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Biomedical subjects

J Grimshaw

Publications and source records attributed to J Grimshaw.

At least 19 recordsLinked to original sources
PubMed1998

Randomised controlled trial of effects of early discharge after surgery for breast cancer.

OBJECTIVE: To determine the effect of early discharge from hospital after surgery for breast cancer on physical and psychological illness. DESIGN: Randomised controlled trial comparing discharge two days after surgery (before removal of drain) with standard management (discharge after removal of drain). SETTING: Regional breast unit. SUBJECTS: 100 women with early breast cancer undergoing mastectomy and axillary node clearance (20) or breast conservation surgery (80). MAIN OUTCOME MEASURES: Physical illness (infection, seroma formation, shoulder movement) and psychological illness (checklist of concerns, Rotterdam symptom questionnaire, hospital anxiety and depression scale) preoperatively and at one month and three months postoperatively. RESULTS: Women discharged early had greater shoulder movement (odds ratio 0.28 (95% confidence interval 0.08 to 0.95); P = 0.042) and less wound pain (odds ratio 0.28 (0.10 to 0.79); P = 0.016) three months after surgery compared with women given standard management. One month after surgery scores were significantly lower on the Rotterdam symptom questionnaire in patients who were discharged early (ratio of geometric mean scores 0.73 (0.55 to 0.98) P = 0.035), but rates of psychological illness generally did not differ between groups. CONCLUSIONS: Increased rates of physical or psychological illness did not result from early discharge after surgery for breast cancer. This policy can be recommended for patients with support at home.

Adult↗
PubMed1998

Teaching the theory behind guidelines: the Royal College of General Practitioners Guidelines Skills Course.

In the face of a perceived lack of widespread understanding of the theoretical issues underlying the development, dissemination and implementation of clinical guidelines, the Royal College of General Practitioners Guidelines Group developed a 2-day course aimed at teaching the theory in these areas. The course was targeted at potential opinion formers and ran on six occasions. Postal questionnaire assessment of the course revealed high levels of satisfaction with all aspects of the course and high levels of reported use of the knowledge gained. Further developments of the course are discussed.

Clinical Competence↗
PubMed1998

Palliative care at home: an audit of cancer deaths in Grampian region.

BACKGROUND: Ninety per cent of the last year of life of cancer patients is spent at home. Some studies have suggested that care in this setting is often suboptimal. Information on the standard of palliative care delivered at home by general practitioners (GPs) and their teams is limited, and clarification of the problems faced is needed. AIM: To audit the home-based palliative care of patients dying of cancer. METHOD: Matched postal questionnaires were sent to the GPs and nurses of 1086 successive patients dying of cancer in whatever setting in the Grampian region of Scotland some six weeks after the death to establish the professionals' perception of symptom control, communication problems, use of services, and information given to patients and relatives. RESULTS: Response rates were 88.8% for GPs (964 out of 1086) and 87.1% for nurses (325 out of 375 that were passed on to nurses). Two-thirds of patients received palliative care at home. Pain was poorly controlled in 15.7%, and poor control of other symptoms ranged from 13.8% (nausea and vomiting) to 21% (depression and dyspnoea). Communication difficulties were present in 93.7% of cases, although only 5.2% of these were of a major nature. District nurses were involved in 76.7% of cases and Macmillan nurses in 28.0%. Twenty-six per cent of referrals to district nurses were assessed as being late in the course of the illness. Patients were fully informed about the diagnosis in 66.3% of cases and about the prognosis in 55.4%. General practitioners were more likely to report the presence of communication problems between themselves and the patient (when compared with nurses: 43.9% versus 28.0%), more likely to report that patients were 'not at all informed' about self-help groups (57.5% versus 36.3%), and were less likely to report the involvement of occupational therapists (21.8% versus 39.7%). CONCLUSIONS: Levels of reporting of poor symptom control by professionals was much lower than levels reported by relatives in other studies, but there was no difference between the reporting of GPs and nurses. However, a number of areas were identified where care could be enhanced by improved teamwork and further education and training in symptom control, as well as in communication, use of services, and information provision.

