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Biomedical subjects

A Hutchinson

Publications and source records attributed to A Hutchinson.

At least 19 recordsLinked to original sources

Development of a symptom based outcome measure for asthma.

Measuring symptom specific health outcome is complex, but the methodologies now exist to develop measures with the appropriate properties. As one element of a major programme to develop multidomain health outcome measures for chronic disease, a symptom based measure for asthma care has been developed for use in general practice and outpatient departments. This article outlines the development process, which used a framework recently described in the theoretical literature to show the constraints that scientific criteria place on the development of outcome measures and the means of overcoming such limiting factors. Although substantial effort is required to undertake a rigorous process of development, useful tools are the result. Two five item, symptom based outcome measures for adult asthma are described.

Ambulatory Care

The role of gravity in gentamicin-induced toxic effects in a rabbit model.

OBJECTIVE: To define the role of gravity in gentamicin sulfate-induced retinal toxic effects by injecting the drug into vitrectomized rabbit eyes oriented in one of two positions. METHODS: Ten right eyes of New Zealand white rabbits underwent a two-port pars plana vitrectomy and were positioned with traction scleral sutures to rotate the medullary ray superiorly (five eyes) or nasally (five eyes). Six eyes received a pars plana intravitreal injection of 400 micrograms (0.1 mL) of gentamicin, and four eyes received 0.1 mL of balanced salt solution only. All eyes were kept in position for 30 minutes after the injection. Unoperated-on fellow eyes served as controls. Three or 5 days later, the eyes were enucleated and histopathologic examination was performed. RESULTS: Light and electron microscopy of gentamicin-treated eyes showed inner-retinal edema and disruption of the nerve-fiber and ganglion-cell layers within the more dependent retina vs sparing of the less dependent half of the retina. Eyes that received balanced salt solution showed rare inflammatory cells along the inner-retinal surface but essentially no inner-layer disruption. Examination of unoperated-on control eyes showed no inflammatory cells, edema, or necrosis. CONCLUSION: Gravitational effects and positioning contribute to the location of gentamicin-induced retinal toxic effects in vitrectomized eyes.

Animals

Do clinicians tell each other enough? An analysis of referral communications in two specialties.

Referral letters and replies are an important vehicle for conveying information about patients and for creating and sustaining professional relationships. Studies of communication between hospital specialists and GPs, however, suggest that improvements could be made to the content of letters. In this study, which is part of a larger study of referral expectations, a sample of 39 letters to and from the ENT and Rheumatology departments at Sunderland Royal Infirmary was analysed to find out what objectives were being achieved through the correspondence between consultants and GPs. An analytical framework of letter content was derived from a review of 25 letters to and from each specialty and from a separate study of doctors' opinions of letter content conducted by two of the authors. Doctors recruited to the present study were involved in devising a weighted scoring system for letter content. Analysis showed that the letters accomplish the basic objective of transferring clinical and administrative information. They were less likely to contain items of a socio-psychological type. There was very little difference in the standardized letter scores between the two specialties. While the level of detail recorded in this sample may be adequate for straightforward referrals, there are indications that clinicians' letters are frequently not addressing nonclinical matters that can be a complicating factor in a proportion (perhaps a fifth) of referrals. This may be a possible topic for audit in multidisciplinary groups.

Communication

An evaluation of ambulatory visit groups in rheumatology out-patients.

The development of case mix measures for National Health Service (NHS) care has become of great importance recently. Much effort has been put into devising measures for in-patient care, but measures for ambulatory (outpatient, day care and primary care) visits are less developed. Ambulatory Visit Groups (AVGs) is an American system devised to aggregate ambulatory visits into iso-resource groups. However, some assumptions made in the construction of the AVG system may not hold for the UK health service, including the use of consultation time as a proxy for the total resource use associated with the out-patient attendance. To test AVGs in the UK context, a three-month prospective study of rheumatology out-patient attendances at two hospitals in Newcastle upon Tyne assembled a database of 3393 'visits', together with resource use data. The AVGs derived from these were analysed to evaluate the homogeneity of the groups with respect to consultation resource use, and the degree to which consultation time can be considered a proxy for resource use in this setting. Consultation time distributions were markedly skewed, and required log transformation before analysis. Variation in log consultation time was found to depend as much on the clinician as on the AVG, and the two were observed to interact. Resource use distributions were also skewed, and were similarly transformed for analysis. Non-parametric analysis of variance showed resource use to be significantly associated with AVG, but the amount of variation associated with the AVG appeared to be small and inconsistent.(ABSTRACT TRUNCATED AT 250 WORDS)

Ambulatory Care

An agenda for change in referral--consensus from general practice.

