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Biomedical subjects

J Emery

Publications and source records attributed to J Emery.

At least 19 recordsLinked to original sources
PubMed2006

Investigation in hydrated thorium phosphates by NMR I-relation proton phosphorus.

The relations between (1)H and (31)P nuclei are investigated by multinuclear and multidimensional nuclear magnetic resonance (NMR) spectroscopy in order to obtain structural information along the transformation of the thorium phosphate hydrogen phosphate hydrate (TPHPH) into the thorium phosphate diphosphate (TPD) when heating. The raw sample obtained at 120 degrees C was heated at 300, 400, 600, 800 or 1100 degrees C and then studied at room temperature. Single acquisition on (1)H and (31)P nuclei, cross-polarization (CP) at the magical angle spinning, Lee-Golburg homonuclear decoupling in two-dimensional experiments, rotational echo double resonance (REDOR and CP-REDOR) and heteronuclear correlation (HETCOR) were performed. These experiments contribute to evidence the differences between the raw sample and that heated. Indeed, above 300 degrees C, hydrogen phosphate groups (HPO(4)) are completely condensed as diphosphate entities (P(2)O(7)). These results confirm that the TPHPH is successively transformed into a low-temperature form of the TPD (called alpha-TPD), then into its well-known beta-form above 950 degrees C.

Journal Article↗
PubMed2005

Barriers to effective communication across the primary/secondary interface: examples from the ovarian cancer patient journey (a qualitative study).

Effective communication across the primary/secondary interface is vital for the planning and delivery of appropriate patient care throughout the cancer patient journey. This study describes GPs' views of the communication issues across the primary/secondary interface in relation to ovarian cancer patients using qualitative interviews with purposively sampled general practitioners (GPs) and an audit of hospital medical records of 30 deceased ovarian cancer patients. Issues raised by the GPs related to the content and format of communications, but of most concern was the tardiness. The time lag between dictation and typing letters ranged from 0 to 27 days, with a delay of up to 8 days for signing before transit through various mail systems to the GP. Three stages in the patient journey were characterized by particular issues: (1) in the pre-diagnostic and diagnostic stage was a need for prompt information regarding the results of tests and diagnoses, and clearer guidance on the use of tests and fast-track referrals; (2) in the active treatment phase, when GPs could lose touch with their patients, they needed effective communication in order to provide moral support and crisis management; and (3) when oncology withdrew and the focus of care switched back to the community for the terminal phase, GPs needed information to enable them to pick up the baton of care. There is a need to develop and evaluate interventions aimed at improving the content and speed of communications between secondary and primary care. Such interventions are likely to be complex and might include the greater use of telephone or fax for more selected communications, a review of secretarial support, the use of email, the development of GP designed proformas, the feasibility of patient/carer letter delivery options, nurse-led communication, universal electronic patient records, or a revisiting of the patient-held record.

Communication Barriers↗
PubMed2003

A targeted approach significantly increases the identification rate of patients with undiagnosed haemochromatosis.

OBJECTIVE: To determine the optimal means of identifying patients with undiagnosed haemochromatosis. DESIGN: Case-control study where cases are defined by the presence of specific clinical diagnoses or symptoms. SETTING: Primary care patients were recruited from three Oxfordshire practices and secondary care patients were recruited from those patients attending specialist clinics in Amiens University Hospital. SUBJECTS: A total of 569 patients recruited via hospital clinics and 60 primary care patients (recruited from 4022 consultations) presenting with the following haemochromatosis associated conditions, diabetes, arthralgia/chronic fatigue, osteoporosis or arthropathy were studied. The control group, a total of 991 healthy volunteers, were recruited through a Health Appraisal Centre. Patients and controls were included in the study if they or their family members had not previously been diagnosed with hereditary haemochromatosis. MAIN OUTCOME MEASURES: Serum ferritin concentration, transferrin saturation (Tsat) and presence of HFE mutations, C282Y and H63D. The check-up in controls consisted of a questionnaire, clinical examination, biochemical tests and screening for the presence of the C282Y and H63D mutations. RESULTS: Patient groups presenting with unstable diabetes or chronic fatigue and arthralgia together with a raised serum ferritin concentration showed an enrichment in the haemochromatosis-associated genotype HH/YY, odds ratio (OR) = 40.1, confidence interval (CI) = 8.0-202.1 and OR = 103, CI = 22.9-469.7, respectively. CONCLUSION: Patients presenting to hospital clinics with haemochromatosis associated conditions should be screened biochemically for iron overload. Only those with a serum ferritin >300 microg L-1 or Tsat >40% should subsequently go on to be genotyped for HFE mutations. The patients at greatest risk of having undiagnosed haemochromatosis are those presenting with unstable diabetes, or fatigue and/or arthralgia in the absence of any other explanation.

