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Biomedical subjects

M Shepherd

Publications and source records attributed to M Shepherd.

At least 55 records · Page 3Linked to original sources
PubMed2000

Predictive genetic testing in diabetes: a case study of multiple perspectives.

Genetic testing is now possible in maturity onset diabetes of the young (MODY), an unusual genetic subtype of diabetes. To date, there has been no research into the implications of genetic testing for MODY families. The case study of the first known instance of predictive genetic testing for diabetes described in this article focuses on the perspectives of the family and the health care professionals involved in the decision-making process. Open-ended interviews were conducted before and after the predictive test. Content analysis highlighted four key areas: autobiographical experiences, motivations for testing, competing priorities in genetic counseling, and differing attitudes to predictive testing for children. Reactions to the predictive test result are presented. The implications of these findings for the provision of predictive genetic testing in diabetes are considered.

Adult↗
PubMed2000

Evidence on the efficacy of insert earphone and sound field VRA with young infants.

Visual reinforcement audiometry (VRA) with insert-earphone stimulus delivery provides a means of obtaining early ear-specific information on the auditory status of infants. The aim of this study was to investigate the efficacy of VRA in young infants, and to compare the use of sound field and insert-earphone stimulus presentation. VRA was performed on 41 normally developing infants aged between 20 and 42 weeks. Infants were tested in the sound field (n=22) and with insert earphones (n=19). Results showed significantly more minimum response levels (MRLs) obtained with sound field testing, and with older children. Nevertheless, in the insert-earphone group, 36% of those aged 32 weeks or more gave two or more MRLs, and 25% of the infants aged 25 weeks or less gave one or more MRLs. This study provides data from developmentally normal infants which confirms the efficacy of insert-earphones as well as sound field VRA with 32-42-week-olds, with reasonable expectation of success. The data in this study also suggest that VRA could be usefully employed for younger infants aged approximately 20-26 weeks where information, although less easily obtained, may be of particular value to early diagnosis and habilitation.

Audiometry↗
PubMed1999

Medicines management. A tension seeker.

Tensions exist across the primary-secondary care interface between GPs and hospital prescribing services. Repeat prescribing arrangements are a good focus for audit, as a patient started by the hospital on a treatment will tend to stay on it after discharge, with knock-on costs for primary care. Cost-effectiveness improvements in prescribing practice have included a significant reduction in hospital prescribing of 'loss-led' oral nitrates in favour of generic equivalents and the adoption as standard of the most cost-effective of the new proton pump inhibitors.

Continuity of Patient Care↗
PubMed1999

Efficacy of three statins at lower maintenance doses.

The purpose of this study was to determine whether patients who are receiving lovastatin 20 mg daily can be switched to daily regimens of lovastatin 10 mg, pravastatin 10 mg, or simvastatin 5 mg without loss of lipid control or an increase in side effects. One hundred five patients were identified whose lipid levels were clinically stable on a regimen of lovastatin 20 mg/d; these patients were randomly allocated to a group that continued to receive lovastatin 20 mg/d (the control group) or a group receiving 1 of the 3 alternative regimens. Patients were evaluated after 6 and 12 weeks of treatment for side effects and changes in liver and muscle enzymes and lipid levels compared with baseline. Of the 105 patients enrolled, 5 withdrew because of side effects, 4 did not return for follow up, and 3 were excluded. Ninety-three patients completed the 12-week study. When baseline values were compared to those at week 12 for each group, the proportions of patients meeting treatment goals for LDL cholesterol, as defined by the National Cholesterol Education Program, were as follows: control group, 30.8% improved; lovastatin 10 mg, 16.7% worsened; pravastatin 10 mg, 27.3% improved; and simvastatin 5 mg, no change. Patients who were switched from lovastatin 20 mg daily to pravastatin 10 mg or simvastatin 5 mg daily did not experience statistically significant changes in mean total cholesterol levels. Patients who were switched from 20 to 10 mg/d of lovastatin experienced increases in mean total cholesterol levels (from 195 mg/dL +/-5 mg/dL at baseline to 200 mg/dL +/-5 mg/dL at 12 weeks; P<0.05). There were no differences in side effects or in elevations in liver or muscle enzymes. Thus patients who are stable on 20 mg/d lovastatin can be switched to a regimen of 10 mg/d pravastatin or 5 mg/d simvastatin.

