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Biomedical subjects

S Heard

Publications and source records attributed to S Heard.

At least 19 recordsLinked to original sources
PubMed2003

An initiative to reform senior house officer training in histopathology.

Senior house officer schools in histopathology have been established in Leeds, Leicester and Southampton, each training six new recruits each year. Nine hours of protected teaching time is provided each week giving a ratio of apprenticeship learning to formal teaching of 3:1. Evaluations have been very positive. Much of this success is attributed to careful planning and adequate funding. This may be a useful model for other specialties to follow.

Attitude of Health Personnel↗
PubMed2001

Substitution of a nursing-led inpatient unit for acute services: randomized controlled trial of outcomes and cost of nursing-led intermediate care.

OBJECTIVES: To evaluate the outcome and cost of transfer to a nursing-led inpatient unit for 'intermediate care'. The unit was designed to replace a period of care in acute hospital wards and promote recovery before discharge to the community. DESIGN: Randomized controlled trial comparing outcomes of care on a nursing-led inpatient unit with the system of consultant-managed care on a range of acute hospital wards. SETTING: hospital wards in an acute inner-London National Health Service trust. SUBJECTS: 175 patients assessed to be medically stable but requiring further inpatient care, referred to the unit from acute wards. INTERVENTION: 89 patients were randomly allocated to care on the unit (nursing-led care with no routine medical intervention) and 86 to usual hospital care. MAIN OUTCOME MEASURES: Length of hospital stay, discharge destination, functional dependence (Barthel index) and direct healthcare costs. RESULTS: Care in the unit had no significant impact on discharge destination or dependence. Length of inpatient stay was significantly increased for the treatment group (P=0.036; 95% confidence interval 1.1-20.7 days). The daily cost of care was lower on the unit, but the mean total cost was pound sterlings 1044 higher-although the difference from the control was not significant (P=0.150; 95% confidence interval - pound sterlings 382 to pound sterlings 2471). CONCLUSIONS: The nursing-led inpatient unit led to longer hospital stays. Since length of stay is the main driver of costs, this model of care-at least as implemented here-may be more costly. However, since the unit may substitute for both secondary and primary care, longer-term follow-up is needed to determine whether patients are better prepared for discharge under this model of care, resulting in reduced primary-care costs.

Aged↗
PubMed2000

Trainee satisfaction before and after the Calman reforms of specialist training: questionnaire survey.

OBJECTIVES: To evaluate the impact of the Calman reforms of higher specialist training on trainee satisfaction. DESIGN: Questionnaire surveys using portable electronic survey units, two years apart. SETTING: Postgraduate, teaching, district general, and community NHS trusts in North Thames. North Thames deanery includes London north of the Thames, Essex, and Hertfordshire. PARTICIPANTS: Trainees in all grades and all specialties: 3078 took part in the first survey and 3517 in the second survey. MAIN OUTCOME MEASURES: Trainees' satisfaction with training in their current post, including educational objectives, training agreements, induction, consultant feedback, hands on experience acquired, use of log books, consultant supervision, and overall satisfaction with the post. RESULTS: In the second survey respondents were more likely to have discussed educational objectives with their consultant, used a log book, and had useful feedback from their consultant. They were more likely to give high ratings to induction, consultant supervision, and hands on experience acquired in the post. Each of these elements was associated with increased satisfaction with the post overall. Improvements were most noticeable at the level of specialist registrar, but changes in the same direction were also seen in more junior grades. CONCLUSIONS: After the reforms of specialist training, trainees in all grades reported greater satisfaction with their current posts. The changes required extra training time and effort from consultants.

Education, Medical, Continuing↗
PubMed2000

Patient-oriented learning: a review of the role of the patient in the education of medical students.