Adult↗
PubMed2001

NMR local range investigations in amorphous starchy substrates I. Structural heterogeneity probed by (13)C CP-MAS NMR.

The (13)C CP-MAS (Cross Polarization and Magic Angle Spinning) NMR signatures of a series of amorphous and semi-crystalline samples prepared from various starchy substrates (native potato starch, amylopectin, amylose) following different techniques of preparation (casting, freeze drying, solvent exchange) are compared. Decompositions of the C1 resonance spectra reveal the existence of four or five main types of alpha(1-4) linkages, which can be quantified. The influence of the intrinsic primary structure (linear or branched) and of the preparation procedure on conformational changes and resulting crystallinity are interpreted in terms of distributions of average glycosidic linkages dihedral angles (Phi, Psi). The role of hydration is also considered. An improved understanding at different structural levels is obtained in relation to local and intermediate range orders. Such information may be useful for the understanding of the structural evolution of a large variety of starchy substrates before or after treatments widely used in industrial processes.

Amylopectin↗
PubMed2001

NMR local range investigations in amorphous starchy substrates: II-Dynamical heterogeneity probed by (1)H/(13)C magnetization transfer and 2D WISE solid state NMR.

In the preceding paper, we have investigated the structural heterogeneous character of a series of amorphous samples prepared from various starchy substrates (native potato starch, amylopectin and amylose) following different techniques of preparation (casting, freeze drying and solvent exchange). Spectral decompositions of the C1 resonances of the (13)C CP-MAS (Cross Polarization and Magic Angle Spinning) spectra under (1)H decoupling have shown the existence of five main types of alpha(1-4) linkages. In this part, 2D solid state NMR WISE experiments and the (13)C/(1)H magnetization transfer in CP as a local probe for both structures and dynamics were used. The (13)C CP magnetization curves versus contact time of each C1 component in each recorded spectrum were fitted with an analytic function taking into account two (1)H reservoirs. Interpretation of the characteristic times derived from fitting yields some improvements on the knowledge of the heterogeneity of the samples and on the water molecules distribution.

Amylopectin↗
PubMed2001

Common hereditary cancers and implications for primary care.

The identification of genes that place individuals at high risk of breast, ovarian, and colorectal cancer has greatly advanced our understanding of cancer predisposition over the past decade. This knowledge has received much attention from the media, and referrals to geneticists and surgeons, and requests for genetic testing, have risen. We review the published evidence for the management of people at increased risk of hereditary cancers, to draw attention to areas of uncertainty and to discuss implications for primary care. We focus on common inherited cancers, since they will have the greatest effect on clinical practice over the next decade. Cancer genetics offers a model of how information on the genetics of other common diseases could affect primary care in the future. Strategies to support the integration of genetic medicine in primary care are needed to enable primary-care practitioners to identify individuals at raised genetic risk and to reassure patients for whom genetic testing and increased surveillance offer little benefit.

Female↗
PubMed2001

Role of PHABULOSA and PHAVOLUTA in determining radial patterning in shoots.

