Oral contraceptives and venous thromboembolism.
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Contraceptives, Oral↗
Biomedical subjects
M A Lewis
Publications and source records attributed to M A Lewis.
Doctors as well as patients need education to ensure adherence to treatment regiments.
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Family Practice↗
Establishing rapid response capability: a German approach.
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Journal Article↗
The use of oral contraceptives and the occurrence of acute myocardial infarction in young women. Results from the Transnational Study on Oral Contraceptives and the Health of Young Women.
The objective of this study was to assess the risk of myocardial infarction (MI) associated with the use of new and old combination oral contraceptives (OC). A matched case-control study in 16 centers in Germany, the United Kingdom, France, Austria, and Switzerland explored the association of current use of combination OC with the occurrence of MI. Our subjects were 182 women aged 16-44 years with MI; the controls were 635 women without MI (at least one hospital control and one community control per case) matched for 5-year age group and region. The main outcome measures were odds ratios comparing current use of a specific group of OC against current use of other groups or against no current use. The adjusted overall odds ratio (OR; 95% confidence intervals) for MI for second generation OC versus no current use was 2.35 (1.42 to 3.89) and 0.82 (0.29 to 2.31) for third generation OC (low dose ethinyl estradiol, gestodene, and desogestrel). A direct comparison of third generation users with second generation users yielded an OR of 0.28 (0.09 to 0.86). In subgroup analyses, the odds ratio for the UK alone was 1.25 (0.36 to 4.29), while for continental Europe it was 0.10 (0.02 to 0.48). For hospital controls, the risk estimated was 0.98 (0.22 to 4.44), and 0.18 (0.04 to 0.65) for community controls. The independent risk of MI among current smokers adjusted for OC use was 7.21 (4.58 to 11.36). Among users of third generation OC, the OR for current smokers was 3.75 (0.65 to 21.74) and among users of second generation it was 9.50 (2.93 to 30.96). A comparison of OC use in the UK for the time before and after regulatory action was taken in October 1995 shows that the likelihood of a control (last control accrued June 1996) being treated with second generation OC is seven times higher after 1 November 1995 than it was before. Third generation OC are the first to be associated with no excess risk of MI. A significantly lower risk of MI is found when comparing use of third generation OC with use of second generation OC. There seems to be an impressive amelioration of risk among smokers using newer OC. An impact of regulatory action in the UK was found in the OC use spectrum of controls.
Adolescent↗
Adherence of Candida albicans to experimental denture soft lining materials.
STATEMENT OF PROBLEM: Colonization of denture soft lining materials by Candida albicans can result in clinical problems. Two experimental silicone soft lining materials have been developed and demonstrate good physical properties. PURPOSE OF STUDY: The aim of this study was to determine the extent of candidal adherence to these materials compared with a commercially available soft lining material and an acrylic resin denture base. MATERIAL AND METHODS: The experimental materials were constructed in a stainless-steel mold, and their surface energies were determined with a dynamic contact angle analyzer. The adherence of three strains of C. albicans was determined with an in vitro assay. In addition, one test strain was used to determine the effect on adherence of precoating the materials with whole saliva. RESULTS: Adhesion to all materials was strain variable, with the lowest adherence recorded for the two experimental materials. Decreased adherence was also apparent after precoating the materials with saliva. Correlation between surface energy of the material and the degree of candidal adhesion was seen for one strain, but no correlation was seen for the other two strains. CONCLUSION: Adherence of C. albicans to the two experimental silicone soft lining materials was significantly less than that for an acrylic resin denture base and a commercially available soft lining material.
Acrylic Resins↗
The incidence of chronic headache in children with shunted hydrocephalus.