AIM: To explore the contribution patients can make to medical education from both theoretical and empirical perspectives, to describe a framework for reviewing and monitoring patient involvement in specific educational situations and to generate suggestions for further research. METHODS: Literature review. RESULTS: Direct contact with patients can be seen to play a crucial role in the development of clinical reasoning, communication skills, professional attitudes and empathy. It also motivates through promoting relevance and providing context. Few studies have explored this area, including effects on the patients themselves, although there are examples of good practice in promoting more active participation. CONCLUSION: The Cambridge framework is a tool for evaluating the involvement of patients in the educational process, which could be used by curriculum planners and teachers to review and monitor the extent to which patients are actively involved. Areas for further research include looking at the 'added value' of using real, as opposed to simulated, patients; more work on outcomes for patients (other than satisfaction); the role of real patients in assessment; and the strengths and weaknesses of different models of patient involvement.

Clinical Competence↗
PubMed2000

The hemodynamic and adrenergic effects of perioperative dexmedetomidine infusion after vascular surgery.

UNLABELLED: We tested dexmedetomidine, an alpha(2) agonist that decreases heart rate, blood pressure, and plasma norepinephrine concentration, for its ability to attenuate stress responses during emergence from anesthesia after major vascular operations. Patients scheduled for vascular surgery received either dexmedetomidine (n = 22) or placebo (n = 19) IV beginning 20 min before the induction of anesthesia and continuing until 48 h after the end of surgery. All patients received standardized anesthesia. Heart rate and arterial blood pressure were kept within predetermined limits by varying anesthetic level and using vasoactive medications. Heart rate, arterial blood pressure, and inhaled anesthetic concentration were monitored continuously; additional measurements included plasma and urine catecholamines. During emergence from anesthesia, heart rate was slower with dexmedetomidine (73 +/- 11 bpm) than placebo (83 +/- 20 bpm) (P = 0.006), and the percentage of time the heart rate was within the predetermined hemodynamic limits was more frequent with dexmedetomidine (P < 0.05). Plasma norepinephrine levels increased only in the placebo group and were significantly lower for the dexmedetomidine group during the immediate postoperative period (P = 0.0002). We conclude that dexmedetomidine attenuates increases in heart rate and plasma norepinephrine concentrations during emergence from anesthesia. IMPLICATIONS: The alpha(2) agonist, dexmedetomidine, attenuates increases in heart rate and plasma norepinephrine concentrations during emergence from anesthesia in vascular surgery patients.

Adrenergic alpha-Agonists↗
PubMed1999

Liposomal prostaglandin E1 (TLC C-53) in acute respiratory distress syndrome: a controlled, randomized, double-blind, multicenter clinical trial. TLC C-53 ARDS Study Group.

