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Biomedical subjects

J Hurley

Publications and source records attributed to J Hurley.

At least 19 recordsLinked to original sources
PubMed2006

Proposed changes to the Mental Health Act of England and Wales: research indicating future educational and training needs for mental health nurses.

Proposed changes to the Mental Health Act (MHA) legislation in England and Wales have been identified as having significant impact upon both mental health service delivery and professional roles. Key issues being identified for both service delivery and professionals are the creation of approved mental health professionals (AMHP), increased demand upon community services and a potential negative impact upon the therapeutic relationship. Mental health nurses in particular have expressed their concerns, through their professional bodies, regarding the impact of the proposed MHA changes upon the therapeutic relationship. The aim of this article is to present findings from recently conducted research that explores experiences and perceptions of approved social workers (ASWs) regarding the impact of invoking the MHA upon the therapeutic relationship. These findings inform wider mental health nursing practice of essential skills and knowledge to protect and potentially enhance the therapeutic relationship while invoking MHA legislation. A questionnaire was distributed to ASWs working within the Trent region. The questionnaire included both closed and open questions inviting respondents to expand upon their experiences with the brief initial findings being earlier published. Semi-structured interviews with eight invited respondents to develop their responses were undertaken enabling an approach that was both conversational and emergent.

Attitude of Health Personnel↗
PubMed2006

'Let a hundred flowers blossom, let a hundred schools of thought contend': a case for therapeutic pluralism in mental health nursing.

With the dominance of cognitive behavioural therapies within mental health nursing educational and practice settings, a danger exists that a narrow application of therapy interventions and micro skills will result. Given the rich and diverse variations of presenting circumstances to community mental health services, an incorporation of therapy approaches beyond the cognitive behavioural model is essential. This paper initially aims to demonstrate the core values of mental health nursing as being at least partially incongruent with those of cognitive behavioural therapies. This paper also aims to provide brief examples of the use of alternate evidential practice-based therapies more reflective of mental health nursing values across a spectrum of community mental health service where the authors are employed.

Community Mental Health Services↗
PubMed2004

Pharmacokinetics of sirolimus in heart transplant recipients with chronic renal impairment.

BACKGROUND: A common clinical problem following organ transplantation is the development of renal failure due to calcineurin inhibitors. Sirolimus offers the potential of providing appropriate immunosuppression without nephrotoxicity. This study evaluates the impact of sirolimus monotherapy on renal function in patients late following heart transplantation and correlates trough sirolimus levels with area-under-the-concentration time curve measurements. METHODS: Six male patients with renal impairment late following heart transplantation (mean 8 years) were offered sirolimus therapy. Calcineurin inhibition was discontinued in all patients on commencing sirolimus. Patients started on sirolimus 2 to 5 mg/d orally. Venous blood samples for pharmacokinetic studies and repeat creatinine clearance were performed before and 6 weeks after commencement of sirolimus in all subjects. RESULTS: Sirolimus trough levels accurately reflected sirolimus area-under-the-concentration time curve measurements. There was no change in renal function. Mean creatinine clearance prior to commencing sirolimus was 26.7 (12.2) mL/min and the post-sirolimus creatinine clearance performed 6 weeks later was 23.4 (11.7) mL/min (P = .64). CONCLUSIONS: Trough levels of sirolimus correlate with drug exposure and may be used to monitor sirolimus therapy. No improvement in renal function following calcineurin inhibitor withdrawal occurred in this cohort.

Aged↗
PubMed2003

Isolated chylopericardium.

A 25-year-old male was discovered to have an asymptomatic pericardial effusion during routine pre-employment medical evaluation. During pericardiocentesis 1200 ml of milky-white fluid was obtained; subsequent biochemical evaluation confirmed the chylous nature of this fluid. Following thorough evaluation a diagnosis of isolated chylopericardium was made. Following several recurrences he underwent thoracotomy with ligation of the thoracic duct and creation of a pericardial window. There are relatively few published reports of true isolated chylopericardium and the aetiology and pathogenesis remain unknown. A primary abnormality of the thoracic lymphatic valve system is postulated. The most effective treatment is surgical with ligation of the thoracic duct above the diaphragm and creation of a pericardial window

Adult↗
PubMed2003

Different responses to preoperative chemotherapy for invasive lobular and invasive ductal breast carcinoma.