Communication↗
PubMed1997

Integrating heterogeneous pieces of evidence in systematic reviews.

Researchers preparing systematic reviews often encounter various types of evidence, which can generally be categorized as direct or indirect. The former directly relates an exposure, diagnostic strategy, or therapeutic intervention to the occurrence of a principal health outcome. Evidence is indirect if two or more bodies of evidence are required to relate the exposure, diagnostic strategy, or intervention to the principal health outcome. Heterogeneity of data sources complicates integration of both direct and indirect evidence. Participants in different studies may have a wide spectrum of baseline risk and sociodemographic and cultural characteristics. A variety of formulations and intensities of exposures, diagnostic strategies, and interventions, as well as diversity in the selection and definition of control groups, may be encountered. Outcome measures may be different, and similar outcomes may be measured or reported differently. Heterogeneity of study designs and of methodologic features and quality within a given design may be found. The effective integration of direct and indirect evidence requires development of explicit models that serve as analytic frameworks for linking the important pieces of evidence. A model can be viewed as a series of subquestions, with each important subquestion warranting a systematic review. Several subjective and quantitative methods can then be used to integrate the evidence. Tabular displays of major findings and strength of evidence for each subquestion can help reviewers, patients, and providers to integrate the differing research findings and draw reasonable conclusions. Various quantitative techniques, such as decision analysis and the confidence profile method, are also available. No single integration approach is clearly superior, none obviates uncertainty, and all underscore the role of careful judgment in integrating evidence.

Evidence-Based Medicine↗
PubMed1997

Identification of alpha 1-acid glycoprotein (orosomucoid) in human synovial fluid by capillary electrophoresis.

Capillary electrophoresis of human synovial fluid in a phosphate borate run buffer containing sodium dodecyl sulphate separates a hydrophilic glycoprotein, hyaluronan and a number of low-molecular-mass components. The hydrophilic glycoprotein is identified as alpha 1-acid glycoprotein (AGP), orosomucoid, by co-injection methods with human AGP and by reaction with neuraminidase which released N-acetylneuraminic acid. Finally, a sample of the glycoprotein was isolated by micropreparative capillary electrophoresis, examined by sodium dodecyl sulphate-polyacrylamide gel electrophoresis methods and shown to give a positive reaction with AGP antibodies. The peak due to AGP in the capillary electrophoresis is broad and gives evidence for the presence of glycoforms.

Antibodies↗
PubMed1997

Analysis of glycosaminoglycans and their oligosaccharide fragments by capillary electrophoresis.

Glycosaminoglycans are high molecular mass polymers found in living tissues. They are degraded by site specific enzymes to oligosaccharide fragments. Polymers and oligomers all carry negative charge and are found as salts soluble in water. Consequently, capillary electrophoresis has come to the fore as an analytical technique in this field. This review discusses application of the technique to the chondroitin-dermatan, heparin and hyaluronan groups of polymer and the derived oligosaccharides. Direct and indirect UV detection are discussed as well as detection methods involving precolumn derivatization. Capillary electrophoresis has found use in the characterisation of heparin and in following the changes in chondroitin and hyaluronan during the onset of arthritic disease in humans. Some glycosaminoglycans have been used as asymmetric anions in the separation of enantiomers of low molecular mass compounds by capillary electrophoresis.

Carbohydrate Sequence↗
PubMed1997

The Chronic Pain Grade questionnaire: validation and reliability in postal research.

