The effect of hormone replacement therapy on the survival of UK women: a retrospective cohort study 1984-2017.

OBJECTIVE: To estimate the effect of estrogen-only and combined hormone replacement therapy (HRT) on the hazards of overall and age-specific all-cause mortality in healthy women aged 46-65 at first prescription. DESIGN: Matched cohort study. SETTING: Electronic primary care records from The Health Improvement Network (THIN) database, UK (1984-2017). POPULATION: 105 199 HRT users (cases) and 224 643 non-users (controls) matched on age and general practice. METHODS: Weibull-Double-Cox regression models adjusted for age at first treatment, birth cohort, type 2 diabetes, hypertension and hypertension treatment, coronary heart disease, oophorectomy, hysterectomy, body mass index, smoking and deprivation status. MAIN OUTCOME MEASURES: All-cause mortality. RESULTS: A total of 21 751 women died over an average of 13.5 years follow-up per participant, of whom 6329 were users and 15 422 non-users. The adjusted hazard ratio (HR) of overall all-cause mortality in combined HRT users was 0.91 (95% CI 0.88-0.94), and in estrogen-only users was 0.99 (0.93-1.07), compared with non-users. Age-specific adjusted HRs for participants aged 46-50, 51-55, 56-60 and 61-65 years at first treatment were 0.98 (0.92-1.04), 0.87 (0.82-0.92), 0.88 (0.82-0.93) and 0.92 (0.85-0.98) for combined HRT users compared with non-users, and 1.01 (0.84-1.21), 1.03 (0.89-1.18), 0.98 (0.86-1.12) and 0.93 (0.81-1.07) for estrogen-only users, respectively. CONCLUSIONS: Combined HRT was associated with a 9% lower risk of all-cause mortality and estrogen-only formulation was not associated with any significant changes. TWEETABLE ABSTRACT: Estrogen-only HRT is not associated with all-cause mortality and combined HRT reduces the risks.

Temporal and spatial performance of vector velocity imaging in the human fetal heart.

OBJECTIVES: To assess the spatial and temporal performance of fetal myocardial speckle tracking, using high-frame-rate (HFR) storing and Lagrangian strain analysis. METHODS: Dummy electrocardiographic signaling permitted DICOM HFR in 124 normal fetuses and paired low-frame-rate (LFR) video storing at 25 Hz in 93 of them. Vector velocity imaging (VVI) tracking co-ordinates were used to compare time and spatial domain measures. We compared tracking success, Lagrangian strain, peak diastolic velocity and positive strain rate values in HFR vs. LFR video storing. Further comparisons within an HFR subset included Lagrangian vs. natural strain, VVI vs. M-mode annular displacement, and VVI vs. pulsed-wave tissue Doppler imaging (TDI) peak velocities. RESULTS: HFR (average 79.4 Hz) tracking was more successful than LFR (86 vs. 76%, P = 0.024). Lagrangian and natural HFR strain correlated highly (left ventricle (LV): r = 0.883, P < 0.001; right ventricle (RV): r = 0.792, P < 0.001) but natural strain gave 20% lower values, suggesting reduced reliability of measurement. Lagrangian HFR strain was similar in LV and RV and decreased with gestation (P = 0.015 and P < 0.001, respectively). LV Lagrangian LFR strain was significantly lower than the values for the RV (P < 0.001) and those using paired LV-HFR recordings (P = 0.007). Annular displacement methods correlated highly (LV = 1.046, r = 0.90, P < 0.001; RV = 1.170, r = 0.88, P < 0.001). Early diastolic waves were visible in 95% of TDI, but in only 26% of HFR and 0% of LFR recordings, and HFR-VVI velocities were significantly lower than those for TDI (P < 0.001). CONCLUSIONS: Doppler estimation of velocities remains superior to VVI but image gating and use of original co-ordinates should improve offline VVI assessment of fetal myocardial function.

Testing for linkage and Hardy-Weinberg disequilibrium.