Report of chronic headache amongst children with shunted hydrocephalus is frequent, and often leads to investigation for raised intra-cranial pressure and shunt malfunction, and much debate has appeared in the literature concerning possible cause. However headache is a common neurological symptom amongst children, and studies of prevalence indicate incidence of frequent non-migrainous headache to be 6.8%, and migrainous headache 4% in the general child population. A relationship between stress and anxiety and headache is recognised, and the hydrocephalic child has many reasons above those of his/her peers to be subject to stress. It is also hypothesised that this group may be more vulnerable than peers to developing a migraine-like condition in the face of adequate shunt function. The clinician dealing with complaint of chronic headache in a hydrocephalic child must therefore be wary of over-investigation in a child with a working shunt, or missing possible shunt malfunction when the only symptom is chronic headache. It was speculated therefore that incidence of non-shunt related chronic headache in this group would be high, and an attempt was made to document incidence of migrainous and non-migrainous headache in the medical notes, and in replies to postal questionnaire sent to a sample of 130 children with shunted hydrocephalus of varying aetiology. Incidence of migrainous headache was documented in the medical notes in 8.5% of cases, with incidence rising to 21.5% using self-report. Incidence of non-migrainous headache was also very high (15.4%) and the overlap between migraine and tension headache, combined with difficulty of diagnosis in children may indicate migraine to be more frequent still. The concept of "Shunt Migraine" is therefore worthy of consideration. Report of chronic headache led to investigation in a large proportion of cases, but symptomatology often continued. Even when shunt malfunction was indicated, shunt revision did not "cure" complaint of headache. Headache was not found to be related to diagnosis associated with hydrocephalus, to presence of seizure disorder, or to the sex of the child, although in common with other studies, there was a strong trend towards girls being statistically more likely to experience headache than boys. There was a relationship however between report of chronic headache, and the sort of school a child was likely to attend; children who attended mainstream school without the support of a Statement of Special Educational Need were more likely to report headache than their peers, and it is hypothesised that these children may be suffering sufficient stress to contribute to maintenance of headache. The importance of the multi-disciplinary team in assessment of children's physical, intellectual and emotional status is stressed, in order that medical interventions have the greatest chance of success.
Cerebrospinal Fluid Shunts↗
How adequate are hospital records?--The first report of the North West Spina Bifida Registry.
The United Kingdom North West Regional Registry of patients with Neural Tube Defects was established in June 1996. The aims of the registry are to keep a record of all patients in a defined geographical location with neural tube defects and to ensure appropriate facilities and follow-up are available. During the first year of the registry 217 patients have been identified and the hospital records of 163 of these reviewed. This report deals with the shortcomings of hospital records identified during this exercise. We identified many inaccuracies and omissions when reviewing case notes. 3% of patients had unclear records as to the presence/absence of shunts. Bladder management was unclear in 17% of patients and bowel management in 26% of cases. There was no record as to the presence/absence of hydronephrosis or renal scarring in 24% and 34% of patients respectively, no blood pressure measurement in 50% of patients and no record of a serum creatinine in 56%. Mobility was not recorded in over 30% of patients. Developmental achievement and school placement were rarely if ever recorded. These results demonstrate the problems with the current medical record system. The potential consequences of this are discussed and means of improving record systems suggested.
Adolescent↗
The spectrum of spinal cord dysraphism and bladder neuropathy in children.
The frequency of bladder neuropathy and its relationship to abnormalities of the neural axis on MR scan was examined in a group of 49 children with known occult spinal dysraphism and 148 children with daytime urinary incontinence. Of the patients with known spinal dysraphism 55% had bladder neuropathy. There was no relationship between either the type of abnormality or the number of abnormalities seen on MR scan and the presence or absence of bladder neuropathy. 5 of the 9 patients with a normal cord had neuropathic bladders. Four of the 148 patients with daytime wetting turned out to have spinal dysraphism. Of the rest, 51 patients required urodynamic studies and of these 12 had clearcut bladder neuropathy. 15 patients had MR scans, all of which were normal. The range of urodynamic findings in those with bladder neuropathy was identical to the range found in patients with spinal dysraphism. On the basis of these findings it is suggested that children with isolated bladder problems could well have spinal cord dysraphism as a cause of these - the lesions being beyond the resolution of MR scanning. For those children with clearcut spinal dysraphism the absence of any relationship between the bladder findings and the lesion places a question mark over the potential benefits of neurosurgical intervention.
