IOP) of > or =5 mmHg was observed in 23 of 34 (68%) treated versus 3 of 30 (10%) untreated eyes (P<0.0001). Glaucoma medication was required in 15 of 34 (44%) treated versus 1 of 30 (3%) untreated eyes (P = 0.0002). Cataract surgery was performed in 15 of 28 (54%) treated versus 0 of 21 (0%) untreated eyes (P<0.0001). Two eyes in the intravitreal TA-treated group required trabeculectomy. There was one case of infectious endophthalmitis in the treatment group. CONCLUSION: Intravitreal TA improves vision and reduces macular thickness in eyes with refractory diabetic macular edema. This beneficial effect persists for up to 2 years with repeated treatment. Progression of cataract and elevation of IOP commonly occur but appear manageable. Spontaneous improvement over years can still occur in eyes that are apparently severely affected by diabetic macular edema.

Aged↗
PubMed2006

The presence of necrosis and/or microvascular proliferation does not influence survival of patients with anaplastic oligodendroglial tumours: review of 98 patients.

Accurate prognosis for patients with anaplastic oligodendroglial gliomas is increasingly difficult to make. Characterisation of these tumours remains challenging, increasing proportions of oligodendroglial diagnoses in gliomas are reported, and no WHO 2000 grade IV exists for them, so that highly anaplastic tumours can only be grouped with glioblastoma (GBM) or with grade III oligodendroglioma, which have differing clinical behaviour. Longer survival times reported for patients with glioblastoma containing an oligodendroglial element (GBMO) suggest that a grade IV for oligodendroglial tumours might exist. In patients with anaplastic gliomas containing an oligodendroglial element, we explored whether microvascular proliferation (MVP) and necrosis were associated with shorter survival, sufficient to create a grade IV. Biopsies for 98 patients with anaplastic oligodendroglioma, anaplastic oligoastrocytoma or tumours with an oligodendroglial and GBM element, discharged 1998-2004, were identified from databases at three allied neurosurgery units. Pathology reports were reviewed for the presence of MVP and necrosis. Anaplastic oligoastrocytoma and GBMO were combined to measure the effect of an astrocytic element on survival. For anaplastic oligodendroglioma patients, median survival time was 24 months, while for anaplastic oligoastrocytoma or GBMO patients, it was 9 months. Age 60 or over (P=0.006) and astrocytic element (P=0.01) were the only independent predictors of survival. Patients 60 and over with an astrocytic element had 4.6 times the risk of death of patients under 60 with anaplastic oligodendroglioma.A grade IV cannot be created using necrosis or MVP since neither feature predicted survival after adjustment for age and an astrocytic element. However age and an astrocytic element were strong predictors of poorer survival in patients with anaplastic oligodendroglial tumours.

Age Factors↗
PubMed2006

High bone turnover is an independent predictor of mortality in the frail elderly.

