Biomedical subjects
Publications and source records attributed to B Chappell.
The case of an elderly man with priapism as his only symptom is presented. The importance of clinical signs and simple investigations to make a diagnosis of aortocaval fistula associated with abdominal aortic aneurysm are discussed.
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Foreskin complaints in childhood, if not manageable conservatively, are usually treated by circumcision. A less radical surgical option, when balanitis xerotica obliterans is absent, is preputioplasty. We sent questionnaires to the parents of 23 boys who had had this procedure and 22 replied. Mean interval since operation was 20 months (range 3-36). The main indications for surgery had been irretractable foreskin in 9, recurrent balanoposthitis in 10 and ballooning on voiding in 3 and the operation had dealt successfully with these in 7, 7, and 3, respectively. In all but one case the parents were satisfied with the cosmetic result. However, in 8 cases (36%) the parents said they would have preferred circumcision and 3 of the boys had been listed for further surgery. Preputioplasty is a satisfactory alternative to circumcision in selected cases.
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The study examined the developmental practicum experiences of second-year graduate students in deaf education. Participants in the study consisted of a convenient sample of five practicum students. Triangulated data for the study came from the researcher's observational notes, e-mail correspondence with participants, and participants' journals. Inductive analysis was used to analyze the data. Results of the study evinced developmental experiences that are different from those reported in previous studies. The results of the study have significant implications for (a) practicum placement of graduate students in deaf education in terms of site-based orientation, use of the clinical model of supervision, opportunities for self-reflection, and periodic practicum seminars; and (b) faculty-student collaborative research in terms of planning, ethical issues, students' time needs, and training.
Epilepsy care in general practice has been criticized, but what do GPs feel they deal with most and complete satisfactorily? If criticism is justified, education should be useful in improving epilepsy care, but what do general practitioners want to learn and how do they want to learn it? Questionnaires about these issues were sent to randomly chosen general practitioners throughout the United Kingdom. One hundred and twenty-four out of 200 (62%) responded. They were not biased by age, sex, type of practice or previous interest in epilepsy. Drug treatment and regular review were the two areas of care GPs said they dealt with most, but only half felt they dealt with them well. Sixty-six percent wanted to learn more about drug treatment, 46% about lifestyle advice, 45% about non-drug treatment, 44% about diagnosis and only 16% did not want to learn more about any aspect of care. Weekdays and evenings were the preferred times for study. Courses up to one full day away from practices were popular, distance learning and personal education plans were not, except for a group of younger GPs. When attending courses multi-disciplinary lectures rated highly and nearly three-quarters preferred to attend courses where epilepsy was covered in conjunction with other conditions. Future epilepsy education for GPs should recognize these findings if attendance and positive outcomes are to be maximized.
OBJECTIVE: To assess interobserver variability in the measurement of carotid stenoses from digital subtraction angiograms displayed in different ways (nonmagnified or magnified, white or black arteries); and to compare human readers with computer-generated densitometric measurements of vessel stenosis. METHODS: Digital subtraction angiograms of 20 proximal internal carotid artery stenoses were laser printed in the following ways: (1) Nonmagnified white artery on a black background; (2) Magnified white artery on a black background; (3) Nonmagnified black artery on a white background; (4) Magnified black artery on a white background. This resulted in 80 images of internal carotid artery stenoses. These stenoses were independently measured by 4 radiologists using the North American Symptomatic Carotid Endarterectomy Trial method. A computer-generated densitometric measurement of the black nonmagnified images was also obtained. RESULTS: The most reliable stenosis measurements were obtained from the nonmagnified black and white artery images. The interobserver variability in the measurement of internal carotid stenoses using these images was quite small. Variability increased with the use of magnification. The computer-generated stenosis measurements were consistently much higher than those of the radiologists. CONCLUSION: There was significant variability in measurements made from magnified images and between human readers and computer-generated measurements. This has great clinical significance. Readers of digital angiographic images must determine the most reliable, reproducible images generated by their equipment, as these measurements significantly affect treatment of patients with symptomatic internal carotid artery stenosis.