This paper concerns several important points when testing for Hardy-Weinberg equilibrium (HWE) and linkage disequilibrium (LD) in genetics. First, we challenge the necessity of using exclusively two-sided tests for LD. Next, we show that the exact 2-sided tests based on the most popular measures of LD are not equivalent, and neither are the standard statistical tests even though the 1-sided tests are equivalent. We show how this results in different inference about LD for two data sets consisting of small groups of markers. Finally, we advocate the use of the conditional p-value for both LD and HWE testing. An important advantage of this p-value is that equivalent 1-sided tests are transformed into equivalent 2-sided tests.

Comparison of bone marrow, disseminated tumour cells and blood-circulating tumour cells in breast cancer patients after primary treatment.

The purpose of this study was to determine whether primary breast cancer patients showed evidence of circulating tumour cells (CTCs) during follow-up as an alternative to monitoring disseminated bone marrow tumour cells (DTCs) by immunocytochemistry and reverse transcriptase (RT)-PCR for the detection of micrometastases. We planned to compare CTC and DTC frequency in low-risk and high-risk patients. We identified two cohorts of primary breast cancer patients who were at low (group II, T(1)N(0), n=18) or high (group III, >3 nodes positive (with one exception, a patient with two positive nodes) n=33) risk of relapse who were being followed up after primary treatment. We tested each cohort for CTCs using the CellSearch system on 1-7 occasions and for DTCs by immunocytochemistry and RT-PCR on 1-2 occasions over a period of 2 years. We also examined patients with confirmed metastatic disease (group IV, n=12) and 21 control healthy volunteers for CTCs (group I). All group I samples were negative for CTCs. In contrast, 7 out of 18 (39%) group II primary patients and 23 out of 33 (70%) group III patients were positive for CTCs (P=0.042). If we count only samples with >1 cell as positive: 2 out of 18 (11%) group II patients were positive compared with 10 out of 33 (30%) in group III (P=0.174). In the case of DTCs, 1 out of 13 (8%) group II patients were positive compared with 19 out of 27 (70%) in group III (P<0.001). Only 10 out of 33 (30%) patients in group III showed no evidence of CTCs in all tests over the period of testing, compared with 11 out of 18 (61%) in group II (P=0.033). A significant proportion of poor prognosis primary breast cancer patients (group III) have evidence of CTCs on follow-up. Many also have evidence of DTCs, which are more often found in patients who were lymph node positive. As repeat sampling of peripheral blood is more acceptable to patients, the measurement of CTCs warrants further investigation because it enables blood samples to be taken more frequently, thus possibly enabling clinicians to have prior warning of impending overt metastatic disease.

Primary determinants of ischaemic stroke/brain abscess risks are independent of severity of pulmonary arteriovenous malformations in hereditary haemorrhagic telangiectasia.

BACKGROUND: Brain abscesses and ischaemic strokes complicate pulmonary arteriovenous malformations (PAVMs). At risk individuals are poorly recognised. Stroke/abscess risk factors have not been defined. METHODS: A cohort study of 323 consecutive individuals with PAVMs (n = 219) and/or the commonly associated condition hereditary haemorrhagic telangiectasia (HHT, n = 305) was performed. Most of the 201 individuals with PAVMs and HHT had no respiratory symptoms, and were unaware they had HHT. Anderson-Gill models assessed constant and time dependent potential predictive variables for stroke/abscess, and rate reduction by PAVM embolisation. RESULTS: 57 individuals with PAVMs and HHT experienced brain abscess or ischaemic stroke, usually prior to the diagnosis of underlying PAVMs/HHT. The primary determinants of stroke and abscess risks were unrelated to severity of PAVMs. Males had higher brain abscess rates (hazard ratio 3.61 (95% CI 1.58, 8.25), p = 0.0024); interventional histories and bacteriological isolates suggested dental sources. Once adjusted for gender, there was a marginal association between brain abscess and low oxygen saturation. For ischaemic stroke, there was no association with any marker of PAVM severity, or with conventional neurovascular risk factors. Surprisingly, low mean pulmonary artery pressure was strongly associated with ischaemic stroke (hazard ratio 0.89 (95% CI 0.83, 0.95) per mm Hg increase; p = 6.2x10(-5)). PAVM embolisation significantly reduced ischaemic stroke rate (p = 0.028); no strokes/abscesses occurred following obliteration of all angiographically visible PAVMs. The mean PAVM diagnosis-treatment interval was longer, however, when neurological risks were unrecognised. CONCLUSIONS: Ischaemic strokes and brain abscesses occur commonly in undiagnosed HHT patients with PAVMs. Risk reduction could be improved.