OBJECTIVE: To evaluate the safety and efficacy of an intravenous liposomal dispersion of prostaglandin E1 as TLC C-53 in the treatment of patients with acute respiratory distress syndrome (ARDS). DESIGN: Randomized, prospective, multicenter, double-blind, placebo-controlled, phase III clinical trial. SETTING: Forty-seven community and university-affiliated hospitals in the United States. PATIENTS: A total of 350 patients with ARDS were enrolled in this clinical trial. INTERVENTION: Patients were prospectively randomized in a 1:1 ratio to receive either liposomal prostaglandin E1 or placebo. The study drug was infused intravenously for 60 mins every 6 hrs for 7 days starting with a dosage of 0.15 microg/kg/hr. The dose was increased every 12 hrs until the maximal dose (3.6 microg/kg/hr) was attained or intolerance to further increases developed. Patients received standard aggressive medical/surgical care during the infusion period. OUTCOME MEASURES: The primary outcome measure was the time it took to wean the patient from the ventilator. Secondary end points included time to improvement of the PaO2/FIO2 ratio (defined as first PaO2/FIO2 > 300 mm Hg), day 28 mortality, ventilator dependence at day 8, changes in PaO2/FIO2, incidence of and time to development/resolution of organ failure other than ARDS. RESULTS: A total of 348 patients could be evaluated for efficacy. The distribution of variables at baseline describing gender, lung injury scores, Acute Physiology and Chronic Health Evaluation II scores, PaO2/FIO2, pulmonary compliance, and time from onset of ARDS or from institution of mechanical ventilation to the first dose of study drug was similar among patients in the liposomal prostaglandin E1 (n = 177) and the placebo (n = 171) treatment arms. There was no significant difference in the number of days to the discontinuation of ventilation in the liposomal prostaglandin E1 group compared with the placebo group (median number of days to off mechanical ventilation, 16.9 in patients receiving liposomal prostaglandin E1 and 19.6 in those administered placebo; p = .94). Similarly, mortality at day 28 was not significantly different in the two groups (day 28 mortality, 57 of 176 (32%) in the liposomal prostaglandin E1 group and 50 of 170 (29%) in patients receiving placebo; p = .55). In contrast, treatment with liposomal prostaglandin E1 was associated with a significantly shorter time to reach a PaO2/FIO2 ratio of >300 mm Hg (median number of days to reaching a PaO2/FIO2 ratio >300 mm Hg: 9.8 days in the liposomal prostaglandin E1 group and 13.7 days in patients receiving the placebo; p = .02). Among the subgroups examined, time to off mechanical ventilation was significantly reduced in patients who received at least 85% of a full dose (i.e., > 45.9 microg/kg) of liposomal prostaglandin E1 (median number of days to discontinuation of ventilation, 10.3 in the liposomal prostaglandin E1 group and 16.3 days in patients receiving placebo; p = .05). The overall incidence of serious adverse events was not significantly different in the liposomal prostaglandin E1 (40%) or placebo-treated (37%) groups. Drug-related adverse events of all kinds were reported in 69% of the patients receiving liposomal prostaglandin E1 compared with 33% of the placebo group, with hypotension and hypoxia (occurring in 52% and 24% of the liposomal prostaglandin E1-treated patients, respectively, and 17% and 5% of the placebo-treated patients, respectively) being noted most frequently. CONCLUSIONS: In the intent-to-treat population of patients with ARDS, treatment with liposomal prostaglandin E1 accelerated improvement in indexes of oxygenation but did not decrease the duration of mechanical ventilation and did not improve day 28 survival.

Adult↗
PubMed1999

Bronchopulmonary segmental lavage with Surfaxin (KL(4)-surfactant) for acute respiratory distress syndrome.

We performed a trial to assess the safety and tolerability of sequential bronchopulmonary segmental lavage with a dilute synthetic surfactant (Surfaxin) in 12 adults with ARDS. Patients received one of three dosing regimens in which aliquots of Surfaxin were administered via a wedged bronchoscope to each of the 19 bronchopulmonary segments. Suctioning was performed 10-30 s after instillation of individual aliquots. Group 1 patients (n = 3) received one 30-ml aliquot of a 2.5-mg/ml concentration of Surfaxin in each segment, followed by a second 30-ml aliquot with a 10-mg/ml concentration. Group 2 patients (n = 4) received two 30-ml aliquots of the 2.5-mg/ml concentration followed by a third lavage with the 10-mg/ml concentration. Group 3 patients (n = 5) received therapy identical to that received by patients in Group 2 and were eligible for repeat dosing 6 to 24 h later. All patients tolerated the procedure. There were no serious adverse experiences ascribed to either the procedure or the surfactant. In the 96 h after treatment initiation, FI(O(2)) decreased from 0.80 to 0.52 and PEEP decreased from 10.3 to 7.6 cm H(2)O. Bronchoscopic "cleansing" of the lungs with dilute Surfaxin may offer a safe and feasible approach to improving outcomes in patients with ARDS. Wiswell TE, Smith RM, Katz LB, Mastroianni L, Wong DY, Willms D, Heard S, Wilson M, Hite RD, Anzueto A, Revak SD, Cochrane CG. Bronchopulmonary segmental lavage with Surfaxin (KL(4)-surfactant) for acute respiratory distress syndrome.

Bronchoalveolar Lavage↗
PubMed1998

Educating towards clinical governance.

Clinical governance represents a culture change in the NHS, making managers of health care institutions responsible for clinical standards as well as the financial bottom line. Doctors and managers will need to be educated to play their full part in this new culture.