AIM: Preoperative chemotherapy (PCT) is used in primary breast cancer, to facilitate breast conservative surgery (BCS). Clinical and pathologic responses are important prognostic parameters. Biologic markers are needed to individualize treatment. PATIENTS AND METHODS: One hundred and thirty-five patients with breast carcinoma were treated with PCT, followed by surgery and adjuvant therapy. Clinical response and pathological complete response (pCR), biological markers and type of surgery were compared between invasive ductal (IDC) and invasive lobular carcinoma (ILC). RESULTS: Overall response (OR) for IDC was 75% compared to 50% for ILC (P=0.0151). Pathological CR was 15% for IDC and 0% for ILC (P=0.0066). Fifty-six percent of the responding patients had BCS, in contrast with 16% of the non-responders. BCS was performed in 50% of patients with IDC, in 38% of the patients with ILC. Salvage surgery was more necessary in ILC (19%) compared to IDC (4%) (P=0.0068). Patients with ILC were more frequently ER-positive and HER-2 negative than patients with IDC. CONCLUSIONS: Clinical and pathological responses are lower in ILC compared to IDC. After PCT, patients with large ILC should preferably be offered mastectomy with immediate breast reconstruction. However, PCT still remains valuable to evaluate tumor response and biologic factors in vivo.

Adult↗
PubMed2001

Devolution to democratic health authorities in Saskatchewan: an interim report.

BACKGROUND: In 1995 Saskatchewan adopted a district health board structure in which two-thirds of members are elected and the rest are appointed. This study examines the opinions of board members about health care reform and devolution of authority from the province to the health districts. METHODS: All 357 members of Saskatchewan district health boards were surveyed in 1997; 275 (77%) responded. Analyses included comparisons between elected and appointed members and between members with experience as health care providers and those without such experience, as well as comparisons with hypotheses about how devolution would develop, which were advanced in a 1997 report by another group. RESULTS: Most respondents felt that devolution had resulted in increased local control and better quality of decisions. Ninety-two percent of respondents believed extensive reforms were necessary and 83% that changes made in the previous 5 years had been for the best. However, 56% agreed that there was no clear vision of the reformed system. A small majority (59%) perceived health care reform as having been designed to improve health rather than reduce spending, contrary to a previous hypothesis. Many respondents (76%) thought that boards were legally responsible for things over which they had insufficient control, and 63% perceived that they were too restricted by rules laid down by the provincial government, findings that confirm the expectation of tensions surrounding the division of authority. Respondents with current or former experience as health care providers were less likely than nonprovider respondents to believe that nonphysician health care providers support decisions made by the regional health boards (45% v. 63%, p = 0.02), a result that confirmed the contention that the role of health care providers on the boards would be a source of tension. INTERPRETATION: Members of Saskatchewan district health boards supported the general goals of health care reform and believed that changes already undertaken had been positive. There were few major differences in views between appointed and elected members and between provider and nonprovider members. However, tensions related to authority and representation will require resolution.

Adult↗
PubMed2001

Ethics, economics, and public financing of health care.

There is a wide variety of ethical arguments for public financing of health care that share a common structure built on a series of four logically related propositions regarding: (1) the ultimate purpose of a human life or human society; (2) the role of health and its distribution in society in advancing this ultimate purpose; (3) the role of access to or utilisation of health care in maintaining or improving the desired level and distribution of health among members of society, and (4) the role of public financing in ensuring the ethically justified access to and utilisation of health care by members of society. This paper argues that economics has much to contribute to the development of the ethical foundations for publicly financed health care. It focuses in particular on recent economic work to clarify the concepts of access and need and their role in analyses of the just distribution of health care resources, and on the importance of economic analysis of health care and health care insurance markets in demonstrating why public financing is necessary to achieve broad access to and utilisation of health care services.