The upper side of the angiosperm leaf is specialized for efficient capture of sunlight whereas the lower side is specialized for gas exchange. In Arabidopsis, the establishment of polarity in the leaf probably requires the generation and perception of positional information along the radial (adaxial versus abaxial or central versus peripheral) dimension of the plant. This is because the future upper (adaxial) side of the leaf develops from cells closer to the centre of the shoot, whereas the future under (abaxial) side develops from cells located more peripherally. Here we implicate the Arabidopsis PHABULOSA and PHAVOLUTA genes in the perception of radial positional information in the leaf primordium. Dominant phabulosa (phb) and phavoluta (phv) mutations cause a dramatic transformation of abaxial leaf fates into adaxial leaf fates. They do so by altering the predicted sterol/lipid-binding domains of ATHB14 and ATHB9, proteins of previously unknown function that also contain DNA-binding motifs. This change probably renders the protein constitutively active, implicating this domain as a central regulator of protein function and the PHB and PHV proteins as receptors for an adaxializing signal.

Amino Acid Sequence↗
PubMed2001

Is informed choice in genetic testing a different breed of informed decision-making? A discussion paper.

Traditionally genetic counselling has promoted a non-directive approach to patients' decision-making but the feasibility of this has been questioned. Unlike most branches of medicine, which are shifting away from a paternalistic model, genetic counselling is approaching shared decision-making from a different perspective. There are certain features of genetic counselling and genetic testing which may complicate the drive towards shared decision-making and informed choice: 1. Genetic test results can have broader implications than non-genetic test results. 2. Genetic test results may be perceived by the patient differently to non-genetic test results. 3. Carrier status for autosomal recessive conditions may be difficult for patients to conceptualize. 4. Decisions in genetic counselling are often multiple and sequential. 5. Most information in genetic counselling is based on probabilities and uncertainties. Each of these features is discussed in relation to achieving shared decision-making in genetic testing and the implications for genetic counsellors are described. The points raised, however, have broader implications for medicine as several of the features, although central to genetic testing, are not entirely unique. Lessons learnt from genetic testing and genetic counselling in achieving shared decision-making could help develop methods of promoting informed choice in other medical arenas such as cancer screening.

Decision Making↗
PubMed2001

New developments in genetics-knowledge, attitudes and information needs of practice nurses.

BACKGROUND: In response to increased referrals to geneticists and the predicted patient demand for genetic counselling, it has been proposed that some genetics services should be provided in primary care. Practice nurses are ideally placed to collect family history information and advise patients accordingly in new patient, family planning, well women/men and chronic disease clinics, but little is known about their knowledge, skills and attitudes towards providing genetic advice. OBJECTIVES: The survey aimed to measure the current situation with regard to: the prevalence of family history recording by practice nurses; confidence in collecting and acting upon family history; and practice nurses' knowledge about familial disorders and genetics. It also investigated what practice nurses think their role should be in relation to the delivery of genetic services; their educational needs; and the most appropriate ways of delivering training/support. METHODS: A postal questionnaire survey was carried out of all practices nurses (n = 909) in four Health Authorities in England (Oxfordshire, Northamptonshire, Nottingham and North Nottinghamshire) and one Health Board in Scotland (Lothian). Analyses were primarily descriptive. RESULTS: A total of 600 nurses (response rate = 66.0%) returned a completed questionnaire. Ninety-six per cent of practice nurses reported that they routinely collect family history information. Over half of the respondents had been consulted in the previous 3 months by patients with a worry about family history of cancer. Approximately 60% of nurses felt confident about collecting the relevant details regarding a family history of breast cancer but felt less confident in collecting the information regarding familial colorectal cancer. Nurses were also unsure how to proceed, with over a third of nurses referring patients to the GP even if they thought the patient was at population risk or, conversely, not referring those that they thought were at considerably higher risk to the GP. There was a reported need for education about familial disease in general and overall agreement that nurses could play a role in genetics in primary care. CONCLUSION: This study provides evidence of considerable activity from practice nurses regarding routine collection of family history. There is a need for further education for practice nurses regarding family history information and the new genetics so that this information is managed appropriately.