UNLABELLED: Osteoporotic fractures are associated with accelerated bone turnover and excess mortality. In a prospective study of 1112 frail subjects (79% female; mean age, 86 years), high bone turnover was an independent predictor of all-cause mortality. This association seemed to be mainly manifested in deaths from cardiovascular causes. INTRODUCTION: Osteoporotic fractures are associated with accelerated bone turnover and excess mortality. In a prospective cohort study of elderly men and women, we assessed whether the rate of bone turnover measured by markers of bone remodeling is a direct predictor of mortality. MATERIALS AND METHODS: We measured serum concentrations of the aminoterminal propeptide of type I collagen (PINP), a marker of bone formation, and of the carboxyterminal telopeptide of type I collagen (CTX-I), a marker of bone resorption, along with serum PTH and 25-hydroxyvitamin D [25(OH)D] levels in 1112 subjects (79% female; mean age, 86 years) living in residential care. Co-morbidity was measured using the Implicit Illness Severity Scale. Fracture data were validated by a radiology report. Mortality and causes of death were ascertained from death certificates. RESULTS: Over a median follow-up of 817 days, 559 (50.3%) subjects died. In univariate analyses, time to death from all causes was significantly (p < 0.01) associated with age (HR = 1.62 per 10 years), male sex (HR = 1.33), immobility (HR = 1.94), co-morbidity (HR = 0.31, mild versus severe), lower weight (HR = 0.83 per 10-kg increase), impaired cognitive function (HR = 2.14, severe versus normal), number of medications (HR = 1.05 each), hip fracture (HR = 2.26), log serum creatinine (HR = 1.67), log PTH (HR = 1.29), CTX-I (HR = 1.70, highest 25% versus lowest 75%), and PINP (HR = 1.46, highest 25% versus lowest 75%). In multivariate analysis adjusting for age, sex, immobility, co-morbidity, weight, cognitive function, number of medications, PTH, and hip fracture status, the highest quartile was significantly more likely to die than the rest for both serum CTX-I (HR = 1.39; 95% CI: 1.14-1.70; p = 0.002) and PINP (HR = 1.25; 95% CI: 1.02-1.52; p = 0.03). For individual causes of death, CTX-I was significantly associated with deaths from cardiac causes (HR = 1.78: 95% CI: 1.27-2.50; p < 0.001). CONCLUSIONS: We conclude that in the frail elderly, high bone turnover is associated with all cause mortality independently of age, sex, health status, serum PTH levels, and hip fracture status. The mechanism of the effect of bone turnover on mortality seems to be mainly manifested in deaths from cardiovascular causes.

Aged↗
PubMed2005

Risk of complications in a second pregnancy following caesarean section in the first pregnancy: a population-based study.

OBJECTIVE: To estimate the risks of maternal and perinatal morbidity and mortality in a second pregnancy, attributable to caesarean section in a first pregnancy. DESIGN AND SETTING: Cross-sectional analytic study of hospital births in New South Wales, based on linked population databases. PARTICIPANTS: 136 101 women with one previous birth who gave birth to a singleton infant in NSW in 1998-2002. MAIN OUTCOME MEASURES: Crude and adjusted odds ratios (aOR) and 95% confidence intervals (95% CI) for maternal and perinatal morbidity and mortality. RESULTS: 19% of mothers had a caesarean section in their first pregnancy. Compared with mothers who had had primary vaginal births, mothers who had had primary caesarean section and underwent labour in the second birth were at increased risk of uterine rupture (aOR, 12.3; 95% CI, 5.0-30.1; P < 0.0001), hysterectomy (3.5; 1.5-8.4; P < 0.01), postpartum haemorrhage (PPH) following vaginal delivery (1.6; 1.4-1.7; P < 0.0001), manual removal of placenta (1.3; 1.1-1.6; P < 0.01), infection (6.2; 4.7-8.2; P < 0.0001) and intensive care unit (ICU) admission (3.1; 2.1-4.7; P < 0.0001); among mothers who did not undergo labour (ie, had an elective caesarean section), there was a lower risk of PPH (0.6; 0.5-0.7; P < 0.0001) and ICU admission (0.4; 0.3-0.5; P < 0.0001). For infants there was increased risk of preterm delivery (1.2; 1.1-1.3; P < 0.0001) and neonatal intensive care unit admission following labour (1.6; 1.4-1.9; P < 0.0001) in the birth after primary caesarean section. The occurrence of stillbirth was not modified by labour. CONCLUSIONS: Caesarean section in a first pregnancy confers additional risks on the second pregnancy, primarily associated with labour. These should be considered at the time caesarean section in the first pregnancy is being considered, particularly for elective caesarean section for non-medical reasons.

Adult↗
PubMed2005

Effect of age-related chronic immobility on markers of bone turnover.