Canada↗
PubMed2001

A prospective randomized, controlled trial comparing synchronized nasal intermittent positive pressure ventilation versus nasal continuous positive airway pressure as modes of extubation.

OBJECTIVE: To determine whether synchronized nasal intermittent positive pressure ventilation (SNIPPV) would decrease extubation failure compared with nasal continuous positive airway pressure (NCPAP) in preterm infants being ventilated for respiratory distress syndrome (RDS). METHODS: Infants who were </=34 weeks' gestational age and who were ventilated for RDS were randomized to either SNIPPV or NCPAP after extubation. The criteria for extubation were peak inspiratory pressure of </=16 cm H(2)O, positive end expiratory pressure of </=5 cm H(2)O, intermittent mandatory ventilation rate of 15 to 25, and fraction of inspired oxygen </=0.35. Pulmonary function tests (PFT) were obtained before extubation. After extubation, blood gases were monitored for a minimum of 72 hours. Success was defined as remaining in the selected mode of treatment or demonstrating improvement (switching to oxyhood/nasal cannula/room air) by 72 hours. RESULTS: Thirty-two (94%) of 34 infants were extubated successfully with the use of SNIPPV versus 18 (60%) of 30 with the use of NCPAP (P <.01). There was no difference in apnea/bradycardia episodes in the 2 groups during the 72-hour study period. Among 55 infants who had PFT, 80% (8 of 10) with dynamic lung compliance of >/=0.5 mL/kg/cm H(2)O and expiratory airway resistance of </=70 cm H(2)O/L/s were extubated successfully. In infants with poor lung function (dynamic lung compliance: <0.5 mL/kg/cm H(2)O; expiratory airway resistance: >70 cm H(2)O/L/s), successful extubation was seen in 93% (27 of 29) in the SNIPPV group and 60% (15 of 25) in the NCPAP group. When weight was controlled for at the time of extubation, the odds of success in the SNIPPV group were 21.1 times higher (95% confidence interval: 3.4, 130.1) than that of the NCPAP group. CONCLUSIONS: SNIPPV is more effective than NCPAP in weaning infants with RDS from the ventilator. PFT may be useful in predicting successful extubation.

Female↗
PubMed2001

Breast cancer and human immunodeficiency virus: a report of 20 cases.

Carcinoma of the breast is the most common malignancy in women in the United States. More than 40% of patients with human immunodeficiency virus (HIV) infection develop cancer during their illness, but breast cancer has seldom been reported. Twenty patients with breast cancer and HIV infection seen at the University of Miami/Jackson Memorial Hospital between January 1988 and August 2000 were retrospectively analyzed. Seventeen patients had a previous or concurrent diagnosis of HIV at the time of the breast cancer diagnosis. Their CD4 count ranged from 13-1126/microL (median, 309/microL). Most patients were premenopausal (16 of 20), with ages ranging from 31-61 years (median, 44 years). All stages of breast cancer were seen: ductal carcinoma in situ (2 patients), stage I (1 patient), stage II (9 patients), stage III (6 patients), and stage IV (2 patients). Ten tumors had estrogen receptors. Four of the 13 patients who underwent axillary lymph node dissection had abnormal lymph node findings, including 2 with follicular hyperplasia and 2 with caseating granulomas. Seven patients received chemotherapy with very poor tolerance. Estrogen receptor-positive patients were treated with tamoxifen. Of the 18 patients who presented with local disease, 7 have died: 2 of breast cancer, 4 of acquired immunodeficiency syndrome, and 1 of cardiac arrest. Nine patients remain free of disease (5 of them > 5 years) and 2 patients are alive with metastatic disease. Breast cancer in the HIV-positive population is similar to that seen in seronegative women. Most of the patients that are long-term survivors were treated with surgery and tamoxifen. The benefits of adjuvant chemotherapy are not clear.

Adult↗
PubMed2000

Racial and ethnic disparities in faculty promotion in academic medicine.