Clinical Competence↗
PubMed2001

Referral of patients with a family history of breast/ovarian cancer--GPs' knowledge and expectations.

BACKGROUND: Primary care is expected to play a significant role in the management of patients with genetic problems. Currently, this particularly involves patients with a family history of cancer. If GPs are to exercise their gatekeeper role efficiently in this area, they must be able to evaluate genetic risk and make appropriate referral decisions. OBJECTIVES: The aim of this study was to examine GPs' ability to assess risk and to make appropriate referral decisions for women with a family history of breast/ovarian cancer, and to determine their expectations of a referral to secondary care. METHOD: A questionnaire survey was carried out of the 282 GP principals working within Bedfordshire Health Authority. GPs were asked to make decisions for six simulated cases of women presenting with a family history of breast or ovarian cancer. RESULTS: A total of 164 (58%) GPs returned completed questionnaires. Across the six family histories, the percentage of GPs making an appropriate risk assessment ranged from 21% [95% confidence interval (CI) 14-27%] to 63% (95% CI 56-71%), and an appropriate referral decision ranged from 40% (95% CI 32-48%) to 80% (95% CI 73-86%). Regardless of their accuracy of risk assessment, most GPs were consistent in deciding not to refer low risk women and to refer moderate and high risk women (range 71-85% of GPs for the six family histories). Only 43 (26%, 95% CI 20-33%) of GPs knew the three most important criteria for risk assessment. CONCLUSIONS: GPs require more help and education to enable them to perform their gatekeeper role satisfactorily when assessing patients with a family history of breast/ovarian cancer.

Adult↗
PubMed2001

Unique gene expression patterns in liver and kidney associated with exposure to chemical toxicants.

DNA arrays containing 260 unique genes involved in phase I and II metabolism, heat shock, DNA repair, inflammation, transcription, and housekeeping were used to examine gene expression patterns in liver and kidney in response to five classes of chemicals (polyaromatic hydrocarbons: benzo(a)pyrene, 3-methylcholanthrene; DNA alkylators: dimethylnitrosamine, ethylnitrosourea; peroxisome proliferators: diethylhexylphthalate, clofibrate; heavy metals: CdCl(2), HgCl(2); and oxidative stressors: CCl(4), bromobenzene). Time course experiments in mice were carried out in both tissues for each chemical and dose-response studies were used to further evaluate several of these chemicals. Each pair of chemicals yielded a similar pattern of gene expression distinct from the other four classes of chemicals. Both peroxisome proliferators up-regulated Cyp4a10, acyl-CoA thioesterase, and insulin-like growth factor binding protein-1, whereas the DNA alkylators altered the expression of monokine induced by gamma-interferon, the metallothioneins, p21, and several acute phase proteins. For each of the five classes of chemicals tested, several genes that were induced or repressed were common in each chemical exposure, whereas other genes were unique for that specific class of compound. Both time and dose are important factors in differentiating between chemical classes. Likewise, comparison of changes in messenger RNA expression between the kidney and liver of treated animals indicates that gene arrays may be useful in determining the comparative toxicity of chemicals in various tissues but that exposure to uncharacterized chemicals will have to be monitored in several tissues.

Alkylating Agents↗
PubMed2001

RAGs: A novel approach to computerized genetic risk assessment and decision support from pedigrees.

