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Biomedical subjects

A Gray

Publications and source records attributed to A Gray.

At least 109 records · Page 6Linked to original sources
PubMed1998

Persistence of parvovirus B19 DNA in testis of patients with testicular germ cell tumours.

Germ cell tumours (GCT) of the testis are the most common malignant tumours occurring in young adults. In view of the young age of patients, the increasing incidence of GCT and the overexpression of wild-type p53 observed in a majority of tumours, the possibility of the involvement of a virus in the development of this cancer was considered. Testicular GCT were analysed for the presence of cytomegalovirus and Epstein-Barr virus (EBV), which are known to cause overexpression of wild-type p53 protein, and parvovirus B19. The testicular tissue of 39 patients with testicular GCT and 12 patients with healthy testicular tissues was tested for presence of viral DNA by PCR. Neither cytomegalovirus nor EBV DNAs were detected in the 39 tumours analysed, but parvovirus B19 DNA sequences were demonstrated in the testicular tissue of 85% (33/39 cases) of patients with GCT. The sera of 16 of the 39 patients with GCT were tested for the presence of parvovirus B19 IgM and IgG. B19-specific IgG was detected in the sera of 11 patients (69%). Only one case was positive for parvovirus B19 IgM, which was also shown to have B19 genome sequences in the serum by PCR, indicating that in a majority of cases an acute B19 infection can be excluded as being the source of the B19 DNA sequences in the testis. B19 DNA could not be detected in normal testicular tissue and thus parvovirus B19 could play a role, direct or indirect, in the development of testicular GCT or have tropism for the tumour cells.

Adolescent↗
PubMed1998

Wine tasting and dental erosion. Case report.

A case of widespread dental erosion is reported in an individual who had worked in the wine industry for ten years. This occupation involved daily tasting of at least 20 wines, but often more. The erosion manifested as dental sensitivity with there being cervical erosion, occlusal pitting, and loss of enamel around restorations. The effect of immersing unerupted human teeth in white wine (pH 3.3) was examined with the scanning electron microscope, where marked surface changes had occurred after 24 hours of exposure.

Adult↗
PubMed1998

Pay in the British NHS: a local solution for a national service?

An important component of the reforms of the British National Health Service (NHS) has been devolution of a previously highly centralised pay bargaining system to the local provider level. As the wage bill is by far the single largest item of health care expenditure, the implications of this change may be far-reaching. This article surveys the available theory and evidence from an economic perspective. It reviews the development of pay determination mechanisms in the NHS and the extent to which local pay has been adopted since the reforms were introduced. It then considers the theory of local pay and general evidence on local pay variations in the UK, before turning to the available evidence on local labour markets in the health care sectors of the UK and USA. It concludes with a discussion of the policy and research implications of current developments on local pay bargaining in the NHS. In particular, it suggests that judgements over the success or failure of local pay bargaining will concern: first, whether the weakened monopsony position of the NHS at national level results in higher pay for the more powerful employee groups; second, whether fragmentation of bargaining weakens the negotiating and lobbying power of national trade unions and professional organisations; third, whether competition between providers leads to higher or lower costs; and fourth, whether any efficiency gains from local bargaining outweight the higher transaction costs involved.

Collective Bargaining↗
PubMed1998

The distribution of health care costs and their statistical analysis for economic evaluation.

OBJECTIVE: Where patient level data are available on health care costs, it is natural to use statistical analysis to describe the differences in cost between alternative treatments. Health care costs are, however, commonly considered to be skewed, which could present problems for standard statistical tests. This review examines how authors report the distributional form of health care cost data and how they have analysed their results. METHOD: A review of cost-effectiveness studies that collected patient-level data on health care costs. To supplement the review, five datasets on health care costs are examined. Consideration is given to the use of parametric methods on the transformed scale and to non-parametric methods of analysing skewed cost data. RESULTS: Since economic analysis requires estimation in monetary units, the usefulness of transformation-based methods is limited by the inability to retransform cost differences to the original scale. Non-parametric rank sum methods were also found to be of limited use for economic analysis, partly due to the focus on hypothesis testing rather than estimation. Overall, the non-parametric approach of bootstrapping was found to offer a useful test of the appropriateness of parametric assumptions and an alternative method of estimation where those assumptions were found not to hold. CONCLUSIONS: Guidelines for the analysis of skewed health care cost data are offered.

Cost-Benefit Analysis↗
PubMed1998

The use and cost of HIV service provision in England in 1996. National Prospective Monitoring System (NPMS) Steering Group and NPMS Working Party on Costs.