UNLABELLED: The effects of acute immobilization on bone turnover are well known, but the effects of chronic hypomobility with aging have not been studied. In a cohort of 1064 frail elderly subjects, immobility was significantly associated with serum PINP but not serum CTx after adjusting for confounders. The effect of immobility may be more marked on bone formation than on bone resorption. INTRODUCTION: Accelerated bone turnover and rapid bone loss caused by acute immobilization is well recognized, but the effects of age-related chronic reduction in mobility on bone turnover have been less well studied. We assessed the associations between bone turnover and measures of mobility in a cohort of elderly subjects. MATERIALS AND METHODS: We measured serum levels of the aminoterminal propeptide of type I collagen (PINP), a marker of bone formation, and serum concentrations of the carboxyterminal telopeptide of type I collagen (CTx), a marker of bone resorption, as well as serum intact PTH, serum 25 hydroxyvitamin D (25OHD), mobility, and static balance in a well-characterized sample of 1064 elderly men and women living in residential aged care facilities. Serum creatinine, phosphate, albumin, and calcium were measured in a randomly selected subgroup of 447 subjects. RESULTS: The subjects were elderly and frail; their mean age was 86.0 years (range, 65-101 years); 69% used a walking aid; and 77% were vitamin D deficient (serum 25OHD level < 39 nM). Both serum PINP and CTx increased with age in both sexes. Elevated PINP or CTx was significantly correlated with high PTH, creatinine, and albumin in both genders, except for albumin in women. Age- and gender-adjusted serum CTx and PINP were significantly higher in those with poorer mobility and those with worse static balance. In multivariate analyses, higher serum PINP but not CTx was associated with poorer mobility and worse static balance. CONCLUSIONS: Our findings suggest that poor mobility contributes to the state of accelerated bone turnover usually seen in the elderly. The effect of chronic relative immobility may be more marked on bone formation than bone resorption.

Age Factors↗
PubMed2005

What progress has been made in surgical management of patients with astrocytoma and oligodendroglioma in Australia over the last two decades?

BACKGROUND: Most primary brain cancers are associated with a dismal prognosis because of their aggressive behaviour and high mortality. Surgical resection with adjuvant radiotherapy is a major treatment for these cancers but little has been published about their surgical management in Australia. OBJECTIVE: To determine changes since 1977 in demographic characteristics, tumour frequencies, surgical management, morbidity and survival for 1,339 patients discharged with astrocytoma (A) and oligodendroglioma (O), which comprise the majority of primary brain cancers, recorded prospectively in northern Sydney neurosurgery databases. Discharges were grouped into eras reflecting changes in diagnostic and surgical technology. RESULTS: Between eras 1977-79 and 1999-2002, mean age increased by 9.5 years, and inpatient stay fell from 21 to 9 days. The proportion of O rose as A fell. Of 144 re-biopsies, 16% had less anaplastic pathology, 54% the same and 30% more anaplastic pathology than the first biopsy. Stereotactically assisted surgery increased, with overall rates of burr hole for biopsy decreasing and of craniotomy rising. Between 1980-86 and 1999-2002, inpatient mortality declined from 7.3 to 2.3% of discharges, reopening of craniotomy and wound complication rates fell, while postoperative neurological deficit rose. Deep vein thrombosis and pulmonary embolism rates for discharges increased significantly. Age and histopathologic grade were predictors of survival from 1980. Sex and era of diagnosis did not influence survival. After adjustment for age using proportional hazards regression, survival improved only for anaplastic A, with a 60% improvement for patients diagnosed in era 3, and a 50% improvement for patients diagnosed in era 4 relative to those in era 1. CONCLUSIONS: Although markers of inpatient care have improved since the 1980s, age-adjusted survival has not increased except for patients with anaplastic A.

Astrocytoma↗
PubMed2005

Intravitreal triamcinolone-induced elevated intraocular pressure is associated with the development of posterior subcapsular cataract.