Interval estimates of weighted effect sizes in the one-way heteroscedastic ANOVA.

A framework for comparing normal population means in the presence of heteroscedasticity and outliers is provided. A single number called the weighted effect size summarizes the differences in population means after weighting each according to the difficulty of estimating their respective means, whether the difficulty is due to unknown population variances, unequal sample sizes or the presence of outliers. For an ANOVA weighted for unequal variances, we find interval estimates for the weighted effect size. In addition, the weighted effect size is shown to be a monotone function of a suitably defined weighted coefficient of determination, which means that interval estimates of the former are readily transformed into interval estimates of the latter. Extensive simulations demonstrate the accuracy of the nominal 95% coverage of these intervals for a wide range of parameters.

Circulating levels of cobalt and chromium from metal-on-metal hip replacement are associated with CD8+ T-cell lymphopenia.

We carried out a cross-sectional study with analysis of the demographic, clinical and laboratory characteristics of patients with metal-on-metal hip resurfacing, ceramic-on-ceramic and metal-on-polyethylene hip replacements. Our aim was to evaluate the relationship between metal-on-metal replacements, the levels of cobalt and chromium ions in whole blood and the absolute numbers of circulating lymphocytes. We recruited 164 patients (101 men and 63 women) with hip replacements, 106 with metal-on-metal hips and 58 with non-metal-on-metal hips, aged < 65 years, with a pre-operative diagnosis of osteoarthritis and no pre-existing immunological disorders. Laboratory-defined T-cell lymphopenia was present in 13 patients (15%) (CD8(+) lymphopenia) and 11 patients (13%) (CD3(+) lymphopenia) with unilateral metal-on-metal hips. There were significant differences in the absolute CD8(+) lymphocyte subset counts for the metal-on-metal groups compared with each control group (p-values ranging between 0.024 and 0.046). Statistical modelling with analysis of covariance using age, gender, type of hip replacement, smoking and circulating metal ion levels, showed that circulating levels of metal ions, especially cobalt, explained the variation in absolute lymphocyte counts for almost all lymphocyte subsets.

Mortality in rheumatoid arthritis. Increased in the early course of disease, in ischaemic heart disease and in pulmonary fibrosis.

OBJECTIVE: To examine the cause of death in a large UK inception cohort of rheumatoid arthritis (RA), and whether this was related to disease duration and severity, treatment effects or extra-articular features and complications of RA. METHODS: Standard clinical, laboratory, radiological and socio-economic measures were recorded at baseline and yearly in an inception cohort started in nine centres in 1986. Date and the cause of death were based on death certificates and the comparisons made with age and sex matched population figures. Risk factors for mortality were identified from baseline measures of disease. RESULTS: There were 459 deaths (32%) in 1429 patients followed for up to 18 yrs. Standard mortality ratio was 1.27. Survival was significantly lower in the first 7 yrs of RA. Excess mortality was seen in cardiovascular disease (31%), pulmonary fibrosis (4%) and lymphoma (2.3%). Baseline predictors for mortality were men, older age, poor function, lower socio-economic status, extra-articular features, comorbidity, rheumatoid factor, X-ray erosions, high-ESR and low-haemoglobin. CONCLUSION: There was a modest increase in mortality in RA, mainly in the first 7 yrs. Deaths from cardiovascular disease and pulmonary fibrosis were higher than expected, but treatment-related deaths were low. Risk factors included less favourable socio-economic status, markers of disease severity and diminished function within the first year.

Increased periconceptual maternal glycated haemoglobin in diabetic mothers reduces fetal long axis cardiac function.