OBJECTIVE: The aim of the study was to measure the use and estimate the cost of HIV service provision in England. DESIGN AND SETTING: Standardised activity and case-severity data were collected prospectively in 10 English HIV clinics (5 London and 5 non-London sites) for the periods 1 January 1996 to 30 June 1996 and 1 July 1996 to 31 December 1996 and linked to unit cost data. In total, 5440 patients with HIV infection attended during the first 6 months and 5708 during the second 6 months in 1996. MAIN OUTCOME MEASURES AND RESULTS: The mean number of inpatient days per patient-year for patients with AIDS was 19.7 [95% confidence interval (CI): 13.7 to 25.7] for January to June and 20.8 (95% CI: 15.3 to 26.4) for July to December 1996. The mean number of outpatient visits for asymptomatic patients with HIV infection was 14.8 (95% CI: 11.9 to 17.6) and 13.3 (95% CI: 10.8 to 15.7) for the respective periods and 16.1 (95% CI: 13.21 to 18.97) and 15.7 (95% CI: 11.2 to 20.2), respectively, for patients with symptomatic non-AIDS (i.e. symptomatic patients with HIV infection but without AIDS-defining conditions). Substantial centre-to-centre variation was observed, suggesting that many clinics can continue the shift from an inpatient- to an outpatient-based service. Cost estimates per patient-year for HIV service provision for 1996 varied from 4695 Pounds (95% CI: 3769 Pounds to 5648 Pounds) for asymptomatic patients, to 7605 Pounds (95% CI: 6273 Pounds to 8909 Pounds) for symptomatic non-AIDS patients to 20,358 Pounds (95% CI: 17,681 Pounds to 23,206 Pounds) for patients with AIDS. CONCLUSIONS: Different combinations of antiretroviral therapy affect the cost estimates of HIV service provision differently. Anticipated reduction in inpatient-related activity through the increased use of combination antiretroviral therapy will further shift service provision from an inpatient- to outpatient-based service and reduce costs per patient-year. The extent and duration of such effects are currently unknown. The long term effects of combination treatment on the morbidity and mortality patterns of individuals infected with HIV are also currently unknown, as are their implications on the use and cost of HIV service provision. Multicentre databases like the National Prospective Monitoring System (NPMS) will provide healthcare professionals with information to improve existing services and anticipate the impact of new developments.

Acquired Immunodeficiency Syndrome↗
PubMed1997

Impact of the NHS reforms on English hospital productivity: an analysis of the first three years.

OBJECTIVES: To evaluate the effect of purchaser mix, market competition, and trust status on hospital productivity within the NHS internal market. METHODS: Hospital cost and activity data were taken from routinely collected data for acute NHS hospitals in England for 1991-2 to 1993-4. Cross sectional and longitudinal regression methods were used to estimate the effect of trust status, competition, and purchaser mix on average hospital costs per inpatient, after adjusting for outpatient activity levels, casemix, teaching activity, regional salary variation, hospital size, scale of activity, and scope of cases treated. RESULTS: Real productivity gains were apparent across the study period for NHS hospitals on average. Casemix adjustment drastically improved cross sectional comparisons between hospitals. Gaining trust status and increasing host district purchaser share were associated with productivity increases after adjustment for casemix, regional salary differences, and hospital size and scope. Hospitals that became trusts during the study period were on average less productive at the beginning of the period than those that did not, and there were no significant productivity differences between trust waves at the end of the period in 1993-4. Market concentration was not associated with productivity differences. CONCLUSION: Further analysis is needed to determine whether overall and trust associated productivity gains are transient effects, one off shifts, or self perpetuating reorientations of organisational behaviour. Hospitals may have chosen to become trusts because they anticipated being able to increase productivity. Increases in the proportions of small purchasers were associated with increasing costs. Importantly, this study could not adjust for changes in the quality of care.

Cross-Sectional Studies↗
PubMed1997

Vagal control of left ventricular contractility is selectively mediated by a cranioventricular intracardiac ganglion in the cat.

Activation of the vagus nerve leads to decreases in sinoatrial (SA) rate, atrioventricular (AV) conduction, and myocardial contractility. Previous data are consistent with the hypothesis that vagal control of cardiac rate and AV conduction are mediated by two anatomically separated and physiologically independent parasympathetic intracardiac ganglia located in fat pads on the surface of the right and left atria, respectively. These data suggested that vagal control of ventricular contractility might be mediated through another intracardiac ganglion. We examined the ventricles of cat hearts histologically for the presence of ganglia. Multiple small basophilic ganglia composed of a few neurons, and an occasional larger ganglion were found embedded in the epicardial fat surrounding the cranial margin of the anterior surface of the left ventricle, near the juncture with the right ventricle, which we refer to as the CV ganglion. In anesthetized cats, right cervical vagal stimulation decreased SA rate by 44 +/- 5%, decreased the rate of AV conduction by 68 +/- 14%, and reduced ventricular contractility by 19.5 +/- 5.7%. Vagally induced negative inotropism was almost completely prevented by microinjection of a ganglionic blocking drug into the CV ganglion. However, these injections into the CV ganglion did not significantly effect vagally induced decreases in either SA rate or AV conduction. We conclude: (1) that ganglia are found in a fat pad on the surface of the left ventricle of the cat heart and (2) that the CV ganglion selectively mediates the negative inotropic effect of vagal stimulation on the left ventricle. Greater understanding of the physiological functions of intracardiac neuronal circuits may help in developing new strategies to treat disorders of cardiac contractility such as congestive heart failure.

