Biomedical subjects
M McNicol
Publications and source records attributed to M McNicol.
Alternative models of organisation are needed.
Anyone considering a fundamental rethink of the role of consultants risks exposing tensions in the medical profession that have characterised the development of medical practice since the 18th century. That tense story was one of beds and money, power and domination. Rethinking the role of consultants must now take into account the relationship between consultants and their specialist colleagues and general practitioners; examine the distribution of work between consultants and junior doctors; and relate the contribution of the consultant as specialist to that of other health professionals. After half a century of a national health service characterised by equity of access to care, we urgently need to debate the roles of those who work in it and in doing so to focus primarily on the needs of patients.
Implementing clinical guidelines. Has a lot to offer patient care.
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Team working: the key to implementing guidelines?
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Secondary care beyond Tomlinson: an opportunity to be seized or squandered?
The Tomlinson report's emphasis on primary care and its essentially quantitative analysis of hospital care in London leaves little space for a picture of how secondary care for Londoners should look. In this article Fiona Moss and Martin McNicol argue that most outpatient work does not need to be done in hospitals. With proper organisation and better premises a genuinely specialist consultative service can be provided in primary health care centres, with benefit to patients and communication between primary and secondary care doctors. Hospitals would then house those outpatient services that needed major investigative facilities and much reduced inpatient capacity. It may no longer be necessary for each acute unit to offer a full range of services. Such a pattern of secondary care will have implications for the organisation of accident and emergency services and for postgraduate training. Above all Moss and McNicol argue that Tomlinson's recommendations demand that general practitioners and specialists should re-examine the services hospitals provide and agree on the best settings for different sorts of health care and the most appropriate skills to provide it.
Radiological features during and following treatment of spinal tuberculosis.
A retrospective study was performed in order to document the sequence and time scale of radiological changes occurring during the healing of spinal tuberculosis. 28 episodes occurred in 26 patients, of whom only two were Caucasian. All demonstrated good response to conventional chemotherapy. Soft-tissue masses increased in size for up to 1.5 months and took about 12 months to resolve. Bone destruction was seen in all cases and progressed in 70% of patients, whilst on treatment. There was loss of vertebral body height in 79%, which progressed for up to 14 months; any recovery of height was a very late feature. Sclerosis was seen at presentation in 52% and developed in most of the remaining patients within 5 months of instigating treatment. It progressed for up to 14 months and took, on average, 31 months to return to normal. Reduction in disc height was commonly seen and the vertebrae fused in three-quarters of those affected, the time of onset of fusion being very variable. To manage patients with spinal tuberculosis, an appreciation of the variability of radiological changes that can occur during treatment is necessary.
An inhibitor of the toxicity of tumour necrosis factor in the serum of patients with sarcoidosis, tuberculosis and Crohn's disease.
The activated macrophages present in the T cell-dependent granulomata of sarcoidosis and tuberculosis are primed for enhanced release of cytokines including tumour necrosis factor (TNF or cachectin). Release of this cytokine can induce an acute-phase response, fever, and necrosis in suitably prepared sites of inflammation; if chronic, its presence may contribute to weight loss. These clinical features are characteristic of tuberculosis, but not of sarcoidosis, though alveolar macrophages from both diseases release large quantities of TNF in vitro. We therefore postulated the presence in sarcoidosis patients of an inhibitor of TNF. We have studied levels of TNF inhibitory activity by determining the quantity of TNF required to give 50% kill of L929 cells in the presence of 20% heat-inactivated serum derived from various disease states (37 sarcoidosis, 13 tuberculosis, 13 Crohn's disease, 17 healthy donors). Normal sera used in this way do not inhibit significantly, but inhibition of TNF toxicity is caused by most sera from both sarcoidosis and tuberculosis. Used at 20%, five out of 37 sarcoidosis sera and one out of 13 tuberculosis sera caused complete inhibition of TNF, even when the latter was added at 100 times the concentration required to give 50% kill in control wells. This inhibitor may have an important physiological role.
Trends in the epidemiology of tuberculosis--a physician's view.
It is likely that the incidence of tuberculosis will continue to decline, although there will be problems in areas with large numbers of immigrants from Third World countries. They will present problems only if they come from countries with high incidence of primary drug resistance. In the indigenous population there is one problem group--middle aged and elderly men often with sputum positive disease. Diagnosis tends to be delayed, they may not co-operate with treatment and there is a significant death rate. Despite the very substantial decline in incidence, it is probably premature to abandon BCG vaccination, although this will have to be reconsidered within the next 10 years.
Spread of tuberculosis within a family.
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Management of terminally ill cancer patients and facilities and services for their care.
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Computed tomography in pulmonary sarcoidosis.
A group of 34 proven cases of pulmonary sarcoidosis was investigated by computed tomography (CT) to determine whether CT provided any information beyond that obtained from conventional chest films. Computed tomography disclosed a surprisingly high prevalence of minor pleural changes in sarcoidosis, including two patients with small pleural effusions. Unsuspected bullae and isolated "granulomatous" nodules were additionally demonstrated. Increases in lung density and alterations in gravity dependent vascular perfusion were assessed; these may reflect alterations in the vascular bed, and the increased density is possibly due to diffuse invasion of the lung not recognizable by conventional chest X-ray films. Tracheal compression was noted in one case and vertebral densities in three. Prominence of "small air spaces" was recorded in four patients; the nature of the pathology responsible for this finding is at present speculative. While not replacing conventional chest radiography, CT does make a definite contribution to the assessment of pulmonary sarcoidosis.
Treatment of tuberculosis.
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