OBJECTIVE: To compare ventricular long axis function in fetuses of diabetic mothers (FDM) with contemporaneously studied normal controls (N) and to assess the effect of pre-pregnancy diabetic control on these measurements. DESIGN: Long axis function was compared in 41 FDM and 159 N fetuses in a cross sectional observational study. SETTING: Fetal medicine unit. METHODS AND RESULTS: Echocardiography confirmed structural normality. Pulsed wave valvar Doppler velocimetry, lengthening and shortening myocardial velocities, and amplitude of ventricular long axis movement were recorded at the base of the left and right ventricular free walls and septum. Periconceptual diabetic control was assessed by haemoglobin A1c (HbA1c) in early pregnancy. Doppler and myocardial velocities were negatively related and myocardial thickness was positively related with HbA1c. In both cohorts all variables except mitral and tricuspid late filling (A wave) velocities were dependent on gestational age. FDM gestational age related values were higher for most variables and robust analysis of covariance showed significantly different maturation patterns in mitral valve E:A ratio (p = 0.036) and pulmonary velocity (p = 0.04), late lengthening myocardial velocities (left p = 0.016 and right p = 0.066), left myocardial shortening velocities (p = 0.008), and left free wall (p = 0.03) and septal (p = 0.04) amplitude of motion. FDM septal thickness was significantly increased throughout gestation (p < 0.0001). CONCLUSION: Periconceptual diabetic control influences fetal cardiac performance and myocardial hypertrophy but, unlike the pathophysiology of adult ventricular hypertrophy, is accompanied by functional adaptation. It is unlikely to explain the increased rate of late stillbirth observed in diabetic pregnancies.

Cell-mediated immunity of patients who have had basal cell carcinomas.

The cell-mediated immunity of patients who had basal cell carcinomas (BCCs) removed was studied by measuring cuntaneous delayed hypersensitivity reactions to recall antigens (Multitest CMI, Pasteur-Merieux), and by measuring lymphocyte counts and subsets. One group of patients had multiple BCCs (3 or more) removed and were considered to have a high risk of new BCC formation. The other group consisted of patients who had one BCC and had not developed another within 5 years; these were considered to have a low risk of new BCC formation. The low-risk patients had significantly larger cutaneous reactions to recall antigens (p < 0.05) and significantly fewer were anergic (p < 0.01). There was a correlation between smaller cutaneous reactions and increasing numbers of BCCs (p < 0.05). There was no significant difference between the groups in lymphocyte counts or subsets, but the low-risk patients had a significantly higher CD4:CD8 ratio (p < 0.05) than the high-risk group. The Multitest CMI test can be used to determine which patients are at risk of developing many BCCs.

Prediction of prostate cancer in extended-field biopsies of the prostate.

OBJECTIVES: To assess the prediction of prostate cancer using extended-field prostatic biopsies (8-11 cores), as such biopsy protocols are recommended to increase the detection of prostate cancer, and as fewer cancers are missed this should improve the prediction of biopsy outcome from the patients' history, transrectal ultrasonography (TRUS) and serum markers. PATIENTS AND METHODS: In all, 260 patients were prospectively evaluated and 206 with a total prostate-specific antigen (PSA) level of < 20 ng/mL were included. All patients were evaluated for age, family history, lower urinary tract symptoms (LUTS), medication for LUTS, previous prostate biopsy, the presence of cysts, a digital rectal examination, calcifications or hypoechoic lesions on TRUS, total and transitional zone volume, total PSA (tPSA), PSA density (tPSAD), total PSA transition zone density (tPSATZD), complexed PSA (cPSA), cPSA density (cPSAD), cPSA transitional zone density (cPSATZD), free/total (f/t)PSA ratio and free/complexed PSA ratio (f/cPSA). Logistic regression was used to predict the outcome; 80% of the patients were used to generate the models and 20% to test the prediction. RESULTS: Two models were constructed; the most accurate contained family history, cPSA, cPSAD, cPSATZD, f/cPSA, PSAD and tPSATZD (sensitivity 91%, specificity 70%). A workable and concise model contained tPSATZD, cPSATZD and f/cPSA, and had a sensitivity of 93% and a specificity of 60%. The best single predictor was tPSATZD with a sensitivity of 92% and a specificity of 55%. Using regression models can produce considerable gains in specificity. This would allow unnecessary prostate biopsies to be avoided for a third of patients compared with tPSA alone. CONCLUSIONS: The present analysis for PSA indices appeared to be slightly more accurate than those in previously published studies. Most of this improvement in diagnostic accuracy was ascribed to the use of an extended-field biopsy protocol. Prostate cancer in a first-degree relative was the only variable that contributed significantly to the regression model. tPSATZD was the best volume-adjusted PSA index. The f/tPSA appeared to be the best test with no volume adjustment, followed by f/cPSA and cPSA. Although the models are cumbersome and expensive for use in general urological practice they could be used to optimize biopsy strategies on the basis of predicted cancer probabilities in screening studies. The cost of the models may compare favourably with tPSA because of the high specificity that can be achieved.