Administrative Personnel↗
PubMed1994

A phase II multicenter, double-blind, randomized, placebo-controlled study of three dosages of an immunomodulator (PGG-glucan) in high-risk surgical patients.

OBJECTIVE: To examine the safety and efficacy of multiple doses of PGG-glucan (poly-[1-6]-B-D-glucopyranosyl-[1-3]-B-D-glucopyranose) in high-risk patients undergoing major thoracic or abdominal surgery. DESIGN: An interventional, multicenter, double-blind, randomized, placebo-controlled study. SETTING: Four university-affiliated medical centers. PATIENTS: Sixty-seven high-risk patients undergoing major thoracic or abdominal surgery. INTERVENTION: Patients were randomized in a 1:1:1:1 ratio to receive saline placebo or PGG-glucan at a dose of 0.1 mg/kg, 0.5 mg/kg, and 1.0 mg/kg or 2.0 mg/kg. One dose was administered before surgery and three doses were administered after surgery. MAIN OUTCOME MEASURES: To examine the safety and efficacy of PGG-glucan infusion and to identify potentially important factors for a planned phase III study. RESULTS: A dose-response trend with regard to infection incidence among patients who received PGG-glucan was observed. Serious infections occurred in four patients who received placebo and in three patients who received PGG-glucan at a dose of 0.1 mg/kg. However, only one patient who received PGG-glucan at a high dose had a serious infection. The incidence and severity of adverse events was comparable in all groups. CONCLUSIONS: PGG-glucan was generally safe and well tolerated, may decrease postoperative infection rates, and warrants further investigation in a planned phase III trial.

Adjuvants, Immunologic↗
PubMed1993

Use of ultrahigh frequency ventilation in patients with ARDS. A preliminary report.

STUDY OBJECTIVE: Our objective was to compare the efficacy of ultrahigh frequency ventilation (UHFV) (frequencies > 3 Hz) with respect to oxygenation, airway pressures, and hemodynamic parameters in patients with adult respiratory distress syndrome (ARDS) who were not responding to conventional ventilation. DESIGN: We used a prospective, multicenter, nonrandomized study design in which each patient served as his own control. SETTING: Three university-affiliated, tertiary-care medical centers participated. PATIENTS: Persons aged 16 to 79 years old with ARDS and unresponsive to conventional ventilation, as defined by a Food and Drug Administration (FDA) approved protocol, were included. INTERVENTIONS: Ninety patients who were not responding to conventional ventilation were changed to UHFV using a microcomputer-controlled device. MEASUREMENTS AND RESULTS: The patient's blood gas, hemodynamic, and airway pressure variables were measured just before, and at 1 and 24 h after the switch to UHFV. We demonstrated clinically significant improvements in arterial oxygen tension (PaO2) and reductions in peak and mean inspiratory pressures. CONCLUSIONS: In a multicenter study, UHFV improved respiratory gas exchange and reduced airway pressure variables at both 1 h and 24 h after the onset of UHFV when compared with conventional ventilation just prior to the change and without hemodynamic deterioration, in patients with severe ARDS.

Adolescent↗
PubMed1992

Bacteriology of anal fistulae.

Anal fistulae are said to arise from cryptoglandular infection of the anal glands, which lie within the intersphincteric space. The type and virulence of the micro-organism responsible may determine whether an anal fistula develops. The microbiology of chronic anal fistulae has not been reported previously. Twenty-five consecutive anal fistulae were studied prospectively (eight intersphincteric fistulae, 12 trans-sphincteric fistulae, two suprasphincteric fistulae, one extrasphincteric fistula, one superficial fistula, one anovaginal fistula). There were 18 men and seven women, with a median age of 42 (range 22-71) years. Patients with Crohn's disease or acute anorectal suppuration were excluded. In 18 patients, 0.1 ml granulation tissue from the track of the fistula was obtained and processed within 4 h using standard microbiological techniques. Sixty-nine isolates representing at least 17 species were obtained. The predominant organisms were Escherichia coli (22 per cent), Enterococcus spp. (16 per cent) and Bacteroides fragilis (20 per cent). The majority of the growths were obtained only from enrichment. Bacteria from only one patient grew at a dilution of 10(3). Granulation tissue from 25 patients was processed for mycobacterial culture, and Mycobacterium tuberculosis was grown from one patient. No other mycobacterium was isolated. The chronic inflammation in anal fistulae does not seem to be maintained by either excessive numbers of organisms or organisms of an unusual type.