The Chronic Pain Grade questionnaire has been proposed as an interview-administered, multi-dimensional measure of chronic pain severity in selected populations with chronic pain in the United States of America. It has not previously been tested in the United Kingdom, in self-completion form or in an unselected general population. We undertook a postal survey to assess its reliability, validity and acceptability in these circumstances, using a general practice population in Scotland, with a practice population of 11202 patients. A random sample of 400 patients aged over 18 was drawn, stratified for age, gender and receipt or non-receipt of regular prescriptions for pain-relieving medication. The dimensions and sub-scales of the Chronic Pain Grade were compared with the SF-36 general health questionnaire and questions relating to duration of any pain and attempts to seek treatment for this. The methodological approach proposed by Streiner and Norman (1989) was used to assess validity and reliability. A response rate of 76% was achieved. Cronbach's alpha was > 0.9 and item-total correlations were all high, indicating good internal consistency and reliability. Validity was confirmed by psychometric testing, including confirmatory factor analysis. Good correlations with comparable dimensions of the SF-36 general health questionnaire confirmed convergent validity. Construct validity was confirmed by testing scores against duration of pain and treatment sought for pain. We concluded that the Chronic Pain Grade questionnaire is a useful, reliable and valid measure of severity of chronic pain. It translates well into UK English and is acceptable in general population postal research.

Chronic Disease↗
PubMed1997

Can audit of a local protocol for the management of lipid disorders effect and detect a change in clinical practice?

OBJECTIVE: To audit the implementation of a local protocol for the management of lipid disorders in Grampian. INTERVENTION: A local protocol for the detection and management of lipid disorders, developed by a multi-disciplinary group and based on available national guidelines and systematic reviews, was disseminated and implemented using the audit cycle. DESIGN: An uncontrolled before and after study using four surveys of different aspects of lipid management in primary and secondary care. RESULTS: There was evidence of change in clinical practice following protocol implementation. Improvements in patient care were identified. However, some areas of inappropriate practice remained unaltered. Changes in dietary therapy indicated an improvement in the appreciation of the importance of appropriate dietary advice. There was an increase in the proportion of patients who were appropriately screened and managed, and appropriately referred to the lipid clinic. The health status of patients being screened/treated following guidelines was poorer suggesting a reduction in screening of low risk patients and an increase in lipid assessment of patients with other health problems or risk factors i.e. more appropriate screening. However, after the protocol was disseminated, general practitioners screened less often for secondary causes of hyperlipidaemia.

Aged↗
PubMed1996

Quantitative analysis of hyaluronan in human synovial fluid using capillary electrophoresis.

The glycosaminoglycan, hyaluronan, can be detected in human synovial fluid by capillary electrophoresis (CE). Variations in peak shape make this technique unsuitable for quantitative analysis of hyaluronan in raw synovial fluid. Quantitative analysis was achieved by hydrolysis of the polymeric hyaluronan to the tetrasaccharide by the action of testicular hyaluronidase and separation of the product using CE. A UV detector operating at 200 nm was used. The X-ray contrast material, omnipaque, a propriety aqueous solution of iohexol was used as internal standard. A second peak in the electropherogram of synovial fluid was quantified. The variation in concentrations of these two components correlate with the arthritic disease state of a joint.

Arthritis, Rheumatoid↗
PubMed1995

'Life' for a non-progressor.

A "non-progressor" with HIV, diagnosed in 1984, comments from a personal perspective on how people with HIV are affected by social and professional attitudes. The failure of some professionals to develop an understanding of HIV beyond their own particular field of expertise contributes to the disempowerment experienced by those infected and can result in broader social and and psychosocial aspects of HIV, such as discrimination, being inadequately addressed.

HIV Infections↗
PubMed1995

Developing clinically valid practice guidelines.

Valid guidelines, when appropriately disseminated and implemented, can lead to changes in clinical practice and improvements in patient outcome. Guidelines are more likely to be valid if they are developed using systematic reviews, national or regional guideline development groups (including representatives of key disciplines) and explicit links between recommendations and scientific evidence. This paper discusses the practical implications of adopting this approach for guideline development and the role of peer review guidelines as another element of the process to ensure validity. Considerable resources are required to develop evidence-linked guidelines, but this investment can be recouped by relatively small changes in the process or outcome of care. Good leadership and technical support are required for the successful development of clinically valid guidelines, which is dependent upon the small-group processes of guideline development panels and the translation of evidence into recommendations. Future guideline developers need to gain expertise in these areas. Research priorities are identified.