In the past decade there has been increasing interest in the part that general practice can play in the care of people with epilepsy. Primary care services for epilepsy vary from practice to practice. Some studies have suggested that people with epilepsy prefer secondary care services and are not keen for their epilepsy to be managed in general practice, but much of the data were collected in secondary care. This study collected data from various sources about present provision of services, patient satisfaction with services, views about service development, areas where GP knowledge may be improved and whether the site of data collection influenced the results. A questionnaire was piloted, then distributed and collected through branches of the British Epilepsy Association, general practice and secondary care clinics. Data collected were both quantitative and qualitative. One hundred and seventy-eight questionnaires were collected from three sources. The responders were a severe seizure group. Structured care in general practice was uncommon with 54% being seen only when needed. Dose and type of antiepileptic medication was rarely altered in general practice. Information about their condition was given to 44% of the responders by their GP. Sixty-one percent would prefer their epilepsy care to be 'shared' between primary and secondary services. The majority of patients were satisfied with GP services, felt they could easily discuss their epilepsy, but 58% felt they 'rarely' or 'never' received enough information about their condition in general practice. Satisfaction with GP care varied, dependent on where the data were collected. Patients would value more information and more time to discuss the effects of their epilepsy. In conclusion general practice care for epilepsy is still reactive. Patients value more information and more time to discuss implications. The data collection point affects the results; any conclusions about the organisation of epilepsy care should draw data from community patient samples.
This study aimed to assess the uptake and use by general practitioners of a free epilepsy audit protocol, and describe the care provided by practices which returned completed audits. A protocol for epilepsy audit in general practice was designed and described in the medical press. Practices were invited to reply. Responders were provided with the protocol. A total of 215 practices responded to the articles in the press. Questionnaires asking how they had used the audit protocol were sent to them 18 months later. One hundred and seventy (79%) of the 215 responding practices returned the questionnaires. Forty-seven (28%) had collected some or all of the data. Twenty-two (13%) submitted data of which 12 (7%) matched the original protocol. Aggregated list sizes for these 12 practices was 75689 and 502 (0.66%) patients were being treated. Of these, 60% were seizure free and 11% were having more than one seizure per month. Seventy-one were receiving monotherapy and only two patients were taking more than three drugs. Eighty-eight per cent of patients still having seizures had been seen by their GP for their epilepsy in the last 12 months. In 18% of cases, information on epilepsy lifestyle issues had been given and noted. Offering a free epilepsy audit package can stimulate interest amongst practices in the topic and resulted in 13% collecting and submitting their data for analysis. Practices reported a higher prevalence for epilepsy (0.66%) than in previous studies. The majority of patients with active epilepsy (88%) had been seen by a general practitioner in the last 12 months. Most (71%) were receiving monotherapy, but recording of seizure frequency and provision of information about epilepsy was low.
Generic prescribing for epilepsy remains controversial. This study aimed to ascertain if a change occurred in the incidence of seizures or side-effects when a different pharmaceutical manufacturer's version of the same antiepileptic drug was taken (a 'switch'). Forty general practices with a list size of 350 168 were recruited. They identified 2285 people being treated for epilepsy with either carbamazepine, phenytoin or sodium valproate. A questionnaire was sent to the people with epilepsy. Those who recalled taking a different pharmaceutical manufacturer's supply of the same antiepileptic drug over the last 2 years were interviewed by their practice if they reported a problem with the control of their epilepsy after a 'switch'. One thousand, three hundred and thirty-three (58.8%) people with epilepsy responded: 251 (18.7%) had experienced a 'switch', 27 (10.8%) reported 'validated' problems; 25 (9.9%) reported unproven problems; 22 (8.8%) reported problems, but follow-up was incomplete; 177 (70.5%) reported no problems. This study suggests that money saved by generic prescribing is outweighed by negative health gain for the person with epilepsy, increased work in general practice, and increased social costs.