Adult↗
PubMed1999

Institutionwide pain management improvement through the use of evidence-based content, strategies, resources, and outcomes.

The Agency for Health Care Policy and Research pain guidelines and implementation theories were used in this improvement initiative to ensure that evidence-based pain management reached every provider and patient in a large tertiary care hospital. Implementation strategies, products, and outcome measures are described for use in the clinical setting. Critical success factors and implementation barriers are also addressed.

Evidence-Based Medicine↗
PubMed1999

Missense mutations in the insulin promoter factor-1 gene predispose to type 2 diabetes.

The transcription factor insulin promoter factor-1 (IPF-1) plays a central role in both the development of the pancreas and the regulation of insulin gene expression in the mature pancreatic beta cell. A dominant-negative frameshift mutation in the IPF-l gene was identified in a single family and shown to cause pancreatic agenesis when homozygous and maturity-onset diabetes of the young (MODY) when heterozygous. We studied the role of IPF-1 in Caucasian diabetic and nondiabetic subjects from the United Kingdom. Three novel IPF-1 missense mutations (C18R, D76N, and R197H) were identified in patients with type 2 diabetes. Functional analyses of these mutations demonstrated decreased binding activity to the human insulin gene promoter and reduced activation of the insulin gene in response to hyperglycemia in the human beta-cell line Nes2y. These mutations are present in 1% of the population and predisposed the subject to type 2 diabetes with a relative risk of 3.0. They were not highly penetrant MODY mutations, as there were nondiabetic mutation carriers 25-53 years of age. We conclude that mutations in the IPF-1 gene may predispose to type 2 diabetes and are a rare cause of MODY and pancreatic agenesis, with the phenotype depending upon the severity of the mutation.

Adult↗
PubMed1998

HIV-1 DNA shedding in genital ulcers and its associated risk factors in Pune, India.

HIV infection status was determined in 302 consecutive patients with genital ulcer disease (GUD) presenting to two sexually transmitted disease (STD) clinics in Pune, India. Of the 71 (24%) individuals with HIV infection, 67 (94%) were HIV antibody-positive, and 4 (6%) were HIV antibody-negative but p24 antigen-positive at the time of presentation. HIV-1 DNA was detected in 24 (34%) specimens. The genital ulcers of all four acutely infected p24-antigenemic subjects were HIV-1 DNA-positive by polymerase chain reaction (PCR) assay, compared with 20 of 67 (30%) seropositive patients (p = .01). Presence of chancroid, GUD symptoms for > 10 days, and concurrent diagnosis of cervicitis or urethritis were significantly associated risk factors for HIV-1 DNA shedding in ulcers. Early GUD diagnosis and aggressive treatment of HIV-infected patients may significantly reduce secondary transmission of HIV to other sex partners.

Adolescent↗
PubMed1998

Development and evaluation of an inner city mental health team.

The objective of this study was to examine the development and activity of a Community Mental Health Team, originally targeted to meet the needs of African Caribbean, Asian and homeless populations in an inner city area. The study was based on all (n = 1046) client referrals to the Bristol Inner City Community Mental Health Team between 1987 and 1994. Additional qualitative interviews were held with general practitioners (GPs) from each of the nine practices in the area. The setting was the inner city area of Bristol, an area with a population of around 35,000 27% of whom are from ethnic minority communities. This is an area shown in previous research to have a high level of mental health problems. Trends in referral rates, demographic characteristics and seriousness of psychiatric illness amongst those referred to the Inner City Mental Health Team were the main outcome measures used. In the years studied there were significant increases in the number and proportion of overall referrals from GPs and psychiatrists and decreases in referrals from other agencies. In particular, there were reductions in the referral both of clients from the originally identified target groups and of patients with serious mental illness. GPs tended to refer a greater proportion of patients with less serious mental illness. The results of the study showed that a team originally developed to meet the needs of the homeless and those from ethnic minorities has, with the removal of special project funding, shifted its focus away from the client groups for whom it was originally developed to those with less serious mental health problems. These changes are partially attributable both to changes in the remit of the team, making it more acceptable to GPs, and to a growing acceptance of community-based mental health services among GPs and their patients. Changes in the geographic catchment area served by the team has also played a role in the observed trends. Commissioners of mental health services need to bear in mind the needs of high-risk groups when making contracts. It may be that in order to meet effectively the needs of inner city populations with a high prevalence of mental health problems, there is a need for specialist teams with a specific remit.