A Welch-type test for homogeneity of contrasts under heteroscedasticity with application to meta-analysis.

A common problem that arises in the meta-analysis of several studies, each with independent treatment and control groups, is to test for the homogeneity of effect sizes without the assumptions of equal variances of the treatment and the control groups and of equal variances among the separate studies. A commonly used test statistic, frequently denoted as Q, is the weighted sum of squares of the differences of the individual effect sizes from the mean effect size, with weights inversely proportional to the variances of the effect sizes. The primary contributions of this article are the presentation of improved and very accurate approximations to the distributions of the Q statistic when the effect size is a linear contrast such as the difference between the treatment and control means. Our improved approximation to the distribution of Q under the null hypothesis is based on a multiple of an F-distribution; its use yields a substantial reduction in the type I error rate of the homogeneity test. Our improved approximation to the distribution of Q under an alternative hypothesis is based on a shift of a chi-square distribution; its use allows for much greater accuracy in the computation of the power of the homogeneity test. These two improved approximate distributions are developed using the Welch methodology of approximating the moments of Q by the use of multivariate Taylor expansions. The quality of these approximations is studied by simulation. A secondary contribution of this article is a study of how best to combine the variances of the treatment and control groups (needed for the calculation of weights in the Q statistic). Our conclusion, based on simulations, is that use of pooled variances can result in substantially erroneous conclusions.

Computerised dynamic posturography to assess recovery comparing general anaesthesia with sedation and local anaesthesia for day case nasal surgery.

Computerised dynamic posturography (CDP) can be used as an early marker of recovery to street fitness in patients undergoing ambulatory surgery. We studied three groups of patients undergoing nasal surgery. The goal of this study was to determine whether recovery, as assessed by CDP, is more rapid in patients having nasal surgery under sedation coupled with local anaesthesia or those having surgery under general anaesthesia. We further assessed the acceptability of sedation accompanied by local anaesthesia. A control group was included to determine if there is a learning curve to posturography. There was no difference between the two study groups in terms of balance. Balance was not significantly impaired at 3 h postoperative testing.

Impaired cell-mediated immunity of apparently normal patients who had multiple skin cancers.

BACKGROUND: Investigations of the immune status of patients with skin cancer have had conflicting results, possibly because uniform groups of patients were not studied. Patients who had multiple skin cancers (three or more) were studied to determine whether they had impaired cell-mediated immunity (CMI). METHODS: Thirty-four patients and 34 matched control subjects were studied who were younger than 60 years, were not immunosuppressed, and were free from internal cancer. Cell-mediated immunity was tested by the cutaneous reaction to recall antigens (Multitest CMI, Pasteur Merieux, Lyon, France) and the estimation of lymphocyte levels. RESULTS: Patients had significantly lower Multitest CMI scores (P < 0.0005), lower lymphocyte counts (P < 0.02), and were more likely to have a first-degree relative with skin cancer (P < 0.002). Multitest CMI scores decreased with the number of skin cancers removed (P < 0.0006) and were a significant predictor for CD4 (P < 0.04) and CD8 cell counts (P < 0.02). CONCLUSIONS: Patients who had multiple skin cancers had impaired CMI, and the degree of impairment correlated with the number of skin cancers removed.

Lymphocyte counts of patients who have had skin cancer.