Adolescent↗
Communication disturbances in the natural speech of schizophrenic patients and non-schizophrenic parents of patients.
Subclinical communication disturbances in the relatives of schizophrenic patients appear to be heterogeneous in both form and origin. The Communication Disturbances Index (CDI) was applied to the natural speech of stable schizophrenic out patients, non-schizophrenic parents of patients, and control subjects. The parents of schizophrenic patients displayed more frequent overall instances of communication failure in their speech than the controls. The specific types of disturbance that were more frequent were structural lack of clarity, vague references and ambiguous word meanings. The parents did not differ significantly from the patients with regard to total CDI ratings. However, patients made more frequent missing-information references than parents, and parents made more frequent vague references than patients. High CDI scores in parents were associated with more severe lifetime core positive symptoms in their patient offspring.
Adult↗
Characterisation of the inflammatory cell infiltrate in chronic hyperplastic candidosis of the oral mucosa.
The inflammatory cell infiltrate in biopsy material of chronic hyperplastic candidosis (CHC) from the oral mucosa was characterised using immunocytochemical techniques. Nine specimens were stained for human kappa and lambda immunoglobulin light chains, CD68 antigen (macrophages), lysozyme (macrophages, granulocytes), CD3 antigen (T-lymphocytes), CD20 antigen (B-lymphocytes) and leucocyte common antigen (LCA). In addition, these and a further 13 specimens were also examined for immunoglobulin (Ig)-containing cells (IgA, IgG and IgM). The density of the infiltrate varied considerably between cases; T-lymphocytes were the dominant cell type (53.9%), with fewer B-lymphocytes (8.2%) and macrophages (14.2%). Many Ig-containing cells were seen, and although IgG-containing cells predominated, (60.8%, SD +/- 9.0) there was a high proportion of IgA-containing cells (36.7%, SD +/- 9.1) with few IgM-containing cells (2.5%, SD +/- 3.0). Many neutrophils, together with smaller numbers of T-lymphocytes and macrophages, were seen in the epithelium. It is suggested that mucosal defence to Candida infection involves a cell-mediated reaction in which there is recruitment of macrophages and local production of immunoglobulin with a prominent IgA component.
Adult↗
Unilateral multicystic dysplastic kidney: the case for nephrectomy.
Management of unilateral multicystic dysplastic kidneys (MCDK) presents physicians and surgeons with a significant dilemma. Recent studies have indicated that the incidence of short term complications of MCDK is low and many authors have recommended conservative non-operative treatment. Surgery has been proposed by some because of the potential complications of hypertension, infection, and malignant change. Three children with hypertension secondary to MCDK seen at this institution in the past four years, one of whom had been discharged from follow up as a result of 'disappearance' of the cystic kidney on ultrasound examination, are reported. We believe that the risks of hypertension secondary to MCDK have been understated, and that based on the conclusions of these studies, many children may be receiving suboptimal follow up. We currently favour elective nephrectomy as the treatment of choice for this lesion.
Adolescent↗
Prolidase deficiency and systemic lupus erythematosus.
Two children with prolidase deficiency, an inborn error of proline metabolism, developed clinical and immunological abnormalities consistent with a diagnosis of systemic lupus erythematosus (SLE). The first child died from septicaemia, and SLE was only diagnosed during his terminal illness. As a result of this diagnosis his cousin, who was already known to have prolidase deficiency, was investigated further and a diagnosis of SLE confirmed. Following treatment with oral prednisolone her clinical condition has improved, although she has a persistently raised erythrocyte sedimentation rate (ESR) and florid facial rash. Both prolidase deficiency and SLE are associated with disturbances in immune function and have clinical features in common. It is likely that prolidase deficiency is a risk factor for the development of SLE. Additionally, patients with SLE should-where there is a family history or presentation in childhood-be specifically investigated for prolidase deficiency, since standard immunological or haematological investigations will not identify the characteristic biochemical abnormalities.
