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Edwards SJ, Braunholtz DA, Lilford RJ, Stevens AJ. Ethical issues in the design and conduct of cluster randomised controlled trials. BMJ (CLINICAL RESEARCH ED.) 1999; 318:1407-9. [PMID: 10334756 PMCID: PMC1115783 DOI: 10.1136/bmj.318.7195.1407] [Citation(s) in RCA: 183] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Alizai NK, Thomas DF, Lilford RJ, Batchelor AG, Johnson N. Feminizing genitoplasty for congenital adrenal hyperplasia: what happens at puberty? J Urol 1999; 161:1588-91. [PMID: 10210421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
PURPOSE We document the postpubertal outcome of feminizing genitoplasty. MATERIALS AND METHODS A total of 14 girls, mean age 13.1 years, with congenital adrenal hyperplasia were assessed under anesthesia by a pediatric urologist, plastic/reconstructive surgeon and gynecologist. Of these patients 13 had previously undergone feminizing genitoplasty in early childhood at 4 different specialist centers in the United Kingdom. RESULTS The outcome of clitoral surgery was unsatisfactory (clitoral atrophy or prominent glans) in 6 girls, including 3 whose genitoplasty had been performed by 3 different specialist pediatric urologists. Additional vaginal surgery was necessary for normal comfortable intercourse in 13 patients. Fibrosis and scarring were most evident in those who had undergone aggressive attempts at vaginal reconstruction in infancy. CONCLUSIONS These disappointing results, even in the hands of specialists, highlight the importance of late followup and challenge the prevailing assumption that total correction can be achieved with a single stage operation in infancy. Although simple exteriorization of a low vagina can reasonably be combined with cosmetic correction of virilized external genitalia in infancy, we now believe that in some cases it may be best to defer definitive reconstruction of the intermediate or high vagina until after puberty. The psychological issues surrounding sexuality in these patients are inadequately researched and poorly understood.
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Miller D, Briggs J, Rahman MS, Griffith-Jones M, Rane V, Everett M, Lilford RJ, Bulmer JN. Transcervical recovery of fetal cells from the lower uterine pole: reliability of recovery and histological/immunocytochemical analysis of recovered cell populations. Hum Reprod 1999; 14:521-31. [PMID: 10100004 DOI: 10.1093/humrep/14.2.521] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The aim of this work was to isolate, enumerate and attempt the identification of fetal cells recovered from the lower uterine pole. Immediately before elective termination of pregnancy at 7-17 weeks gestation, samples were recovered by transcervical flushing of the lower uterine pole (n = 108) or transcervical aspiration of mucus from just above the internal os (n = 187), and their contents examined using histological, immunohistochemical and molecular techniques. Syncytiotrophoblasts were identified morphologically in 28 out of 89 (31%) and 50 out of 180 (28%) flushings and aspirates respectively (mean 29%). Immunocytochemistry with monoclonal antibodies (mAbs) recognizing trophoblast or epithelial cell antigens on a smaller number of samples (n = 69) identified putative placental cells in 13 out of 19 (68%) and 25 out of 50 (50%) flushings and aspirates respectively (mean 55%). These included groups of distinctive cells with a small, round, hyperchromatic nucleus, strongly reactive with mAbs PLAP, NDOG1 and FT1.41.1. Smaller groups of larger, amorphous cells, usually containing multiple large, pale staining nuclei, reactive with mAb 340 and to a lesser degree with mAb NDOG5 were also observed. Taking cellular morphology and immunophenotype into consideration, the smaller uninucleate cells were likely to be villous mesenchymal cells, while the larger cells were possibly degrading villous syncytiotrophoblast. There was no significant difference in the frequency of fetal cells obtained by the two recovery methods. Squamous or columnar epithelial cells, labelled strongly with antibodies to cytokeratins or human milk fat globule protein, were observed in 97% (29 out of 30) of aspirates. The use of cervagem in a small number of patients prior to termination of pregnancy did not appear to influence the subsequent recovery of placental cells. Y-specific DNA was detected by polymerase chain reaction (PCR) in 13 out of 26 (50%) flushings and (99 out of 154) 64% aspirates analysed (mean 62%). In-situ hybridization (ISH) revealed Y-specific targets in 40 out of 69 (60%) of aspirates analysed. A comparison of PCR data obtained from transcervical recovered samples and placental tissues showed a concordance of 80% (76 out of 95), with 10 false positives. Comparing the PCR data from tissues with data derived by ISH from 41 aspirates gave a concordance of 90% with two false positives. Although syncytiotrophoblasts were much more likely to be present in samples containing immunoreactive placental cells, the detection rates of fetal-derived DNA were similar regardless of the morphological and/or immunological presence of placental cells. We conclude that the transcervical recovery of fetal cells, while promising, requires considerable additional effort being expended in further research and development, particular in the sampling procedure.