BACKGROUND: Investigations of lymphocyte counts in patients with skin cancer have given conflicting results, possibly because homogeneous groups of patients were not studied. OBJECTIVE: Our purpose was to measure lymphocyte counts in patients with skin cancer to determine whether any abnormalities were associated with the number of cancers removed and to determine whether a lymphocyte count could identify patients at risk of the development of large numbers of cancers. METHODS: Apparently otherwise normal patients who had histologically confirmed skin cancers removed were studied. One group consisted of patients who had one skin cancer removed but had not had another within a minimum of 5 years. The other group consisted of patients who had had three or more skin cancers. Standard flow cytometry was used to determine the total lymphocyte count, CD4 (helper cell) count, and CD8 (cytotoxic cell) count. RESULTS: Ninety-six patients with multiple skin cancers, and 24 with one skin cancer were studied. Only basal cell carcinomas (BCCs) were removed from 84 patients and the results from this homogeneous group were as follows: women had a higher CD4 cell count than men (p < 0.05); patients with 20 or more BCCs had a lower lymphocyte count (p < 0.01); and patients with one BCC had a higher CD4/CD8 ratio than those who had multiple BCCs (p < 0.05). CONCLUSION: Differences were found between men and women, as well as between subgroups of patients with skin cancer. However, the range of lymphocyte counts was large and it was not possible to determine a threshold below which patients had a worse prognosis. A lymphocyte count is not a reliable way of predicting which patients will have a large number of skin cancers.

The involvement, understanding and attitudes of dietitians towards research and audit.

AIM: To investigate the involvement of dietitians in research and audit and to assess their understanding of and attitudes towards these activities. METHODS: A postal questionnaire was used to investigate the knowledge, attitude towards and involvement in research and audit of State Registered Dietitians practising in the National Health Service (NHS) in the UK. RESULTS: A response rate of 64% was achieved. Few respondents (15%) were currently involved in research, although more (65%) were currently involved in audit. Involvement in audit rose significantly with increasing grade and managerial responsibility. Dietitians qualifying more recently were more likely to believe that their college training prepared them to undertake research, but felt less confident about undertaking audit. Experience of audit made respondents more confident about auditing their work and improved their belief that they understood audit terminology. Higher grade dietitians were more likely to see audit as an important part of their role than were their more junior colleagues. Understanding of the terms 'research' and 'audit' was poor, although 48% of respondents identified the link between the two activities. Perceived constraints to involvement in research and audit were identified. CONCLUSION: The present level of involvement of dietitians in research and audit activities falls below that recommended in the BDA's (1997a) National Professional Standards for Dietitians Practising in Healthcare. This study identifies factors that influence dietitians' involvement in, understanding of and attitudes towards research and audit and recommends ways of increasing their involvement in these activities.

Orthopaedic intervention in early rheumatoid arthritis. Occurrence and predictive factors in an inception cohort of 1064 patients followed for 5 years.

OBJECTIVES: To assess the occurrence of and predictive factors for orthopaedic surgery in an inception cohort of rheumatoid arthritis (RA) patients recruited and followed prospectively for 5 yr in nine regions in England. METHODS: Standard clinical, laboratory and radiological assessments and all interventions were recorded at baseline and yearly in RA patients (less than 2 yrs symptoms) prior to the use of disease-modifying drugs. RESULTS: One thousand and sixty-four patients completed 5 yr of follow-up. Two hundred and sixty-four orthopaedic procedures for RA were performed in 181 (17%) patients at a median of 36.5 months from baseline. Seventy-five (7%) had replacements of major joints. Risk factors at baseline for large joint replacement surgery were a low haemoglobin concentration [odds ratio scores (OR) 3.4, 95% confidence interval (CI) 2.1-5.8] and high scores for erythrocyte sedimentation rate (ESR) (OR 3.2, CI 1.8-5.3), disease activity (DAS) (OR 2.1, CI 1.2-3.5) and Larsen X-rays (OR 2.6, CI 1.4-4.8). For hand or foot joint surgery (4%), risk factors included female gender (OR 3.2, CI 1.3-7.6), joint score (OR 2.3, CI 1.2-4.3), erosions (OR 2.3, CI 1.1-4.8), DAS (OR 2.4, 1.3-4.5) and Health Assessment Questionnaire score (OR 1.9, CI 1.0-3.6). No significant associations were seen for tendon, soft tissue or other minor procedures (6%). The HLA-DRB1 RA shared epitope was associated with any type of orthopaedic surgery (OR 1.7, CI 1.1-2.7). CONCLUSIONS: Eleven per cent of RA patients treated with conventional drug therapy for 5 yr underwent large- or small-joint surgery, an outcome which could be compared against that for new disease-modifying drugs. Risk factors varied according to type of surgery, but included standard clinical and laboratory measures. In order to reduce the eventual need for surgery, a therapeutic target in the first year of RA is the suppression of disease activity, as measured by haemoglobin and ESR. These are useful details for clinicians, health professionals and patients.