OBJECTIVE: To investigate the association between elevated intraocular pressure (IOP) and accelerated cataract formation in patients treated with intravitreal triamcinolone. DESIGN: Analysis of longitudinal data from a randomized, double-masked, placebo-controlled trial of intravitreal triamcinolone for age-related macular degeneration (the Intravitreal Triamcinolone Study). PARTICIPANTS AND CONTROLS: Patients with phakic eyes who participated in a randomized clinical trial of intravitreal triamcinolone for age-related macular degeneration were studied. There were 57 phakic eyes in the treatment group and 54 phakic eyes in the control group. One eye per patient was studied. INTERVENTION: Four milligrams of intravitreal triamcinolone or 1 ml subconjunctival saline. MAIN OUTCOME MEASURES: Intraocular pressure rise of at least 5 mmHg (IOP responders) and progression of posterior subcapsular cataract by 2 or more grades using photographic standards from the Age Related Eye Disease Study. RESULTS: Progression of posterior subcapsular cataract (PSC) by 2 or more grades in the treatment group was significantly higher among 16 IOP responders (51% after 2 years) than among 37 nonresponders (3%; P<0.0001, log-rank test). There was no significant progression of PSC in the placebo group or the opposite eye of the treatment group. Progression of cortical cataracts also was significantly higher among responders than nonresponders (15% vs. 3%; P = 0.015, log-rank test). The progression of nuclear cataracts (13% vs. 3%) was not significantly different between IOP responders and nonresponders (P = 0.3, log-rank test). CONCLUSIONS: Although steroid-related cataracts are unlikely to develop in eyes that do not experience elevated IOP after intravitreal triamcinolone, those eyes that do also have a very high risk of rapidly experiencing posterior subcapsular lens opacification. This strong association suggests that the mechanism responsible for the development of steroid-induced PSC cataract and raised IOP may be similar.

Aged↗
PubMed2005

Proteinuria in pre-eclampsia: how much matters?

OBJECTIVE: To determine, in women with proteinuric pre-eclampsia, whether a discriminant value of proteinuria at the time of diagnosis predicts the presence or absence of subsequent adverse maternal and fetal outcomes. DESIGN: Retrospective cohort study. SETTING: One teaching hospital and two primary referral hospitals in Sydney, Australia. SAMPLE: Three hundred and twenty-one pregnant women with proteinuric pre-eclampsia, managed according to a uniform management protocol. METHODS: All women with the diagnosis of proteinuric pre-eclampsia in the years 1998-2001 were studied. After exclusion of women with pre-eclampsia superimposed on pre-existing hypertension, a twin pair, unavailable spot urine results, 353 women were analysed using logistic regression to determine separately the predictors of any adverse maternal or fetal outcomes at the time of delivery. Receiver operating characteristic (ROC) curves, sensitivity and specificity were then calculated from the data. MAIN OUTCOME MEASURES: Adverse maternal outcomes: severe maternal hypertension (BP > or = 170/110 mmHg), renal insufficiency, liver disease, cerebral irritation, haematological disturbances. Adverse fetal outcomes: small for gestational age, perinatal mortality. RESULTS: There were 108 (34%) adverse maternal outcomes and 60 (19%) adverse fetal outcomes including two stillbirths. In multivariate analysis, an adverse maternal outcome was significantly associated with higher spot urine protein/creatinine ratio at diagnosis (P < 0.0001) with an odds ratio (OR) of 1.003 per mg/mmol (95% confidence interval [CI] 1.002-1.004) and with older maternal age (P= 0.014) with OR 1.06 per year (95% CI 1.01-1.11). An increased risk of adverse fetal outcome was associated with higher spot urine protein/creatinine (P= 0.013; OR 1.44 per log [mg/mmol], 95% CI 1.08-1.92), gestation at diagnosis <34 weeks (P < 0.0001; OR 3.60, 95% CI 1.90-6.82) and early pregnancy systolic blood pressure < or =115 mmHg (P= 0.0002; OR 3.41, 95% CI 1.77-6.57). The area under the receiver operating characteristic (ROC) curve was 0.67 for adverse maternal outcomes and 0.72 for adverse fetal outcomes. CONCLUSIONS: With increasing proteinuria, there is increased risk of adverse maternal and fetal outcomes. Although we did not identify a specific spot protein/creatinine ratio that could be used as a definitive screening value for adverse outcomes, it is possible to utilise data from this study to predict the likelihood of adverse maternal and fetal outcomes. A high spot urine protein/creatinine ratio in pre-eclamptic women of greater than 900 mg/mmol ( approximately 9 g/day), or greater than 500 mg/mmol (approximately 5 g/day) in women over 35 years, is associated with a greatly increased likelihood of adverse maternal outcomes.

Adult↗
PubMed2005

Prenatal risk factors for severe retinopathy of prematurity among very preterm infants of the Australian and New Zealand Neonatal Network.