BACKGROUND: Wide variations in rates of referral from primary to secondary care have been a matter of concern for many years. Effective strategies for optimizing referral depend on doctors being able to understand what the influences on their referral behaviour are, as well as having the ability to identify priority areas for action and to develop strategies for pushing through effective measures. AIM: This study set out to ascertain general practitioners' priorities for change with respect to the referral process, and to set an agenda for change to be tackled by general practitioners, providers, policy makers and educationalists. METHOD: Through the use of the Delphi technique and focused interviews, general practitioners throughout Northumberland contributed to the consensus view. RESULTS: The main themes to emerge related to hospital waiting lists, open access, flow of information between secondary and primary care and general practitioners' knowledge and training. Ideas for implementing change included the production of directories of hospital services and the development of guidelines for the use of the term 'urgent' in referral letters. CONCLUSION: All of the proposed changes are manageable and share the burden between general practice and other professionals with an interest in the referral process.

Attitude of Health Personnel

Communication between general practitioners and consultants: what should their letters contain?

OBJECTIVE: To canvass the views of all general practitioners and consultants working in Newcastle upon Tyne on the content of referral letters and replies, the feasibility of standardising certain aspects of referral letters, and the use of communications data for audit purposes. DESIGN: A postal questionnaire was sent to all general practitioners and consultants in Newcastle upon Tyne in May 1991. Questions were asked about the clinical and administrative content of letters, the utility of standard categories to state the reason for referral, the idea of using letters for feedback purposes, and communications as a potential topic for professionally led audit. SETTING: Area served by Newcastle upon Tyne Family Health Services Authority and District Health Authority. RESULTS: Replies were received from 274 (77%) doctors (115 general practitioners and 159 consultants). A majority (225; 82%) were in favour of items defined as "always important" forming a minimum requirement for referral letters and for consultants' replies. Using standardised categories to state the reason for referral was not endorsed: 102 (89%) general practitioners and 132 (83%) consultants preferred referrers to use their own words. Using referral communications to provide feedback was less popular with consultants (54; 34%) than general practitioners (72; 63%). Finally, a majority of doctors (179; 65%) were in favour of using written communications as a topic for professionally led audit. CONCLUSIONS: A high degree of consensus exists among clinicians about the content of referral communications. Although doctors may still reject the concept of standardised communications, they have unambiguously endorsed a standard for communication that they can aspire to, and they are prepared to use it as a yardstick for their actual performance.

Communication

Continuous arteriovenous haemofiltration and respiratory function in multiple organ systems failure.

OBJECTIVE: To determine what change in respiratory function occurred following prolonged and efficient continuous arteriovenous haemofiltration (CAVH) in a group of patients with multiple organ systems failure (MOSF). DESIGN: A retrospective assessment using patient notes and ICU charts. SETTING: The Intensive Care Unit of a large University Teaching Hospital. PATIENTS: All ICU patients satisfying the following criteria: (i) Failure of more than one organ system; (ii) Treatment with CAVH; (iii) Removal of more than 10 l of ultrafiltrate per day; (iv) Continuous haemofiltration for at least 5 days. Thirteen patients satisfied these criteria and 14 episodes of CAVH were analyzed. MEASUREMENTS: All data were recorded from the patient notes and ICU charts apart from the A-aDO2 and PaO2/FiO2 (PF) ratio which were calculated from available values. A mean of 3.5 different organ systems failed during the period of stay. The mean daily ultrafiltrate volume obtained was 23.7 (SD 0.95) l and the mean duration of treatment 9.6 (SD 4.3) days. Significant improvements occurred in the values for the PF ratio and ventilatory modality (p < 0.05), and the FiO2 and A-aDO2 (p = 0.001). The mean PEEP value remained unchanged at 4.8 cmH2O. Ten of the 13 patients subsequently died (77% mortality). CONCLUSIONS: A significant improvement in respiratory function occurred in patients with MOSF who had undergone a prolonged period of intensive CAVH. Haemofiltration may therefore be a useful treatment for respiratory failure in this patient group. Unfortunately the overall mortality of the group remained high.

