Domiciliary thrombolysis by general practitioners.
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Home Care Services↗
Biomedical subjects
J Rawles
Publications and source records attributed to J Rawles.
Quality of life in the first 100 days after suspected acute myocardial infarction--a suitable trial endpoint?
STUDY OBJECTIVE: The aim was to determine the loss of quality of life following admission to hospital with suspected myocardial infarction. DESIGN: The study involved a cohort of admissions, with interview and follow up for 100 days. Main outcome measures were the quality of life prior to admission and at each stage of convalescence, estimated using the Rosser-Kind matrix: the calculated number of quality adjusted days during a 100 d follow up period. SETTING: The study took place in a teaching hospital in Scotland. PATIENTS: 206 patients were admitted with suspected acute myocardial infarction. Infarction was confirmed in 160 (Q wave infarcts 100, non-Q-wave infarcts 60), and unconfirmed in 46. MAIN RESULTS: The quality of life scores before the suspected heart attack were similar for patients whose final diagnosis was Q wave infarction, non-Q-wave infarction, or non-infarction. Of the 160 patients with confirmed infarction, only 54 (34%) had regained their previous quality of life scores at the end of 100 days, compared with 26 of 46 (57%) patients with unconfirmed infarction (p < 0.01). The mean numbers of quality adjusted days lost to patients with Q wave infarction, non-Q-wave infarction, and non-infarction were 17.0, 12.4, and 5.9 respectively (infarction v non-infarction, p < 0.0001). Measurements of both quantity and quality of life contributed to these results. CONCLUSIONS: The number of quality adjusted days lost after acute myocardial infarction is a practicable measurement that is relevant to patients' lives. It might be suitable as an outcome measure for clinical trials of thrombolytic therapy.
Adult↗
General practitioners and emergency treatment for patients with suspected myocardial infarction: last chance for excellence?
Pre-hospital coronary care usually consists of a medically staffed coronary care ambulance going into the community from a hospital base, as pioneered in Northern Ireland. In today's medicopolitical and economic climate, this model is not viable in mainland United Kingdom. Current proposals seem to favour a 'scoop and run' policy for heart attack victims, that utilizes the ambulance service but bypasses the general practitioner. Since the majority of telephone calls from people with suspected myocardial infarction are directed to general practitioners, a preferable alternative would be a 'stay and stabilize' strategy that uses the existing referral pattern and builds on general practitioners' medical education and skills. The role of the general practitioner in the management of patients with suspected myocardial infarction is discussed.
Ambulances↗
Cost effectiveness of cardiac defibrillation by general practitioners.
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Cost-Benefit Analysis↗
Comparison of four different Doppler instruments used to measure linear and volumetric cardiac output: a study of reproducibility and agreement.
Values of stroke distance obtained from 25 subjects with the obsolete Transcutaneous Aortovelograph were compared with those from two commercially available Doppler ultrasound devices, the Doptek Decoder, and the Doppler unit of the Interspec-XL Ultrasound System. Also studied was the Quantascope, an ultrasound device designed to measure stroke volume. In the aortic arch, reproducibility was 4.8% with the Transcutaneous Aortovelograph, 9.1% with the Doptek Decoder, 17.2% with the Interspec, and 23.6% with the Quantascope. In the ascending aorta, reproducibility was worse, being 13.4% for the Doptek, 23.0% for the Interspec, and 28.1% for the Quantascope. There was close agreement between the absolute values of stroke distance obtained with the Transcutaneous Aortovelograph and the Interspec, but lower values were obtained by the Doptek Decoder. There is a need for an updated instrument dedicated to the measurement of stroke distance in the aortic arch.
Adolescent↗
A comparison of the chronic effects of oral xamoterol and enalapril on blood pressure and renal function in mild to moderate heart failure.
1. We compared the effects, after 3 weeks oral therapy, of xamoterol 200 mg twice daily and enalapril 2.5, 5 or 10 mg twice daily on home and clinic blood pressure, glomerular filtration rate (GFR) and renal plasma flow, stroke and minute distances, linear resistance and on plasma renin activity in 19 patients with mild to moderate heart failure in a single-blind randomised crossover study. 2. Enalapril reduced mean home blood pressure by 17/7 mm Hg compared with xamoterol (P less than 0.0001) and by 19/7 mm Hg compared with placebo. Compared with placebo xamoterol had no effect. Enalapril reduced predose blood pressure, compared with xamoterol, on average by 15/5 mm Hg (P = 0.02 systolic, 0.09 diastolic) and by 20/7 mm Hg compared with placebo. At 4 h post-dose the mean differences were: xamoterol-enalapril 13/10 mm Hg (P = 0.01 systolic, 0.0007 diastolic) and placebo-enalapril 23/9 mm Hg. 3. Stroke and minute distances were marginally less 4 h following xamoterol than following enalapril: mean (s.e. mean) values were 9.4 (0.7) vs 10.4 (0.8) cm (P = 0.23) and 699 (51.7) vs 767 (62.1) cm (P = 0.04) respectively. Linear resistance was reduced by enalapril, from the placebo value of 13.2 (1.2) to 11.0 (0.9) mm Hg m-1 and marginally increased by xamoterol, to 14.2 (1.2) mm Hg m-1, the difference between active treatments being statistically significant (P = 0.03). 4. Renal plasma flow, GFR and filtration fraction were not influenced by enalapril or xamoterol therapy. There were no significant correlations between glomerular filtration rate and either blood pressure or stroke distance.(ABSTRACT TRUNCATED AT 250 WORDS)
Adrenergic beta-Agonists↗
The QALY argument: a physician's and a philosopher's view.