OBJECTIVE: To identify prenatal and perinatal risk factors for clinically severe (stage 3 or 4) retinopathy of prematurity (ROP). METHODS: Data were collected prospectively as part of the ongoing Australian and New Zealand Neonatal Network audit of high-risk infants (birth weight of <1500 g or gestational age [GA] of <32 weeks) admitted to a level III neonatal unit in Australia or New Zealand. Prenatal and perinatal factors to 1 minute of age were examined for the subset of infants with GA of <29 weeks who survived to 36 weeks' postmenstrual age and were examined for ROP (n = 2105). The factors significantly associated with stage 3 or 4 ROP were entered into a multivariate logistic regression model. RESULTS: Two-hundred three infants (9.6%) had stage 3 or more ROP. Prematurity was the dominant risk factor, with infants with GA of <25 weeks having 20 times greater odds of severe ROP than infants with GA of 28 weeks. Birth weight for GA also had a "dose-response" effect; the more growth-restricted infants had greater risk, with infants below the 3rd percentile of weight for GA having 4 times greater odds of severe ROP than those between the 25th and 75th percentiles. Male gender was also a significant risk factor (odds ratio: 1.73; 95% confidence interval: 1.25-2.40). CONCLUSIONS: These data, for a large, essentially population-based cohort, suggest that factors related to the degree of immaturity, intrauterine growth restriction, and male gender contribute to severe ROP.

Australia↗
PubMed2004

Prophylaxis for deep venous thrombosis in neurosurgical oncology: review of 2779 admissions over a 9-year period.

OBJECT: Management of disease in patients undergoing neurosurgical treatment for tumors requires balancing the competing risks of hemorrhage and thrombosis. The authors compared the incidence of clinically apparent deep venous thrombosis (DVT) and pulmonary embolism (PE) in patients admitted for treatment of intracranial and spinal tumors at three institutions. At the public hospital (the Royal North Shore Hospital [RNSH]) nonsequential calf compression was used, and at the other two private neurosurgery services sequential calf compression with low-molecular-weight heparin was used in patients undergoing spinal surgery. All patients wore compression stockings and underwent follow-up scanning after surgery. METHODS: The authors identified from their neurosurgery databases 2779 discharges of patients with tumor from the RNSH and private hospitals between January 1, 1995 and December 31, 2003. Patient admissions were relatively well matched for age, sex, duration of stay, and tumor type. For patients who underwent spinal surgery, the incidence of DVT was higher in the RNSH (2.6% of admissions) than in private hospitals, where no case of DVT was seen (p = 0.02). The incidence of PE was higher in admissions patients who had been treated for cranial tumors in the RNSH (2.9%) than in those treated in the private hospitals (1.3%, p = 0.01). Possible reasons for these discrepancies include a higher proportion of ambulatory patients before and after surgery in the group treated at private hospitals. More emergency and semi-emergency surgery was performed in the RNSH than in the private hospitals. Nevertheless, fewer patients discharged from the RNSH had undergone surgery, which is a known risk factor for DVT. CONCLUSIONS: Patients with intracranial tumors had a higher incidence of PE than those with spinal tumors. The incidence of DVT and PE was higher in patients admitted to the public hospital. The incidence of DVT in patients undergoing spinal procedures was lower when low-molecular-weight heparin was used judiciously, but the incidence of PE in patients undergoing cranial procedures was lower with the private hospital protocol, which did not include prophylaxis with anticoagulating agents.

Anticoagulants↗
PubMed2004

Safety of an intravitreal injection of triamcinolone: results from a randomized clinical trial.