Adolescent

Outcome measures for primary health care: what are the research priorities?

A Delphi technique was used to ask general practitioners for their opinions as to which clinical problems and types of measure they thought most appropriate for the development of outcome measures for use in primary health care. The study comprised two rounds of postal questionnaires, targeted at general practitioners in academic departments throughout the United Kingdom and at trainers in the northern region, with the second questionnaire feeding back opinions from the first. Ninety eight participants suggested one or more areas in which outcome measures could be developed, giving a total of 451 suggestions. Consensus produced in the second round indicated that three clinical conditions were preferred for the development of outcome measures: asthma, diabetes and hypertension. Six categories of outcome measures were developed from the responses given in the first round--level of function, level of clinical control, incidence of complications, iatrogenic problems, patient understanding of a condition, and quality of life. Participants gave these measures different levels of importance according to the clinical problem in question. This Delphi study of doctors' opinions is a first step in the development process of appropriate, practicable measures of outcome for use in primary care and has achieved a degree of consensus among general practitioners.

Attitude of Health Personnel

Calcium homeostasis in Trypanosoma brucei. Identification of a pH-sensitive non-mitochondrial calcium pool.

The objective of this study was to characterize mechanisms which maintain intracellular calcium homeostasis in bloodstream forms of Trypanosoma brucei. The identification of homeostatic pathways is required to understand signal transduction in these organisms. The fluorescent probes Fura-2, 2',7'-bis(carboxyethyl)-5(6)-carboxyfluorescein, and bisoxonal were used to measure intracellular calcium ([Ca2+]i), intracellular pH (pHi), and membrane potential, respectively. Homeostatic pathways maintained [Ca2+]i at 98 +/- 12 nM in the presence of 1.8 mM extracellular calcium despite a steady leak of calcium into the cell. The addition of 2.7 microM nigericin acidified the cytosol, depolarized the plasma membrane, and induced an approximate 3-fold increase in [Ca2+]i. The rise in [Ca2+]i could not be induced with valinomycin or gramicidin D under conditions where membrane depolarization occurred. By contrast, the proton ionophore, carbonyl cyanide p-trifluoromethoxyphenylhydrazone, elevated [Ca2+]i in a manner that was not additive with nigericin. Changes in pHi appeared to regulate [Ca2+]i since: 1) stepwise addition of K+ to nigericin-treated cells generated and incremental increase in pHi and concomitant decrease in [Ca]i; 2) addition of serum to nigericin-treated cells allowed simultaneous recovery of pHi and [Ca2+]i; and 3) addition of NH4Cl to untreated cells resulted in a biphasic change in pHi with corresponding biphasic change in [Ca2+]i. The rise in [Ca2+]i was derived from an intracellular pool which was not dependent on functional cytochrome oxidase, mitochondrial alternative oxidase, or the F0F1-ATPase. These data demonstrate that large quantities of calcium are reversibly stored in a non-mitochondrial pH-sensitive intracellular pool in T. brucei. We conclude that changes in pHi can serve to trigger calcium signals in these organisms.

Animals

Factors influencing general practitioners' referral decisions.

This paper presents some findings from a small scale qualitative study of referral decision making conducted in south-east Northumberland in 1988-89. The study was prompted by an interest in variability in referral rates and the view that existing studies had not attempted to understand referral from the perspective of those involved in making the decisions. Our findings suggest that such understandings are crucial in the analysis of referral decisions and in any policy making initiatives designed to influence the pattern of referring.

Clinical Competence

Case mix measures for ambulatory care.

Resource management in Ambulatory Care is recognized as an increasingly important area for development by many countries, and there has been much interest in the part that Case Mix Measures (CMMs) can play in this. There are a number of possible approaches to case mix, and several measures already exist. However, these are at present mainly still at the development stage and all are North American in origin. This paper reviews the role and state of the art of ambulatory CMMs and reports on an initial evaluation of the Ambulatory Visit Group (AVG) methodology using European data. Although the AVG grouper works under limited conditions, important questions remain concerning its validity and usefulness.

Ambulatory Care

Self-help materials for anxiety: a randomized controlled trial in general practice.