This study examined the inter-relationships between employment status, employment experiences, background, educational and epilepsy-related variables in a community sample of 1709 people with epilepsy in England and Wales. A postal questionnaire yielded information which included attitudes to careers advice, experiences with fellow employees and management when in work, experiences of being questioned about epilepsy, and the perceived effect of having epilepsy on employment prospects. In a principal components analysis, a factor of 'employability' was identified that had high loadings for educational qualifications, socioeconomic status and employment history. Good employability was found to be related to perceptions that epilepsy had little or no effect on job prospects, good experiences with work colleagues and management, low seizure severity and good seizure control. Further data analyses which focused on people's actual employment histories confirmed the importance of past experiences in employment, educational qualifications, seizure severity and seizure frequency for distinguishing between groups. The study findings are discussed and, taken together, they imply that quality of medical care, employability and good employment history are interconnected in important ways.
Newborn plasma catecholamine levels are elevated compared to fetal life. Whether this reflects increased catecholamine secretion after birth or decreased clearance is not known. To determine the plasma appearance and clearance rates for catecholamines during the transition to postnatal life, we compared plasma epinephrine appearance and clearance rates in fetal sheep before birth and in newborns after delivery. Plasma epinephrine appearance and clearance rates were measured by radiotracer analysis in eight fetuses at 127 +/- 1 days of gestation and, after cesarean delivery, at 130 +/- 1 days of gestation. There was no difference in plasma epinephrine appearance rate during the fetal (26 +/- 4 ng.kg-1 x min-1) or newborn studies (31 +/- 5 ng.kg-1 x min-1). The fetal plasma epinephrine clearance rate (131 +/- 13 ml.kg-1 x min-1) was significantly higher than newborn plasma epinephrine clearance rate (40 +/- 3 ml.kg-1 x min-1). Thus fetal plasma epinephrine appearance rate is not different from appearance rate in the immediate newborn period when catecholamine levels are higher than during most other physiological circumstances. The increase in circulating catecholamine levels at birth is due in part to a significant decrease in clearance rate. It is likely that removal of the placental contribution to whole body clearance accounts for much of the difference observed in fetal and newborn clearance rates.
To determine how patients with epilepsy feel about their condition, their current medication and their treatment, a mail survey was conducted among a random selection of 800 members of the British Epilepsy Association (BEA). Completed questionnaires were received from 437 members (55% response rate). This high response rate, achieved over a 4-week period, indicates great concern about their condition among the membership sampled. The majority of patients (80%) were adults; 20% were 18 years or younger. Some 72% of patients experienced one or less seizures per month and 52% were employed. Comments from an open-ended question about treatment indicated that respondents would like to see an increase in the provision of services and in the information conveyed (a more interactive communication between the patient and the physician); both issues should improve the emotional support provided by physicians. Positive feelings about medications were reported when seizures were controlled, although unhappiness was expressed with the length of time and varying doses that had to be taken before a 'correct' dosage level was established. Also expressed was a concern about the extent of management and of experimentation with medication left to the patient and care-giver. Opportunities exist for greater communication among physician, patient and care-givers to ease the feeling of frustration, discouragement and isolation seen with a condition which affects 2 to 3% of individuals during their lifetime.
There have been little data on catecholamine sulfoconjugation in developing animals or humans. We studied the differences in free and sulfoconjugated catecholamines at birth in newborn sheep. Baseline concentrations of sulfoconjugated norepinephrine and epinephrine were the predominant form of circulating catecholamine, representing 77 +/- 4 and 65 +/- 12% of total circulating catecholamines, respectively. At birth the free epinephrine concentration increased 10-fold (49 +/- 27 to 653 +/- 21 pg/ml, respectively), and plasma free norepinephrine concentration rose 4-fold (307 +/- 92 to 1,178 +/- 389 pg/ml). In contrast, there was only a transient twofold increase in the sulfoconjugated epinephrine. There was no increase in the sulfoconjugated form of norepinephrine. These data demonstrate that, while the near-term newborn sheep has a well-developed mechanism for sulfoconjugation of circulating catecholamines, this does not occur rapidly. During the logarithmic increases of circulating catecholamines at birth, there are not commensurate increases in the concentration of sulfoconjugated norepinephrine or epinephrine. Thus sulfoconjugation does not appear to represent a significant mechanism for inactivation of the high circulating levels of catecholamines seen at birth.