Sildenafil influences lower urinary tract symptoms.

OBJECTIVE: To assess the possible relationship between erectile dysfunction (ED) and lower urinary tract symptoms (LUTS) in men, and whether treatment of their ED with sildenafil influences their LUTS. PATIENTS AND METHODS: In all, 112 men with ED attending the andrology outpatient clinic were offered oral sildenafil and reviewed 1 and 3 months after treatment. They completed the International Index of Erectile Function and the International Prostate Symptom Score (IPSS) questionnaires at baseline and each review. Scores were designated to indicate the visit number and differences between the visits calculated. RESULTS: A third of the men had an initial IPSS of > 7; there was no relationship between baseline urinary and sexual function scores. After treatment with sildenafil, the urinary scores at 3 months correlated strongly with the sexual function scores. There was a significant inverse relationship between the baseline IPSS and sexual function scores after treatment. The overall trend in the IPSS was towards improvement after treatment with sildenafil. CONCLUSIONS: In men with ED there is no relationship between sexual function scores and urinary symptom scores before treating ED. Treatment with sildenafil appears to improve urinary symptom scores. A lower IPSS at baseline appears to predict a better response to ED therapy with sildenafil.

A methodology for measuring clinical outcomes in an acute care teaching hospital.

The purpose of this study was to assess risk-adjusted outcomes following renal failure, gastrointestinal haemorrhage, stroke, myocardial infarction and heart failure. Length of stay, death and unplanned readmission were compared by treating medical unit adjusting for the four risk factors: severity, comorbidity, sex and age. A significant difference in risk-adjusted deaths and length of stay occurred among units treating heart failure, in length of stay among units treating renal failure, and in deaths among units treating gastrointestinal haemorrhage. A significant difference in death, length of stay and unplanned readmission occurred among units treating stroke. No significant difference in outcomes occurred among units treating myocardial infarction. Outcomes were predicted by age, severity and comorbidity. In conclusion, severity and comorbidity together with age were shown to be good predictors of outcomes. The methodology is considered unsuitable as a regular quality assurance activity.

Comorbidities and prediction of length of hospital stay.

BACKGROUND: Variability in length of stay (LOS) within Australian National Diagnosis Related Groups (AN-DRGs) reflects clinical heterogeneity in age, severity of illness, complications and comorbidities. AIM: To develop a clinically based score which measures patient morbidity and which will better predict LOS compared to existing methods. METHODS: ICD-9-CM codes of diseases and procedures were allocated to one of 23 body system categories to calculate the body burden of disease (BBD) score. Evaluation of BBD in predicting LOS was performed using multiple regression and analysis of variance with a data set of 34,079 cases from 75 AN-DRGs from three Victorian hospitals. RESULTS: Adding BBD and age improved prediction of LOS by 27.2% in AN-DRG version 1.0 and by 17.5% in AN-DRG version 3.1. When using average inlier LOS for AN-DRG, BBD and age improved prediction of LOS by 44.6% and by 14.8% in AN-DRG version 1.0 and version 3.1 respectively. Deaths were positively related to BBD. CONCLUSIONS: BBD is a simple quantitative measure of extent of disease that improves current methods in accounting for variability in LOS.