OBJECTIVE: To determine the safety of a single intravitreal injection of triamcinolone acetonide (4 mg) in patients with subfoveal choroidal neovascularization caused by age-related macular degeneration. METHODS: A double-masked, placebo-controlled, randomized clinical trial was conducted at a public tertiary referral eye hospital. Patients participating had age-related macular degeneration with evidence of choroidal neovascularization, any part of which was classic; age older than 59 years; and best-corrected visual acuity of 20/200 or better. Eyes were assigned to active study treatment or to placebo. Intraocular pressure and cataract grading were performed every 6 months for 3 years. Adverse events, from mild to vision-threatening or life-threatening, were recorded as procedure-related or corticosteroid-related. RESULTS: Seventy-five eyes were assigned to study treatment and 76 eyes to placebo. There were no moderate or severe adverse events related to the surgical procedure in either group. Triamcinolone-treated eyes had a significantly increased risk of developing mild or moderate elevation of the intraocular pressure. Topical glaucoma medication reduced intraocular pressure to acceptable levels in all patients. There was significant progression of cataract in the triamcinolone-treated eyes. CONCLUSION: Despite a significant adverse event profile, intravitreal triamcinolone is generally well tolerated by the human eye as long as patients are carefully followed up by their surgeon and treated appropriately, when necessary.

Aged↗
PubMed2004

A quarter of a century of neurosurgery: the value of a relational database to document trends in neurosurgical practice of a tertiary referral hospital.

OBJECTIVE AND IMPORTANCE: Increasing interest in evidence-based medicine has created a demand for accurate and accessible information on activity and trends in clinical practice. A database of all neurosurgery admissions at a teaching hospital maintained by a scientist has been utilised to examine changes in practice and complications from 1977 to 2001. METHODS: A relational database, set up in 1982, now contains an unbroken record of all neurosurgical admissions at Royal North Shore Hospital (RNSH) since 1976. It supplies information for morbidity and mortality meetings, research and administrative purposes. A total of 23,766 admissions from 1977 to 2001 were examined. Statistical analysis of trends in age, gender, length of stay (LOS), diagnostic mix, surgery rates and complications in admissions was based on diagnostic groupings. RESULTS: Proportions of vascular admissions rose and of trauma admissions fell. Mean age increased significantly for tumour, trauma and spinal patients; geometric mean LOS declined significantly for tumour, spine, vascular, cranial nerve and peripheral nerve groups. Concurrently, inpatient death rate fell significantly for tumour and vascular patients. Deep vein thrombosis (DVT) rose significantly for trauma, vascular, tumour, spinal and infection patients; pulmonary embolism (PE) rose significantly for tumour, trauma and spinal patients. There was no significant change in wound infection rate at approximately 3.5% of all operated patients. Wound haematoma rates fell significantly from 4.0% to 2.9% while the rate of postoperative cerebrospinal fluid (CSF) leak rose significantly from 0.5% to 2.0% of all operated patients. CONCLUSION: The value of the database is demonstrated by its ability to provide analysis which shows statistically significant changes over time. Declining death rate and LOS indicate improved efficiency in managing patients, but these are offset by rising rates of CSF leak, DVT and PE. Such rises reflect the changing patterns of casemix and surgery performed, and increasing financial pressures on hospital departments.

Adult↗
PubMed2004

Intravitreal triamcinolone for diabetic macular edema that persists after laser treatment: three-month efficacy and safety results of a prospective, randomized, double-masked, placebo-controlled clinical trial.

OBJECTIVE: To determine whether an intravitreal injection of triamcinolone acetonide for persistent diabetic macular edema after adequate laser treatment improves visual acuity. DESIGN: Prospective, double-masked, placebo-controlled, randomized clinical trial. PARTICIPANTS AND CONTROLS: Sixty-nine eyes of 43 patients were entered into the study, with 34 eyes randomized to receive active treatment and 35 randomized to receive a placebo injection. Sixty-five of 69 eyes (94%) completed the 3-month study visit. INTERVENTION: Using a 27-gauge needle, 0.1 ml of triamcinolone acetonide was injected through the pars plana. The procedure was performed in a minor procedures area in the outpatient clinic under sterile conditions and using topical and subconjunctival anesthesia. Eyes randomized to placebo received a subconjunctival saline injection using the identical procedure for preparation. MAIN OUTCOME MEASURES: The main outcome measures were improvement of best-corrected logarithm of the minimum angle of resolution visual acuity by 5 or more letters and incidence of moderate or severe adverse events. RESULTS: Eighteen of 33 eyes (55%) treated with triamcinolone gained 5 or more letters of best-corrected visual acuity compared with 5 of 32 eyes (16%) treated with placebo (P = 0.002). Macular edema was reduced by 1 or more grades as determined by masked semiquantitative contact lens examination in 25 of 33 treated eyes (75%) versus 5 of 32 untreated eyes (16%; P<0.0001). Optical coherence tomography showed a mean reduction of central retinal thickness of 152 mum in the 21 treated eyes that were examined compared with a reduction of 36 mum in 20 placebo-treated eyes. Infectious endophthalmitis developed in 1 triamcinolone-treated eye that was treated adequately without loss of visual acuity. CONCLUSIONS: In the short term, intravitreal triamcinolone is an effective and relatively safe treatment for eyes with diabetic macular edema that have failed laser treatment. Although it will be essential to study longer-term outcomes, the use of intravitreal triamcinolone may be considered in 1 eye of patients who continue to lose vision from diabetic macular edema despite conventional management.