To assess whether prolonged intrauterine stress and resultant fetal growth retardation result in depletion of adrenal catecholamines and alter the adrenergic signal transduction system, we studied newborn sheep after single umbilical artery ligation (SUAL)-induced growth retardation. The animals were delivered at term, and postnatal cardiovascular, pulmonary, endocrine, and metabolic responses were measured. We also evaluated the status of myocardial and pulmonary beta-adrenergic receptor number and function. SUAL caused significant growth retardation but relative preservation of brain and adrenal gland weight and adrenal catecholamine content. Blood pressure, plasma free fatty acid, and glucose responses at birth were blunted in SUAL animals. The plasma epinephrine (Epi) and norepinephrine levels were comparable in both groups for the first 2 h of age. By 4 h, both plasma concentration and plasma appearance rate of Epi were reduced to 40% of control in SUAL animals (P less than 0.05). Neither beta-receptor density, affinity, nor adenylate cyclase activity were altered by SUAL in either cardiac or pulmonary membranes. These results suggest that, rather than overt depletion, there is relative sparing of initial adrenal medullary function that later waned. This response and preservation of the beta-adrenergic signal transduction system may represent partial compensation for the physiological stress induced by SUAL.
Regional norepinephrine and dopamine content and cerebral alpha 1- and beta-adrenergic receptor mechanisms were studied in the brain of sham operated control and single umbilical artery ligation (SUAL) induced growth retarded newborn sheep. Brain sparing was evidenced by relative preservation of brain weight compared to other organ systems. Norepinephrine and dopamine content of the brain were not affected by SUAL. This is in contrast to decreased norepinephrine levels in the brown fat, a normally densely innervated peripheral tissue. Alpha 1- and beta-adrenergic receptor numbers and affinity states were similar between the two groups. Coupling between beta-receptor and guanine nucleotide stimulatory protein and agonist stimulated adenylyl cyclase activity were unaffected by SUAL. Brain regional DNA content and protein/DNA ratios were not different between the two groups. These data suggest that single umbilical artery ligation induced fetal growth retardation modifies peripheral but not central catecholaminergic pathways in the sheep. Both growth and expression of specific catecholaminergic signal transduction system are protected in the brain.
Met-enkephalin immunoreactivity (MET-ENKi), total enkephalin immunoreactivity (TOTAL MET-ENKi) and catecholamines were measured in adrenal and extra-adrenal tissue of fetal, newborn and adult rabbits. Met-enkephalin peptides were detected in adrenal and extra-adrenal tissue by 29 days of gestation. There were progressive increases in TOTAL MET-ENKi in both the adrenal and extra-adrenal tissue during development. In 29-day-old fetuses, MET-ENKi represented 43 and 50% of the peptide content in adrenal and extra-adrenal tissues respectively. By 3 days after birth, MET-ENKi represented only 15 and 7% of the peptide content in the same tissues. In the adult adrenals, 10% of enkephalin peptides were found as MET-ENKi. There were progressive increases in adrenal and extra-adrenal catecholamine content in the fetal and newborn rabbits throughout development. The changes in the ratio of MET-ENKi to TOTAL MET-ENKi peptides suggest differences in posttranslational processing of proenkephalin peptide during maturation. We speculate that enkephalin peptides derived from proenkephalin A are important during fetal and early newborn life and that extra-adrenal tissue may be an important source of these peptides during development.
We studied the effects of SKF 104078 in anesthetized, newborn lambs and compared it to nonspecific alpha-receptor blockade by tolazoline. SKF 104078 infusion decreased pulmonary and systemic arterial pressures in newborn lambs when infused during normoxic ventilation. When infused during hypoxia, SKF 104078 decreased cardiac output and systemic blood pressure without affecting pulmonary pressure. Due to the predominance of systemic effects, the usefulness of SKF 104078 in states of hypoxic pulmonary vasoconstriction is limited.