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Sims J, Rink E, Cleary M, Pearson C, Lloyd K, Lilford RJ, Shaw H, Coast J, Richards SH, Peters TJ, Gunnell DJ, Darlow MA, Pounsford J. Hospital at home. BMJ : BRITISH MEDICAL JOURNAL 1998. [DOI: 10.1136/bmj.317.7173.1651] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Lilford RJ, Shaw H. Hospital at home. Costings were inadequate. BMJ (CLINICAL RESEARCH ED.) 1998; 317:1651-2. [PMID: 9917147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
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Edwards SJ, Lilford RJ, Thornton J, Hewison J. Informed consent for clinical trials: in search of the "best" method. Soc Sci Med 1998; 47:1825-40. [PMID: 9877351 DOI: 10.1016/s0277-9536(98)00235-4] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
OBJECTIVE To review the literature on comparisons between different methods of obtaining informed consent for clinical trials. DESIGN Eight hundred and twelve articles were traced, in the process of conducting a systematic review of the ethics of clinical trials, by searching a number of sources: bibliographic databases (Medline, Psychlit and BIDS science and social science indices), hand searches, personal contacts, an original collection and a systematic follow-up of reference lists. Fourteen research reports were found which provided comparative data on different methods of obtaining informed consent. Eleven of these used a randomised design. Studies were classified according to three outcome measures (anxiety, consent rate and understanding). RESULTS The results of the various studies suggest that giving people more information and more time to reflect tends to be associated with a lower consent rate. There seems to be an optimal level of information about side-effects such that patients are not overburdened by detail, while grasping the most important risks. More information in general is associated with greater awareness of the research nature of the trial, voluntariness of participation, right to withdraw and (available) alternative treatments. This result does not, however, extend to explanations of the concept of randomisation on which the literature is contradictory--sometimes more information is associated with increased understanding of the concept and sometimes it is not. Although divulging less information seems to be associated with less anxiety, there is evidence of an interaction with knowledge--high levels of knowledge are significantly associated with less anxiety, irrespective of consent method. The more that patients know before they are invited to participate in a trial, the better equipped they are to cope with the informed consent procedure. CONCLUSION There is some evidence to suggest that there is an optimal amount of information which enhances patient understanding and which might, in turn, reduce anxiety. However. the studies were not altogether conclusive. More work needs to be carried out, especially on public understanding of science and on how different ways of explaining scientific concepts affect that understanding.
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Edwards SJ, Lilford RJ, Braunholtz DA, Jackson JC, Hewison J, Thornton J. Ethical issues in the design and conduct of randomised controlled trials. Health Technol Assess 1998; 2:i-vi, 1-132. [PMID: 10194615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
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Edwards SJ, Lilford RJ, Hewison J. The ethics of randomised controlled trials from the perspectives of patients, the public, and healthcare professionals. BMJ (CLINICAL RESEARCH ED.) 1998; 317:1209-12. [PMID: 9794861 PMCID: PMC1114158 DOI: 10.1136/bmj.317.7167.1209] [Citation(s) in RCA: 132] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Abstract
Randomised control trials (RCTs) are the standard method for treatment evaluation. Unfortunately RCTs are inherently difficult to recruit for, precisely because of the randomisation element that makes them so statistically attractive. Problems of low recruitment are now beginning to impact on trials, with many either not being started or being forced to stop, due to lack of participation. This paper examines one issue that bears on the recruitment problem: equipoise. Equipoise is defined as the point where a rational, informed person has no preference between two (or more) available treatments (Lilford and Jackson, 1995). The use of equipoise as the fundamental criterion for eligibility for a trial seems to impose a hurdle to recruitment. Here we examine the various arguments surrounding its use and measurement. We conclude that effective equipoise based upon constructed "zones of indifference" offers the best chance for bridging the gap between the individual's right to decide and the need for clinical trials to benefit society.