Adult↗
PubMed1998

The establishment of a radioactive waste disposal facility in Western Australia for low level waste.

The Radiation Health Section of the Health Department of Western Australia has been a repository for unwanted radioactive sources for many years. They had been placed in the radioactive store located on the Queen Elizabeth II Medical Centre Campus. After a collection period of more than 20 years the storage facilities of the Radiation Health Section were nearing capacity. A decision was made to relocate these sources into a permanent near surface burial facility. Following extensive community consultation and site investigations, waste originating in Western Australia was disposed of at Mt Walton (East), 80 km North East of Koolyanobbing, Western Australia in November 1992.

Environmental Monitoring↗
PubMed1998

Emil Kraepelin and modern psychiatry.

A brief account is given of the career and scientific contributions of the German psychiatrist, Emil Kraepelin, to whom the concept of schizophrenia is generally attributed. Attention is also drawn to his social and political outlook and its relationship to his work. The implications for contemporary psychiatry are outlined.

Germany↗
PubMed1997

An update to the medical device reporting requirements of the Safe Medical Device Act.

The Safe Medical Devices Act made hospitals, nursing homes, and a variety of other health care organizations responsible for identifying and reporting injuries associated with the use of medical devices. The Final Regulation for the Medical Device Reporting of adverse events became effective on July 31, 1996. The Final Regulations incorporate significant changes from the "Proposed Final Regulations," and these changes need to be conveyed to appropriate staff of all device user facilities. Changes include the mandated reporting of user error, the Food and Drug Administration emphasis on the device manufacturer as the prime investigator of adverse events, the 10-day reporting rule that now becomes effective as soon as the facility becomes aware of the event, and the clarification of definitions for user facilities. Staff education and training are no longer mandated by the regulations, but some education is required if compliance with the law is to be ensured.

Equipment Failure↗
PubMed1997

Definitions of genital ulcer disease and variation in risk for prevalent human immunodeficiency virus infection.

OBJECTIVES: Although genital ulcer disease (GUD) has been associated with human immunodeficiency virus (HIV) infection in a number of studies, definitions of genital ulceration have varied. The authors hypothesized that the association of GUD with prevalent HIV infection may vary according to the definition of GUD that is used. METHODS: As part of a prospective cohort study, 863 patients were interviewed and examined who presented to a sexually transmitted disease (STD) clinic for new symptom evaluation and who agreed to HIV testing to determine demographic and behavioral risk associated with prevalent HIV infection. To determine the association between GUD and prevalent HIV, the following definitions of GUD were used: observed ulcers, history of syphilis, serologic evidence of syphilis, observed culture-proven genital herpes, and serologic evidence of herpes simplex virus type II (HSV-2) infection. RESULTS: Of 481 men and 382 women enrolled, prevalent HIV infection was detected in 12.5% and 5.2%, respectively. In multivariate analyses controlling for known HIV risk behaviors, prevalent HIV infection was associated with observed GUD (odds ratio [OR] = 2.0, 95% confidence intervals (CI) = 1.0-3.9), a history of syphilis (OR = 6.0, CI = 2.8-12.7), and serologic evidence of syphilis (OR = 3.7, CI = 1.9-7.0), but not with serologic evidence of HSV-2 (OR = 1.2, CI = 0.7-2.1), nor with observed HSV-2 culture-positive genital ulcerations (OR = 1.0, CI = 0.4-4.2). Factors contributing to different strengths of association between HIV infection and a history of syphilis or serologic evidence of syphilis included the presence of underdiagnosed syphilis infection in people with reactive serologic tests and the absence of serologic reactivity in people with a positive history. CONCLUSIONS: Although GUD is strongly associated with prevalent HIV, the strength of the association depends on the definition of GUD used. For accurate evaluation of people at risk for HIV, clinicians and researchers should use multiple definitions of GUD.