The efficacy of a self-help package in treating chronic anxiety was evaluated in a randomized controlled trial in which the intervention group received self-help materials in the form of an audiotape and booklet, in addition to their current treatment. The intervention was successful in terms of mean depression scores (P = 0.01), anxiety scores (P = 0.04) and general health questionnaire scores (P = 0.02) which were significantly lower for the intervention group than for the controls. In addition, the depression scores fell faster for the intervention group than for the controls. The overall mean reduction in three months in adjusted depression scores was approximately two points greater for the intervention group than for the controls (P = 0.02). Clinicians welcomed the package as a valuable addition to the therapies available for managing chronic anxiety problems. Further studies should include larger sample sizes, taking into account the non-response to postal questionnaires over time.

Adolescent

Comparison of two scores for allocating resources to doctors in deprived areas.

Current proposals in the general practitioner contract include additional payments to doctors working among deprived populations. The underprivileged area score will be used to identify local authority wards with the greatest levels of deprivation, thus acting as the basis for distributing considerable resources. Two methods of identifying deprived populations--the underprivileged area score and the material deprivation score--were compared to determine whether they result in similar allocation of resources to regions. Financial allocations to regions based on figures derived from the contract differed considerably if the material deprivation score was used instead of the underprivileged area score: Northern and Mersey regions gained over 50% of their allocation whereas East Anglia, Oxford, and South West Thames regions lost more than 30% of theirs. Such differences have considerable implications for doctors working among deprived populations as up to 60m pounds each year might be distributed by these payments.

England

Etomidate infusions for the control of refractory status epilepticus.

Etomidate was used in eight patients to control status epilepticus which had been refractory to previous anticonvulsant therapy. Cortical activity was measured using a Cerebral Function Analysing Monitor and etomidate administered to achieve a 5 microV mean amplitude, avoiding burst suppression if possible with obliteration of any paroxysmal increase in amplitude. Neuromuscular blockade facilitated endotracheal intubation and mechanical ventilation, and corticosteroid replacement was provided. Rapid control of seizure activity, with cardiovascular stability, was obtained in all cases. Initially the mean infusion rate of etomidate required to achieve adequate suppression of cortical activity was 25 micrograms kg-1 min-1, but several patients exhibited tachyphylaxis. Weaning from the infusion presented difficulties in four patients due to recurring seizures. Adrenocortical function returned to normal within 96 hrs of stopping the infusion. At six month follow up, two patients had died, and two patients had significant reduction in cerebral function compared with their pre-morbid state.

Adult

Influence of induced hypotension and spinal distraction on feline spinal somatosensory evoked potentials.

Spinal cord injury may occur during surgical correction of spinal deformity, which is performed frequently under hypotensive anaesthesia. We have investigated the interaction between pharmacologically induced hypotension and distraction on feline spinal cord function. Twelve anaesthetized cats were subjected to hypotension (mean arterial pressure (MAP) 60 mm Hg) using a mixture of sodium nitroprusside and trimetaphan (1:5). No significant changes were observed in somatosensory evoked potentials recorded at T11. In six cats distraction was applied at L2-3 in 2.5-mm increments up to 1 cm, while MAP was maintained at 100 mm Hg (normotensive group). The remaining cats were subjected to the same distraction procedure at an MAP of 60 mm Hg (hypotensive group). In the hypotensive group, a reduction in amplitude of evoked response occurred at significantly less distraction than in the normotensive group. These data indicate that the feline spinal cord is more sensitive to spinal distraction under hypotensive conditions.

Animals

Placental transfer of alfentanil at caesarean section.

Twenty-one women about to undergo elective Caesarean section were given intravenous alfentanil 10 micrograms kg-1 1 min prior to induction of anaesthesia in order to obtund the pressor response to laryngoscopy and endotracheal intubation. Compared with a control group of 16 patients, alfentanil significantly reduced the pressor response to endotracheal intubation (P less than 0.01), without any detectable adverse effect upon the neonate. At delivery, mean maternal alfentanil plasma concentration was 23.5 ng ml-1 (SD 7.5, range 9.8-41.2 ng ml-1) and the mean maternal venous plasma alpha 1-acid glycoprotein (alpha 1-AGP) was 576 mg l-1 (SD 208, range 230-1200 mg l-1). Mean neonatal umbilical venous alfentanil plasma concentration was 7.5 ng ml-1 (SD 1.8, range 3.6-10.6 ng ml-1), while the mean umbilical venous alpha 1-AGP concentration was 189 mg l-1 (SD 76, range 80-410 mg l-1). At delivery, the calculated unbound maternal and foetal plasma alfentanil concentrations were similar.

Alfentanil