CONTEXT: Previous studies have suggested that minority medical school faculty are at a disadvantage in promotion opportunities compared with white faculty. OBJECTIVE: To compare promotion rates of minority and white medical school faculty in the United States. DESIGN AND SETTING: Analysis of data from the Association of American Medical Colleges' Faculty Roster System, the official data system for tracking US medical school faculty. PARTICIPANTS: A total of 50,145 full-time US medical school faculty who became assistant professors or associate professors between 1980 and 1989. Faculty of historically black and Puerto Rican medical schools were excluded. MAIN OUTCOME MEASURES: Attainment of associate or full professorship among assistant professors and full professorship among associate professors by 1997, among white, Asian or Pacific Islander (API), underrepresented minority (URM; including black, Mexican American, Puerto Rican, Native American, and Native Alaskan), and other Hispanic faculty. RESULTS: By 1997, 46% of white assistant professors (13,479/28,953) had been promoted, whereas 37% of API (1123/2997; P<.001), 30% of URM (311/1053, P<.001), and 43% of other Hispanic assistant professors (256/598; P =.07) had been promoted. Similarly, by 1997, 50% of white associate professors (7234/14,559) had been promoted, whereas 44% of API (629/1419; P<.001), 36% of URM (101/280; P<.001), and 43% of other Hispanic (122/286; P =.02) associate professors had been promoted. Racial/ethnic disparities in promotion were evident among tenure and nontenure faculty and among faculty who received and did not receive National Institutes of Health research awards. After adjusting for cohort, sex, tenure status, degree, department, medical school type, and receipt of NIH awards, URM faculty remained less likely to be promoted compared with white faculty (relative risk [RR], 0.68 [99% confidence interval CI, 0.59-0.77] for assistant professors and 0.81 [99% CI, 0.65-0.99] for associate professors). API assistant professors also were less likely to be promoted (RR, 0.91 [99% CI, 0.84-0.98]), whereas API associate professors and other Hispanic assistant and associate professors were promoted at comparable rates. CONCLUSION: Our data indicate that minority faculty are promoted at lower rates compared with white faculty. JAMA. 2000;284:1085-1092

Career Mobility↗
PubMed2000

Minority cancer patients and their providers: pain management attitudes and practice.

BACKGROUND: The goals of the current studies were: 1) to determine the pain treatment needs of socioeconomically disadvantaged African-American and Hispanic patients with recurrent or metastatic cancer and 2) to assess the attitudes of health care professionals who treat them. METHODS: In the first study 108 African-American and Hispanic patients with metastatic or recurrent cancer and pain completed a survey about their pain intensity, pain interference, and attitudes toward analgesic medications. Physicians also rated their patients' pain and the adequacy of the patients' current analgesic prescriptions was assessed. In the second study 55 physicians and nurses who treat these patients completed a questionnaire regarding cancer pain and its management in their practice settings. RESULTS: Approximately 28% of the Hispanic and 31% of the African-American patients received analgesics of insufficient strength to manage their pain. Although the majority of patients received appropriate analgesics, 65% reported severe pain. Physicians underestimated pain severity for 64% of the Hispanic and 74% of the African-American patients. Physicians were more likely to underestimate the pain severity of female patients than male patients. Inadequate pain assessment, patient reluctance to report pain, and lack of staff time were perceived as barriers to pain management. CONCLUSIONS: Although the data suggest recent improvements in analgesic prescribing practices for African-American and Hispanic cancer patients, the majority of patients reported high levels of pain and limited pain relief from analgesic medications. Inadequate pain assessment remains a major barrier to optimal cancer pain treatment.

Adult↗
PubMed2000

A clinical trial of intravenous vinorelbine tartrate plus tamoxifen in the treatment of patients with advanced malignant melanoma.