Animals↗
PubMed1997

Communicating with cancer patients in Saudi Arabia.

The following factors are relevant to the communication problems that exist in this country: 1. CULTURAL ASPECTS: The impression is that patients here cope better with terminal illness at home than do patients elsewhere. The extended family, with its strong ties, and the strong Islamic faith that encourages its members to provide for parents and children in case of need mean that any input by health professionals is magnified by the family in the care of the patient. At first, it was uncertain if foreign health professionals would be accepted into Saudi homes (which are intensely private and protected for the family) for the purpose of caring for patients. This has proved unfounded. Hospitality is a very important part of Saudi society; nurses and doctors are welcomed and respected. Much of this success is due to the use of Saudi men as drivers and translators. These people provide 24-hour service, act as social workers assessing the needs of the family, and are the link between the patient and family, the nurse, and the doctor. 2. "CURE" OR "PALLIATION": The emphasis for cancer patients in Saudi Arabia is still on "curative treatment," even after any realistic hope of a cure is gone. The problem this causes is compounded by many patients being excluded from the decision-making process. Decisions made by the family may not always reflect the patient's wishes. Greater communication is needed to guide treatment decisions. 3. TRUTH-TELLING: Denying information of the patient's illness is probably more a historical than a cultural phenomenon. Similar attitudes prevailed until very recently in practically all other countries. In this very conservative country, people are committed to preserving Islamic culture in the face of Western technology. As medicine continues to demonstrate its effectiveness as well as its limitations, people will come to realize that the right of patients to know and understand their illness allows them to cope much better, and is compatible with the responsibility of the family to care for them. 4. WORK FORCE: The government employs 14,500 doctors, but only 12% are Saudi nationals. Nearly all the 33,000 nursing work force are expatriates. There is a constant turnover of expatriate staff. The commitment to continuing care with proper communication that is required for the whole of medicine is likely to be fully realized only when the majority of the workforce are Saudi nationals. 5. PRIMARY, SECONDARY, AND TERTIARY CARE SERVICES: The Kingdom is well served by a system of 174 public hospitals and numerous private clinics. However, for a patient with a chronic or terminal illness, continuing care, even in the community, tends to be provided by the hospital service; whereas the polyclinics and health centers seem to provide mainly crisis management. The aim should be to develop community care for chronic illness as part of the primary health care system. The impact of Western medicine on Saudi society has been dramatic and sudden, as evidenced by the high growth rate of the population. There is now widespread interest in matching the culture to the technology. Much of the drive to change the attitudes of both patients and health professionals comes from young Western-trained Saudi doctors, who are in the best position to merge the strengths of both cultures in this sensitive area.

Adaptation, Psychological↗
PubMed1997

Magnetic resonance imaging of the shoulder: assessment of effectiveness.

OBJECTIVES: To quantify how magnetic resonance imaging (MRI) influences clinicians' diagnosis, diagnostic confidence and management plans in patients with shoulder problems. To investigate whether such changes are associated with an improvement in health. METHODS: A prospective observational study on all patients referred to a regional centre for MRI of the shoulder over a 6-month period. Data on diagnosis, diagnostic confidence and proposed management before MRI were compared with diagnoses and actual management after MRI. In addition, short form 36 item (SF-36) health survey data were collected at referral and again 6 months later. RESULTS: In 86 of 99 MRI referrals there was sufficient clinical data for the patient to enter the study. MRI led to previously unsuspected diagnoses in 20 of 59 patients where the clinicians had provided full diagnostic information before and after the examination. When MRI confirmed the clinical diagnosis, significant improvements in clinicians' diagnostic confidence were found (P < 0.001). MRI led to a change in management (P < 0.05) in 44 (62%) of the 71 patients where full management plans were available. Health survey results were available in 62 patients; although there were some improvements in SF-36 scores, these did not reach statistical significance. CONCLUSION: Magnetic resonance imaging of the shoulder significantly influences clinicians' diagnoses and management plans. However, patients do not record a statistically significant improvement in health-related quality of life over 6 months.

Adolescent↗
PubMed1997

Trauma triage: a comparison of CRAMS and TRTS in a UK population.