Adolescent↗
PubMed1997

Awareness & knowledge of AIDS & HIV risk among women attending STD clinics in Pune, India.

The present study attempts to understand the awareness, knowledge and risk to HIV/AIDS among two groups of women: one reporting sex-work (FSW) and second reporting other work (FOW) from two clinics in Pune. The patients are screened for HIV and enrolled in the study. This paper includes 711 women covered between May 1993 and April 1995, 409 FSW and 302 FOW women, who differed by several characteristics. The FSW are older, less educated, unmarried, staying away from home, speak Kannada with 60 per cent using condoms for preventing pregnancy. FOW are ever-married women and among Family Planning method users only 7 per cent used condoms and 84 per cent had tubal ligation. At enrollment 47 per cent FSW and 14 per cent FOW were HIV positive with less than one third of all the women reporting AIDS knowledge. Among the knowledgeable women, 82 per cent understood the sexual route, half knew of transmission by blood and a third understood the vertical route of transmission; 77 per cent FSW and 48 per cent FOW knew that condom was protective. FSW reporting consistent condom use in past three months had greater knowledge of AIDS transmission, were more likely to have used condoms as contraceptive or had tubal ligation and less likely to have history of STD. This suggests the HIV/AIDS awareness and educational programs are having a limited effect specially among the married women who do not perceive of the risk of STD/HIV from their spouses and requires urgent preventive measures through innovative approaches that focus on female controlled methods. It is of critical importance that family planning and STD/HIV programs be integrated.

Acquired Immunodeficiency Syndrome↗
PubMed1996

Epidemiologic and microbiologic correlates of Chlamydia trachomatis infection in sexual partnerships.

OBJECTIVES: To determine the frequency of Chlamydia trachomatis genital infection within sexual partnerships using highly sensitive polymerase chain reaction (PCR) amplification and to identify the variables that might modify transmission. DESIGN: Cross-sectional study of sexual partnerships comparing in vitro culture and PCR amplification for C trachomatis. SETTING: Two outpatient sexually transmitted disease clinics. PARTICIPANTS: Four hundred ninety-four people in sexual partnerships attending sexually transmitted disease clinics. MAIN OUTCOME MEASURE: Genital infection with C trachomatis. METHODS: DNA sequencing was performed to examine specific genotypes within and between partnerships. Cross-sectional analysis was performed to determine characteristics associated with concordance or discordance of infection with partnerships. RESULTS: Cultures were positive for C trachomatis in 8.5% of males and 12.9% of females (P=.03). Using PCR, more infections were identified both in males (14.2%) and in females (15.8%), and the difference in infection rates analyzed by sex was no longer significant. In 20.4% of 494 couples, at least 1 partner had PCR results positive for C trachomatis, with a concordant infection rate of 10.7%, significantly higher than the 5.5% concordant infection rate demonstrable by culture (P<.01). Male-female and female-male transmission frequencies were equal (68%). The nucleotide sequences of the major outer membrane protein gene products were identical and unique for each of 15 culture-negative, PCR-positive concordant partnerships. In concordant infections, factors associated with infection in female partners were age less than 20 years, more than 1 partner in the past 6 months, and cervical ectopy greater than 25%. CONCLUSIONS: Using PCR, the frequency of chlamydia transmission by infected males and females was nearly identical. The high rate of concordant infection, high frequency of infection among asymptomatic individuals, and high frequency of transmission regardless of sex underscore the importance of routine screening for chlamydia in both males and females, along with provision of treatment to all sexual partners of chlamydia-infected individuals.

Adolescent↗