Amino Acid Metabolism, Inborn Errors↗
A comparison of double-cuffed with single-cuffed Tenckhoff catheters in the prevention of infection in pediatric patients.
Double-cuffed peritoneal catheters (DCCs) may be more effective at preventing penetrating infection than single-cuffed catheters (SCCs). The aim of this study was to see whether DCCs conferred any benefit in the pediatric population. Twenty consecutive SCCs inserted for chronic dialysis were compared with 20 subsequent DCCs. All catheters were inserted by a single operator (MAL). Outcome was assessed by the number of exit-site infections (ESIs) and episodes of peritonitis. There was no difference in the age or sex distribution of the groups, both having 50% of patients under 5 years. The SCCs were followed for 106 patient-months (1 still in situ) and the DCCs for 145 patient-months (11 still in situ). Peritonitis-related catheter loss was significantly more common with SCCs (9 vs 1, p < 0.01). S. aureus was a significantly more common cause of peritonitis in SCCs (10 vs 3, p < 0.03), although almost all ESIs were with this organism. The relative risk of S. aureus peritonitis with a SCC compared to a DCC was 2.077 (95% confidence interval, CI, 1.17-3.69), and the relative risk of catheter loss with peritonitis was 7.5 for SCCs (95% CI 1.14-49.6). In conclusion, double-cuffed peritoneal catheters are more effective than single-cuffed catheters in preventing penetrating infection in infants and children.
Adolescent↗
Veno-venous haemodiafiltration in meningococcal septicaemia.
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Female↗
Third generation oral contraceptives and risk of venous thromboembolic disorders: an international case-control study. Transnational Research Group on Oral Contraceptives and the Health of Young Women.
OBJECTIVE: To test whether use of combined oral contraceptives containing third generation progestogens is associated with altered risk of venous thromboembolism. DESIGN: Matched case-control study. SETTING: 10 centres in Germany and United Kingdom. SUBJECTS: Cases were 471 women aged 16-44 who had a venous thromboembolism. Controls were 1772 women (at least 3 controls per case) unaffected by venous thromboembolism who were matched with corresponding case for age and for hospital or community setting. MAIN OUTCOME MEASURES: Odds ratios derived with stratified analyses and unconditional logistic regression to adjust for potential confounding variables. RESULTS: Odds ratios (95% confidence intervals) for venous thromboembolism were: for any oral contraceptives versus no use, 4.0 (3.1 to 5.3); for second generation products (low dose ethinyl-oestradiol, no gestodene or desogestrel) versus no use, 3.2 (2.3 to 4.3); for third generation products (low dose ethinyloestradiol, gestodene or desogestrel) versus no use, 4.8 (3.4 to 6.7); for third generation products versus second generation products, 1.5 (1.1 to 2.1); for products containing gestodene versus second generation products, 1.5 (1.0 to 2.2); and for products containing desogestrel versus second generation products, 1.5 (1.1 to 2.2). Probability of death due to venous thromboembolism for women using third generation products is about 20 per million users per year, for women using second generation products it is about 14 per million users per year, and for non-users it is five per million per year. CONCLUSIONS: Risk of venous thromboembolism was slightly increased in users of third generation oral contraceptives compared with users of second generation products.
Adolescent↗
Third generation oral contraceptives and risk of myocardial infarction: an international case-control study. Transnational Research Group on Oral Contraceptives and the Health of Young Women.