Adult↗
PubMed1992

Acute leukemia with t(1;3)(p36;q21), evolution to t(1;3)(p36;q21), t(14;17)(q32;q21), and loss of red cell A and Le(b) antigens.

At transformation of refractory anemia with ring sideroblasts to acute nonlymphocytic leukemia (ANLL) the bone marrow cells of a 75-year-old woman showed three different karyotypes, i.e., 46,XX,46,XX,t(1;3)(p36;q21) and 46,XX,t(1;3)(p36;q21),t(14;17)(q32;q21). She received no antileukemic therapy, and 1 year later, all her bone marrow cells were t(1;3)(p36;q21),t(14;17)(q32;q21). In association with the onset and first 11 months of ANLL, the platelet count increased 10-fold to a peak of 750 x 10(9)/L, providing further evidence that the t(1;3)(p36;q21) translocation causes stimulation of thrombopoiesis. Six months after transformation, her red cells showed reduced expression of A and Leb antigens. Serum alpha-n-3-acetylgalactosaminyl transferase (blood group A transferase) and red cell adenylate kinase were both reduced. The genes for both these substances are at 9q34, which suggests an abnormality here, although cytogenetically chromosome 9 appeared normal. This is the first case with t(1;3)(p36;q21) to show concurrent loss of red cell antigens and the first report detailing the course of untreated ANLL with t(1;3)(p36;q21).

ABO Blood-Group System↗
PubMed1990

A pseudo-outbreak of Pseudomonas on a special care baby unit.

Following isolation of a multi-antibiotic-resistant pseudomonad from a newborn infant on admission to the Special Care Baby Unit and further isolation of apparently the same organism from two additional infants, a full investigation was instigated in an attempt to discover the source of the organism. This revealed a further 13 infants apparently colonized with the same organism. Repeated screening of the infants with a commercial sterile swab/transport medium failed to isolate the organism. Examination of bottles of the in-house transport medium, which had been stored under a sink, produced further isolates of the same organism. Water splashed from the sink was suspected as the ultimate source of contamination. Biochemical characterization showed that P. pickettii and at least one other Pseudomonas species were involved. The epidemiological, clinical and economic implications of the 'outbreak' are discussed together with the ultimate financial implications for investigation of such incidents.

Cross Infection↗
PubMed1990

Investigation of a pseudo-outbreak of 'Pseudomonas thomasii' in a special-care baby unit by numerical analysis of SDS-PAGE protein patterns.

Forty-two cultures of pseudomonas comprising 28 clinical isolates from a pseudo-outbreak on a Special-Care Baby Unit and 14 reference strains, including 9 type strains, of various Pseudomonas species, were characterized by one-dimensional sodium dodecyl sulphate-polyacrylamide gel electrophoresis (SDS-PAGE) of whole-cell proteins. The protein patterns were highly reproducible and were used as the basis for a numerical analysis which divided the strains into 9 phenons. Two of the 28 clinical isolates were identified by biochemical tests as P. pickettii and their identification was confirmed by SDS-PAGE as they fell in the same phenon as the type strain of the species. The remaining 26 isolates, which could not be identified on phenotypic tests, fell in the same phenon as three reference strains of 'P. thomasii'. The protein patterns provided the first clear evidence that P. pickettii and 'P. thomasii' were separate taxa and that the 'outbreak' was polymicrobial in origin, in line with the probable aqueous source of contamination. We conclude that high-resolution SDS-PAGE of proteins provides an effective method of identifying and differentiating pseudomonads, especially where this cannot be done adequately using conventional biochemical tests.

Bacterial Proteins↗