BACKGROUND: The aim of the current trial was to assess the efficacy and toxicity of weekly intravenous vinorelbine tartrate with daily oral tamoxifen in the treatment of patients with advanced or metastatic malignant melanoma. METHODS: Thirty-one patients were treated with vinorelbine tartrate, 30 mg/m(2) intravenously, weekly every 13 weeks and then every 2 weeks thereafter until progression of disease or severity of toxicity warranted discontinuation. Tamoxifen, 10 mg orally, twice a day was administered daily starting on Day 1 of chemotherapy with vinorelbine tartrate. Thirty patients had cutaneous melanoma with metastases and 1 patient had ocular melanoma with metastases. Eight patients had received prior chemotherapy. RESULTS: Of the 30 evaluable patients with cutaneous melanoma, 6 achieved a partial response, for an overall response rate of 20% (95% confidence interval, 7-38%). There was no response in the patient with ocular melanoma. Major sites of response include the adrenal gland, lung, tonsil, and cutaneous/subcutaneous tissues. Three patients had a prolonged duration of response lasting > or = 12 months. Side effects generally were mild and tolerable. Grade 3 or 4 hematologic toxicity occurred in 26% and 13% of patients, respectively. Nonhematologic toxicity included mild fatigue, paresthesia, and local arm discomfort from infusion. CONCLUSIONS: Weekly intravenous vinorelbine tartrate plus daily oral tamoxifen appears to be active in the treatment of patients with malignant melanoma. Further clinical trials in malignant melanoma patients treated with vinorelbine tartrate and tamoxifen appear warranted.

Administration, Oral↗
PubMed2000

Purification of myristoylated and nonmyristoylated neuronal calcium sensor-1 using single-step hydrophobic interaction chromatography.

Neuronal calcium sensors (NCSs) belong to a family of Ca(2+)-binding proteins, which serve important functions in neurotransmission, and are highly conserved from yeast to humans. Overexpression of the neuronal calcium sensor-1, called frequenin in the fruit fly and in frog, increases the release of neurotransmitters. Studying the functional role of frequenin in mammals and understanding its structural dynamics is critically dependent on the availability of active purified protein. Neuronal calcium sensors like other members of the family share common structural features: they contain four EF-hands as potential binding sites for Ca(2+) and an N-terminal consensus sequence for myristoylation. Previously, recoverin, distantly related to NCSs, has been expressed and purified from Escherichia coli, involving a combination of different chromatographic steps. NCS-1 has earlier been purified adopting a two-step procedure used for recoverin purification. We have overexpressed NCS-1 from rat in its myristoylated and nonmyristoylated form in E. coli and purified it from crude lysates using a single-step hydrophobic interaction chromatography. The purified protein was identified by Western blotting and mass spectrometry and assayed for its ability to bind Ca(2+) using a Ca(2+) shift assay, terbium fluorescence, and Stains-all binding. The present protocol provides a rapid, more efficient and simplified, single-step method for purifying NCS-1 for structural and functional studies. This method can also be applied to purify related proteins of the superfamily.

Animals↗
PubMed2000

Laparoscopic suture rectopexy without resection is effective treatment for full-thickness rectal prolapse.

PURPOSE: The study was undertaken to evaluate the role of laparoscopic suture rectopexy without resection as a safe and effective treatment for full-thickness rectal prolapse. METHOD: Data were prospectively collected and analyzed on 25 patients who underwent laparoscopic rectopexy without resection for full-thickness rectal prolapse between October 1994 and July 1998. Four patients had conversions from laparoscopic to open surgery. Two patients had recurrent prolapse previously managed by Delorme's procedure. Another two patients had solitary rectal ulcer syndrome associated with their full-thickness rectal prolapse. There were a total of three males. Mean age was 72 (range, 37-89) years. The preoperative and postoperative course of each patient was followed up, with attention paid to first bowel movement, hospital stay, duration of surgery, fecal incontinence, constipation, recurrent prolapse, morbidity, and mortality. Follow-up was made by clinic appointments and, if necessary, by telephone review. RESULTS: Median follow-up period was 26 (range, 1-41) months. Mean duration of surgery was 96 (range, 50-150) minutes. Postoperatively, the median time for first bowel movement was four (range, 2-10) days. Median hospital stay was seven (range, 3-23) days. Overall, 15 patients (60 percent) either improved or remained unchanged with respect to continence. There was an improvement in 10 of 20 patients (50 percent) among those with continence Grade 2 or more (P < 0.05). Seven patients (28 percent) remained incontinent. No patient became more incontinent after surgery. Constipation, which was present in 9 patients (36 percent) preoperatively, affected 11 patients (44 percent) after rectopexy (P > 0.05; not significant). Postoperative morbidity included a port site hernia and deep venous thrombosis in one patient, a repaired rectal perforation, a retroperitoneal hematoma with prolonged ileus (1 case), and a superficial wound infection (1 case). One patient with solitary rectal ulcer syndrome in the laparoscopic surgery group remained unhealed despite resolution of the rectal prolapse after rectopexy and required abdominoperineal resection. Two patients (laparoscopic surgery = 1 and open surgery = 1) had severe constipation after surgery and both required loop colostomies. There were no cases of operative mortality or recurrent prolapse. CONCLUSION: Laparoscopic suture rectopexy without resection is both safe and effective in this frequently frail population and offers a minimally invasive approach that may have potential advantages for selected groups of patients with full-thickness rectal prolapse.