The CRAMS scale and the Triage Revised Trauma Score (TRTS) were compared to assess their potential use as a prehospital method of activating hospital trauma teams. We studied patients from the resuscitation room of Leeds General Infirmary who had enough data recorded to allow calculation of the admission TRTS and CRAMS scale. Patients were defined as having major injury if they died in hospital, were admitted to the ICU or had an Injury Severity Score (ISS) of > 15. Each triage scale was compared by calculating multiple sensitivity/specificity pairs and plotting the results on a receiver operator (ROC) curve. The optimal cut-offs on each scale were compared directly. Ninety-seven (46 per cent) of a total of 213 patients fulfilled the study criteria for major injury. The best cut-off points were a CRAMS of < 9 and a TRTS of < 12. The TRTS was significantly more specific (0.9 versus 0.75) but at a cost of poor sensitivity (0.6 versus 0.69, not significant). The performance of both scales was similar when compared on the ROC curve. CRAMS and the TRTS were unable to identify major injuries in our sample with sensitivity and specificity adequate to support their use as a tool to activate trauma teams in the UK.

Adult↗
PubMed1997

Evaluation of index and profile measures of health status in a randomized controlled trial. Comparison of the Medical Outcomes Study 36-Item Short Form Health Survey, EuroQol, and disease specific measures.

OBJECTIVES: The authors compare two generic measures of health status with disease-specific measures in a randomized controlled trial of transurethral resection of the prostate with laser vaporization prostatectomy for benign prostatic hypertrophy. METHODS: Patients entered into the trial completed the following questionnaires prior to treatment and at follow-up at 3 months and 1 year. The Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) is a generic measure that produces an eight-dimension profile as well as two summary measures of health status (the physical component score and the mental component score). The EuroQol provides two single index measures of health status; one intended to convey the utility (or lack of) that an individual derives from his or her own health state compared with alternative states and a second simple visual analog scale "thermometer" of health status. The American Urological Association symptom score and the Bothersome index are disease-specific indices of health status for use specifically with benign prostatic hypertrophy patients. RESULTS: The EuroQol indicates no statistically significant improvements with time for either arm of the trial. The SF-36 physical and general health perceptions domains indicates statistically significant improvements for the transurethral resection of the prostate arm alone at 3 months and 1 year, as do the physical summary score at the 3-month follow-up visit. The effect sizes of these improvements, however, are small, using standard criteria. In contrast, statistically significant differences are found with time for both transurethral resection of the prostate and laser prostatectomy on both disease-specific measures, which also indicate statistically significant superior outcome for the transurethral resection of the prostate arm compared with the laser arm. CONCLUSIONS: The results indicate that the disease-specific measures are more sensitive to change than the generic measures of outcome. Possible explanations for this are discussed.

Follow-Up Studies↗
PubMed1997

Paramedic use of nalbuphine in major injury.

Paramedic training and skills have been introduced in the United Kingdom in an attempt to improve prehospital patient care. There is presently little control and quality assurance in this potentially difficult environment and paramedic protocols have not been validated. We studied the use of nalbuphine by paramedics for patients with major injury in West Yorkshire. A case-control study was carried out using two cohorts of patients from the regional Major Trauma Outcome Study (MTOS) database; one group had received prehospital nalbuphine by paramedics (the intervention) and a matched group who had not (the control). Both groups of patients were reviewed by a panel of three consultants and a paramedic to assess which patients received or could have received nalbuphine appropriately. Only 85 patients from a database of 4170 patients received nalbuphine. Fifty-two (61%) patients were thought by the panel to have been given nalbuphine appropriately. The panel also concluded that 21 (18%) of the 115 patient control group could have been administered nalbuphine but did not receive the drug. This study demonstrates inadequate and sometimes inappropriate use of nalbuphine in prehospital trauma care. Quality assurance and audit systems should be implemented to identify and correct these deficiencies.

Adolescent↗
PubMed1997

On-scene times for trauma patients in West Yorkshire.

OBJECTIVE: To assess whether length of time on-scene in patients with major injury was associated with severity of injury or with abnormal on-scene physiology. METHODS: A retrospective analysis of a convenience sample of patients in whom prehospital on-scene times were entered onto the regional major trauma database. On-scene times of patients were analysed to assess whether ultimate injury severity score or on scene physiology measurements affected times. This was undertaken by examining subgroups of patients with similar injury severity or physiological measurements by Wilcoxon-Mann-Whitney testing and comparing 95% confidence intervals of the mean on-scene times. RESULTS: The mean on-scene time for 111 non-entrapped patients was 26 minutes (95% confidence interval 23.5 to 28.6). Patients with injury severity score of > 15, with a Glasgow coma scale of < 13, and with an abnormal pulse spent significantly less time on-scene than less severely injured or physiologically deranged patients. CONCLUSIONS: Paramedics have the ability to recognise patients with severe injury and reduce on-scene times. On-scene times were consistently long throughout all subgroups of major trauma patients.

Adolescent↗