The arguments used by Gavin Mooney in his scornful response to Castigating QALYs, are examined. In spite of the rhetoric there is a broad measure of agreement about the deficiencies of QALYs as a means of distributing scarce resources. The main area of conflict is that John Rawles favours compaigning for more resources while Gavin Mooney, constrained by his remit as a health economist, favours acceptance of the present level of funding and better methods of distributing resources.
Attitude of Health Personnel↗
The management of suspected myocardial infarction by Scottish general practitioners with access to community hospital beds.
General practitioners working in 20 community hospitals in Scotland participated in a survey of the management of myocardial infarction. During one year they suspected acute myocardial infarction in 451 patients. Of these patients, 278 (62%) were admitted to a community hospital, 125 (28%) to a district general hospital and 48 (11%) were kept at home. The main reasons given for admission to a community hospital were for monitoring and investigation, while the main reasons for admission to a district hospital rather than a community hospital were the relative youth of the patient and the severity of the illness. Acute myocardial infarction was confirmed in 323 (72%) cases, but in 26 (6%) cases the final diagnosis was other than ischaemic heart disease. Patients with acute myocardial infarction who entered a community hospital did so a median of two hours 25 minutes after the onset of symptoms. Among 18 patients admitted to a community hospital in whom resuscitation was attempted after cardiac arrest four (22%) were subsequently discharged from hospital. The mortality rate from acute myocardial infarction in the community studied was 171/418 (41%), of whom 95 died suddenly before coming under medical care. It is concluded that in rural areas of Scotland an acceptable standard of care for patients with acute myocardial infarction, including the administration of thrombolytic therapy, could be provided rapidly by general practitioners working in community hospitals.
Adult↗
Evaluation of a long acting formulation of nicardipine in hypertension by clinic and home recorded blood pressures and Doppler aortovelography.
1. A novel formulation of nicardipine (50% standard (short acting), 50% sustained release) was evaluated in mild hypertension in a double-blind, randomized, placebo-controlled study, using clinic measurements (Hawksley) augmented by home recorded blood pressures (Copal UA 251). 2. Nicardipine 60 mg twice daily for 28 days produced a highly significant reduction in sitting blood pressure compared with placebo both pre dose (mean difference 17/8 mm Hg) and 2 h post dose (mean difference 34/26 mm Hg). 3. Home recordings confirmed the hypotensive effect and also revealed a consistent 'peak' effect between 2-4 h after dosing (mean difference 32/22) mm Hg). 4. Doppler aortovelography at 2 h post-dose showed a significant increase in in stroke and minute distance (linear analogues of stroke volume and cardiac output respectively) compared with placebo. The increase in stroke distance was linearly related to change in plasma concentration of nicardipine. 5. Of the 14 patients enrolled in the study, nine experienced troublesome adverse effects on nicardipine (headaches, facial flushing, palpitations, ankle oedema) and two of these were unable to complete the study as a result. 6. This formulation of nicardipine, in the fixed dosage used in this study, is characterized by an effective antihypertensive action but also by an unacceptable adverse effect profile, presumably due to an excess of its 'short acting' component.
Blood Pressure↗
Castigating QALYs.
The ethical problem of how to apportion limited resources amongst the needy has been forced on us by arbitrary limitation of health expenditure. Its solution would not be required if health expenditure were higher. Distribution of resources according to best value for money, assessed as Quality Adjusted Life Years (QALYs) per unit cost, has been suggested as a possible solution, but leads to absurd anomalies. In the calculation of QALYs the implied value of life is no more than the absence of suffering. The use of QALYs for the comparison of treatments that are symptomatic or life-saving therefore leads to serious undervaluation of life and treatments that prolong it. Moreover, distribution of resources by best value for money, however assessed, is inequitable since for a given degree of suffering those whose illnesses happen to be cheaper to treat will be treated in preference to those whose treatments are more expensive.
Economics↗
Measurement of cardiac output.
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Cardiac Output↗
Cardiac output in twin pregnancy.
No significant difference has been found in either stroke volume or cardiac output between twin pregnancies and singleton pregnancies. Cardiac output is less in preeclamptic twin pregnancies.
Blood Pressure↗
A simple, non-invasive method of assessing the acute hemodynamic effects of doxorubicin.
Left ventricular stroke distance was measured by Doppler ultrasound in 10 doxorubicin-treated and 10 control patients. Measurements were made 10 min, 2 h and 4 h after drug administration. Stroke distance (a linear analogue of stroke volume) increased significantly from 12.6 cm (S.D. 2.7) before and 12.5 cm (S.D. 2.7) 10 min after, to 13.6 cm (S.D. 2.8) 2 h after and 13.7 cm (S.D. 2.7) 4 h after doxorubicin (p less than 0.05). Throughout the study period there were no significant changes in stroke distance in the control patients who were infused with similar fluid volumes, and no significant changes in heart rate or blood pressure in either group. These observations confirm previous findings made by radionuclide ventriculography, a much more complex, expensive and hazardous technique, not amenable to repetition at short time intervals. The measurement of stroke distance by Doppler ultrasound is a convenient bedside method of assessing acute hemodynamic changes after doxorubicin or any drug affecting cardiac function. The method we describe is eminently suitable for investigating the cardiotoxicity of chemotherapeutic agents.
Adult↗