OBJECTIVE: To test whether use of combined oral contraceptives containing third generation progestogens is associated with altered risk of myocardial infarction. DESIGN: Matched case-control study. SETTING: 16 centres in Austria, France, Germany, Switzerland, and the United Kingdom. SUBJECTS: Cases were 153 women aged 16-44 with a myocardial infarction event. Controls were 498 women (at least 3 controls per case) unaffected by myocardial infarction who were matched with their corresponding case for age and for hospital or community setting within four months of the index infarction. MAIN OUTCOME MEASURES: Odds ratios derived with stratified analyses and unconditional logistic regression to adjust for potential confounding variables. RESULTS: The estimated odds ratio for myocardial infarction of third compared with second generation oral contraceptives among all 651 study subjects was 0.36 (95% confidence interval 0.1 to 1.2) (P = 0.11). The odds ratio for the United Kingdom and Germany alone was 0.45 (0.1 to 1.8) (P = 0.26). Other odds ratios for the five countries were 3.1 (1.5 to 6.3) (P = 0.003) for use of second generation products v no current use and 1.1 (0.4 to 3.4) (P = 0.9) for use of third generation products v no current use. Among the confounding variables the independent contribution of smoking (for which adjustment was made in the above estimates) proved to be important (10.1 (5.7 to 17.9), P < 0.001). CONCLUSION: An odds ratio of 0.45 with wide confidence intervals shows that third generation oral contraceptives compared with second generation products are associated with a reduced risk of myocardial infarction or with no difference. This finding from an interim analysis should be interpreted with extreme caution. However, the excess risk of venous thromboembolism associated with the use of third generation products may be balanced by the reduced risk of myocardial infarction associated with the same products.
Adolescent↗
Could preferential prescribing and referral behaviour of physicians explain the elevated thrombosis risk found to be associated with third generation oral contraceptives?
BACKGROUND: Recently published case-control studies on third versus second generation oral contraceptives showed a slightly increased risk for venous thromboembolism (VTE) and led to a discussion about biases or confounders external to the study such as, preferential prescribing of third generation pills to women at higher risk and differential diagnostic behaviour. METHODS: An interview survey with 102 physicians was performed in 2 weeks of December 1995 in Germany and 1209 of their patients were included in a retrospective cohort analysis of drug utilization and risk markers. RESULTS: German physicians previously preferred to prescribe third generation pills whenever an increased risk was perceived, i.e. risk for VTE and for arterial thrombosis (risk factors, personal or family history of cardiovascular diseases). Almost all predefined risk scenarios were associated with an increased attention to non-specific venous symptoms and patients were more frequently sent for intensive diagnostic search for venous thromboses. The behaviour was not directly dependent on the type of OC; however the third generation pills were indirectly associated with higher risk in the pill-taking women. The physicians' view was confirmed by the analysis of the cohorts of patients: preferential prescribing was also found in this data set, although it was not as impressive as in the physicians responses. CONCLUSION: The possibility cannot be excluded that preferential prescribing and differential diagnostic behaviour alone could have explained the roughly two-fold increased odds ratios from case-control studies recently published, had this information been available among the study variables.
Journal Article↗
Competition in a spatially heterogeneous environment: modelling the risk of spread of a genetically engineered population.
In recent years regulations have been developed to address the risks of releasing genetically engineered organisms into the natural environment. These risks are generally considered to be proportional to the exposure multiplied by the hazard. Exposure is, in part, determined by the spatial spread of the organisms, a component of risk suited to mathematical analysis. In this paper we exampine a mathematical model describing the spread of organisms introduced into a hetereogeneous environment, focusing on the risk of spread and plausibility of containment strategies. Two competing populations are assumed, one the natural species and the other an engineered species or strain, both of which move randomly in a spatially heterogenous environment consisting of alternating favourable and unfavourable patches. The classical Lotka-Volterra competition model with diffusion is used. Analyses of the possible spread and invasion of engineered organisms are thus reduced to finding periodic travelling wave solutions to the model equations. We focus on whether a very small number of engineered organisms can spatially invade a natural population. Initially we investigate the problem for spatially periodic diffusion coefficients and demonstrate that, under the right circumstances and a large enough unfavourable patch, invasion does not succeed. However, if spatially periodic carrying capacities are assumed along with spatially varying diffusion rates, the situation is far more complex. In this case containment of the engineered species is no longer only a simple function of the unfavourable patch length. By using perturbation solutions to the nonuniform steady states, approximate invasion conditions are obtained.
DNA, Recombinant↗