Consensus Statements as Topic↗
PubMed1994

Quantitative analysis of hyaluronan in vitreous humor using capillary electrophoresis.

Capillary electrophoresis was used for the separation and quantitative analysis of the glycosaminoglycan hyaluronan in human and bovine vitreous with detection by UV absorbance at 200 nm. Calibration was carried out using standards made up from known concentrations of hyaluronan of umbilical cord origin. The purity of the standard was examined by 1H NMR (nuclear magnetic resonance). Concentrations as low as 25 micrograms/mL could be detected by capillary electrophoresis. Confirmation that the signal was due to hyaluronan was obtained by depolymerization of the native mucopolysaccharide by hyaluronidase. This resulted in loss of the hyaluronan peak and appearance of several new peaks corresponding to the oligomeric fragments which had shorter migration times. Capillary electrophoresis is a reproducible and sensitive technique for the quantification and characterisation of hyaluronan in vitreous samples.

Animals↗
PubMed1994

Fundholding: the next five years.

On 1 April 1993 third-wave fundholders (second-wave fundholders in Scotland) received their budgets. In some areas, over 50 per cent of the population are now served by fundholding practices. This paper examines the limited evidence to date on the effects of fundholding. Four areas of concern are identified: priority setting by fundholders; the management of financial risk; budget setting; and the allocation of resources between fundholders and non-fundholders. In each of these areas, ways in which the scheme might be improved are discussed.

Budgets↗
PubMed1994

A taxonomy of shared care for chronic disease.

BACKGROUND: Shared care is promoted as a way of integrating primary and secondary services and achieving one of the targets set for the NHS in the 1990s. We aimed to compose a taxonomy of shared care schemes for chronic disease in order to inform the development of develop shared care. METHODS: A two-phase postal questionnaire survey of Scotland and North West Thames Region, England. In the first phase we identified the number of shared care schemes for chronic disease, which were followed up in the second phase. RESULTS: Shared care schemes were classified into six groups, or models, according to their method of data transfer. These are: (I) community clinics, where the specialist undertakes a clinic in general practice; (II) basic, where communication comprises the regular exchange of letters or standardized record sheets; (III) liaison, where the hospital team and general practitioner (GP) meet to discuss and agree the management of patients under shared care; (IV) shared care record cards, where the exchange of information is made through a booklet or 'cooperation card', commonly carried by the patient; (V) computer-assisted shared care, where a circuit of information is established between GP and hospital specialist based on data collected at each patient visit and mediated through computer-generated summaries; (VI) electronic mail, where hospital specialist and GP both have access to the same data on patients shared between them. CONCLUSION: Despite substantial variation in the operation of shared care, schemes can be broadly classified and constructed in six different ways. In establishing this taxonomy, a choice is offered to health care workers wishing to develop shared care.

Chronic Disease↗
PubMed1994

The detection, quantification and partial characterisation of cathepsin B-like activity in human pathological synovial fluids.

In this study, the levels of the cysteine proteinase--cathepsin B were measured in diseased synovial fluids using a steady state fluorometric assay. Cathepsin B-like activity was shown to be present in all the samples analysed, with the rheumatoid arthritic synovial fluids possessing significantly higher concentrations (mean value ca. 416 mg/l) than the osteoarthritic fluids (mean value ca. 142.4 mg/l). In addition, upon treatment with pepsin, all of the rheumatoid arthritis samples were shown to possess additional cathepsin B-like activity, suggesting the presence of a reservoir of latent precursor molecules. By utilising a recently developed biotinylated affinity label for cathepsin B-like proteinases and sheep anti-(human cathepsin B) antibodies, used in combination with SDS-PAGE and Western blotting, the rheumatoid arthritic synovial cathepsin B was shown to exist in two forms with apparent molecular masses of M(r) 29,000 and 42,000. We propose that the former is a functionally active proteinase, whereas the latter is a pepsin activatable proform which, when cleaved by this aspartyl proteinase, is converted into a catalytically competent species of M(r) 20,000.

Affinity Labels↗