Aged↗
PubMed2004

A randomized crossover trial of PAPNET for primary cervical screening.

OBJECTIVE: To develop and demonstrate efficient methods to estimate the relative true positive and false positive rates of two cervical screening tests (conventional cytology and PAPNET). METHODS: We designed the study to meet stringent methodologic criteria for comparison of two tests while simultaneously minimizing the numbers requiring reference standard verification. We used a cytology reference standard and also assessed histology when available. For the primary analysis, slides with discordant results around the test threshold (CIN 1) were reviewed by a panel of two cytopathologists, blind to previous results, to establish the reference standard result (reference standard threshold for abnormality CIN2). Where histology was available, a secondary analysis was conducted with the reference standard based on the highest grade lesion (either cytology or histology). RESULTS: Among 21,747 Pap smears, 372 were discordant around the test threshold, requiring verification. In the primary analysis PAPNET detected four more true positives than conventional reading; difference in sensitivity 1.29% (95%CI -5.79 to 8.36%, P=.40). There were two extra false positives using PAPNET; difference in the false positive rate 0.0097% (95%CI -0.122 to 0.142%, P=.47). The results of the combined cytology and histology analysis were similar; difference in true positive rate 0.29% (95%CI -6.76 to 7.34%, P=.50) and difference in false positive rate 0.024% (95%CI -0.098 to 0.15%, P=.39). CONCLUSION: This is an efficient and valid study design where the objective is to examine the comparative accuracy of two tests. The design provides an efficient means of estimating the difference between true positive and false positive detection by the two tests, which often is sufficient information for policy decisions.

Adolescent↗
PubMed2004

The influence of clinical information on the accuracy of diagnostic mammography.

OBJECTIVE: This study examined the influence of knowledge of clinical information on the accuracy of mammography in women referred for investigation of breast symptoms. METHODS: Subjects were sampled from all women consecutively attending a symptomatic breast clinic and aged 25-55 years. This included all 240 women shown to have breast cancer and 240 age-matched women shown not to have cancer. Mammography films were prospectively reported by two radiologists independently of each other in a blinded manner and without knowledge of any clinical information. The films were then re-read with information about the type and site of symptoms (and without knowledge of the level of suspicion of cancer on clinical examination). The accuracy of reading with and without information on symptoms was compared using sensitivity and specificity and receiver operating characteristic (ROC) curves. The effect of age on changes in test accuracy was examined. RESULTS: Reporting the mammogram with knowledge of clinical information (compared to without any information) significantly improved sensitivity (75.8 vs. 71.3%, P = 0.003) for one radiologist, with a non-significant reduction in specificity (85.4 vs. 87.1%, P = 0.22). For the other radiologist, it resulted in non-significant improvement in both sensitivity (75.4 vs. 73.8%, P = 0.13) and specificity (89.2 vs. 87.9%, P = 0.25). Age did not have a statistically significant effect on changes in test accuracy in our data. ROC curves for both radiologists showed that reporting mammography with knowledge of clinical information resulted in small (about 2%) but significant improvement in overall test accuracy. CONCLUSION: Our findings support the provision of clinical information relating to patients' presentation to radiologists reporting diagnostic mammography.

Adult↗