Adult↗
PubMed2000

The many meanings of deinsuring a health service: the case of in vitro fertilization in Ontario.

There is currently much international interest in principles and processes for determining which services should qualify for health insurance packages. However, there has yet been little analysis of the implications of actual deinsurance decisions made by such priority-setting exercises. This paper reports experience from the case of in vitro fertilization (IVF) deinsurance in Ontario, Canada. The analysis addresses some of the more social aspects of financial incentives by characterizing funding structures as means of communicating complex policy objectives, rather than mechanistic reward-penalty systems. Deinsuring IVF was intended to support several policy goals, including: controlling public expenditures, restricting public coverage to 'medically necessary' services, applying evidence of effectiveness as a criterion for medical necessity and implementing part of a policy program to control new reproductive technologies. It may seem a modest step to remove one dubious service from public insurance coverage. Nevertheless, as interpreted by stakeholders, deinsurance of IVF may inadvertently promote the opposite of what policy makers intended. This case suggests that priority-setting decisions based on incomplete information, inconsistently applied principles and too little attention to health system dynamics (perhaps the norm in 'real-world' priority-setting) can have the perverse effect of undermining progress toward health reform goals of improved health, reduced expenditures and more rigorously evaluated services. The case of IVF in Ontario offers several lessons for other jurisdictions engaged in priority-setting and service deinsurance: (1) individual services interact with the rest of the system and cannot be removed without systemic effects, (2) inconsistent use of coverage principles can undermine legitimacy of both priority-setting principles and processes and (3) 'evidence-based' decisions can founder on differing stakeholder ideas about appropriate evidence and on the inconsistent message given by commercializing ineffective or unproven care.

Fertilization in Vitro↗
PubMed2000

Needs-based primary medical care capitation: development and evaluation of alternative approaches.

OBJECTIVE: To develop and evaluate alternative methods of adjusting primary medical care capitation payments for variations in relative need for health care among enrolled practice populations. METHODS: We developed alternative needs-based capitation formulae and applied them to a sample of capitation-funded primary care practices to assess each formula's performance against a reference standard of capitation payments based on age, sex and self-assessed health status of the enrolled populations. The alternative formulae were based on: (1) age and sex; (2) age, sex and individually-measured socioeconomic characteristics; (3) age, sex and socioeconomic characteristics imputed from census data for enrollees' neighbourhood of residence; (4) age, sex and standardized mortality ratio for enrollees' neighbourhood of residence. RESULTS: Age/sex-adjusted capitation payments for the six practices studied ranged from 10% higher to 18% lower than the reference standard payments. Capitation formulae based on socioeconomic and mortality data did not perform consistently better than the current age/sex-based formula. CONCLUSIONS: Primary medical care capitation payments adjusted only for age and sex do not reflect the relative health care needs of enrolled practice populations. Our alternative formulae based on socioeconomic and mortality data also failed to reflect relative needs. Methods that use other approaches to adjusting for differences in relative need among enrolled populations should be investigated.

Adolescent↗