OBJECTIVES: To assist general practitioners in evaluating patients' genetic risk of cancer on the basis of family history data. METHODS: A new computer application, RAGs (Risk Assessment in Genetics), has been developed to help doctors create graphical family trees and assess the genetic risk of breast and colorectal cancer. RAGs possesses two features that distinguish it from similar software: (i) a user-centred design, which takes into account the requirements of the doctor-patient encounter; (ii) effective and accessible risk reporting by employing qualitative evidence for or against increased risk, which is more easily understood than numerical probabilities. The system allows any rule-based genetic risk guideline to be implemented, and may be readily modified to cater for the varying degrees of information required by different specialists. RESULTS: RAGs permits fast, accurate data entry, and results in more appropriate management decisions than those made via other techniques. In addition, RAGs enables both the clinician and the patient to understand how it arrives at its conclusions, since the use of qualitative evidence allows the program to provide explanations for its reasoning. CONCLUSIONS: The RAGs system promises to help practitioners be more effective gatekeepers to genetic services. It may empower doctors both to make an informed choice when deciding to refer patients who are at increased genetic risk of breast or colorectal cancer, and to reassure those who are at low risk.

Breast Neoplasms↗
PubMed2001

Risk assessment in genetics: a semi-quantitative approach.

Public awareness of genetic predisposition to diseases such as breast cancer threatens to put severe strain on genetics services. Computer-based decision support for general practitioners (GPs) has the potential to reduce unnecessary referrals, but issues of communicating about levels of risk and uncertainty must be addressed. An argumentation logic formalism can subsume both traditional probability theory and more qualitative, reason-based approaches to communicating uncertainty, and we propose that qualitative, argument-based presentation will make uncertainty information more accessible and comprehensible to both patient and GP. We describe software that uses an argumentation approach to assess genetic risk during a GP consultation and provide referral advice along with detailed qualitative explanations for its advice. The software was evaluated in real-life GP consultations in which actors played patients concerned about genetic risk, and in use by GPs evaluating simulated cases. Significant improvement in accuracy of assessment and appropriateness of referrals was found. GPs viewed the software and the qualitative reporting approach highly favourably.

Breast Neoplasms↗
PubMed2000

Computer support for interpreting family histories of breast and ovarian cancer in primary care: comparative study with simulated cases.

OBJECTIVES: To evaluate the potential effect of computer support on general practitioners' management of familial breast and ovarian cancer, and to compare the effectiveness of two different types of computer program. DESIGN: Crossover experiment with balanced block design. PARTICIPANTS: Of a random sample of 100 general practitioners from Buckinghamshire who were invited, 41 agreed to participate. From these, 36 were selected for a fully balanced study. INTERVENTIONS: Doctors managed 18 simulated cases: 6 with computerised decision support system Risk Assessment in Genetics (RAGs), 6 with Cyrillic (an established pedigree drawing program designed for clinical geneticists), and 6 with pen and paper. MAIN OUTCOME MEASURES: Number of appropriate management decisions made (maximum 6), mean time taken to reach a decision, number of pedigrees accurately drawn (maximum 6). Secondary measures were method of support preferred for particular aspects of managing family histories of cancer; importance of specific information on cancer genetics that might be provided by an "ideal computer program." RESULTS: RAGs resulted in significantly more appropriate management decisions (median 6) than either Cyrillic (median 3) or pen and paper (median 3); median difference between RAGs and Cyrillic 2.5 (95% confidence interval 2.0 to 3.0; P<0.0001). RAGs also resulted in significantly more accurate pedigrees (median 5) than both Cyrillic (median 3.5) and pen and paper (median 2); median difference between RAGs and Cyrillic 1.5 (1.0 to 2.0; P<0.0001). The time taken to use RAGs (median 178 seconds) was 51 seconds longer per case (95% confidence interval 36 to 65; P<0.0001) than pen and paper (median 124 seconds) but was less than Cyrillic (median 203 seconds; difference 23. (5 to 43; P=0.02)). 33 doctors (92% (78% to 98%)) preferred using RAGs overall. The most important elements of an "ideal computer program" for genetic advice in primary care were referral advice, the capacity to create pedigrees, and provision of evidence and explanations to support advice. CONCLUSIONS: RAGs could enable general practitioners to be more effective gatekeepers to genetics services, empowering them to reassure the majority of patients with a family history of breast and ovarian cancer who are not at increased genetic risk.

Breast Neoplasms↗