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Lilford RJ, Pauker SG, Braunholtz DA, Chard J. Decision analysis and the implementation of research findings. BMJ (CLINICAL RESEARCH ED.) 1998; 317:405-9. [PMID: 9694762 PMCID: PMC1113676 DOI: 10.1136/bmj.317.7155.405] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Jordan J, Dowswell T, Harrison S, Lilford RJ, Mort M. Health needs assessment. Whose priorities? Listening to users and the public. BMJ (CLINICAL RESEARCH ED.) 1998; 316:1668-70. [PMID: 9603758 PMCID: PMC1113243 DOI: 10.1136/bmj.316.7145.1668] [Citation(s) in RCA: 127] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Chard JA, Lilford RJ, Court BV. Qualitative medical sociology: what are its crowning achievements? J R Soc Med 1997; 90:604-9. [PMID: 9496271 PMCID: PMC1296669 DOI: 10.1177/014107689709001104] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Doctors and epidemiologists seldom read or cite qualitative medical sociology; it is little published in medical journals. A large number of articles bewail this lack and provide arguments explaining and justifying the subject. Any examples used in such articles are selected ad hoc. We made a systematic search for the literature and used citation analysis to select the world's top 100 articles. We analysed this trawl and provide resumés of a selection from the 'classics'. Mental health and the organization of medicine are the themes within medical sociology with highest impact. Much highly cited work consists of historical and theoretical analysis done 'at the desk' rather than observation or interview 'in the field'. Citation rates, even for the most famous works in medical sociology, are a small fraction of those for high impact biomedical research.
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Gupta JK, Khan KS, Thornton JG, Lilford RJ. Management of fetal choroid plexus cysts. BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY 1997; 104:881-6. [PMID: 9255077 DOI: 10.1111/j.1471-0528.1997.tb14345.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Ayres JG, Lilford RJ. Treatment of paraquat poisoning. Thorax 1997; 52:588. [PMID: 9227737] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Abstract
We describe the case histories of five women who developed a severe ulcerating and constricting condition of the vagina following hysterectomy. Three of these women had other classic ulcerative conditions of skin, mouth or colon. One of these women has been described previously.
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Abstract
Three male fetuses examined sonographically in late gestation to assess growth and well-being were found to have evidence of gallbladder cholelithiasis. Postnatally, all three were asymptomatic but they had variable sonographic findings. In two, the abnormalities noted sonographically had resolved spontaneously by 6 weeks of age, but the third patient had a persistent gallbladder "calculus" at 6 months. All three boys, now aged 9 months to 4 years, remain well, with no evidence of biliary tract disease. Sonographic evidence of fetal gallbladder cholelithiasis may be found in late gestation, is more common among boys, and frequently is associated with benign spontaneous resolution.
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Lilford RJ, Braunholtz D. The statistical basis of public policy: a paradigm shift is overdue. BMJ (CLINICAL RESEARCH ED.) 1996; 313:603-7. [PMID: 8806254 PMCID: PMC2352073 DOI: 10.1136/bmj.313.7057.603] [Citation(s) in RCA: 123] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The recent controversy over the increased risk of venous thrombosis with third generation oral contraceptives illustrates the public policy dilemma that can be created by relying on conventional statistical tests and estimates: case-control studies showed a significant increase in risk and forced a decision either to warn or not to warn. Conventional statistical tests are an improper basis for such decisions because they dichotomise results according to whether they are or are not significant and do not allow decision makers to take explicit account of additional evidence--for example, of biological plausibility or of biases in the studies. A Bayesian approach overcomes both these problems. A Bayesian analysis starts with a "prior" probability distribution for the value of interest (for example, a true relative risk)--based on previous knowledge--and adds the new evidence (via a model) to produce a "posterior" probability distribution. Because different experts will have different prior beliefs sensitivity analyses are important to assess the effects on the posterior distributions of these differences. Sensitivity analyses should also examine the effects of different assumptions about biases and about the model which links the data with the value of interest. One advantage of this method is that it allows such assumptions to be handled openly and explicitly. Data presented as a series of posterior probability distributions would be a much better guide to policy, reflecting the reality that degrees of belief are often continuous, not dichotomous, and often vary from one person to another in the face of inconclusive evidence.
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Lilford RJ. Proposed academy of medicine. Proposal is a fudge between academy of medicine and of health. BMJ (CLINICAL RESEARCH ED.) 1996; 313:233. [PMID: 8696226 PMCID: PMC2351609 DOI: 10.1136/bmj.313.7051.233b] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Thornton JG, Lilford RJ. Preterm breech babies and randomised trials of rare conditions. BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY 1996; 103:611-3. [PMID: 8688384 DOI: 10.1111/j.1471-0528.1996.tb09826.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Broughton Pipkin F, Crowther C, de Swiet M, Duley L, Judd A, Lilford RJ, Onwude J, Prentice C, Redman CW, Roberts J, Thornton J, Walker J. Where next for prophylaxis against pre-eclampsia? BRITISH JOURNAL OF OBSTETRICS AND GYNAECOLOGY 1996; 103:603-7. [PMID: 8688382 DOI: 10.1111/j.1471-0528.1996.tb09824.x] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Hirst J, Dowswell T, Hewison J, Lilford RJ. Women's views of their first antenatal visit. Br J Gen Pract 1996; 46:319. [PMID: 8762752 PMCID: PMC1239648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
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