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Biomedical subjects

A Hutchinson

Publications and source records attributed to A Hutchinson.

At least 19 recordsLinked to original sources
PubMed1992

Communication between general practitioners and consultants: what should their letters contain?

OBJECTIVE: To canvass the views of all general practitioners and consultants working in Newcastle upon Tyne on the content of referral letters and replies, the feasibility of standardising certain aspects of referral letters, and the use of communications data for audit purposes. DESIGN: A postal questionnaire was sent to all general practitioners and consultants in Newcastle upon Tyne in May 1991. Questions were asked about the clinical and administrative content of letters, the utility of standard categories to state the reason for referral, the idea of using letters for feedback purposes, and communications as a potential topic for professionally led audit. SETTING: Area served by Newcastle upon Tyne Family Health Services Authority and District Health Authority. RESULTS: Replies were received from 274 (77%) doctors (115 general practitioners and 159 consultants). A majority (225; 82%) were in favour of items defined as "always important" forming a minimum requirement for referral letters and for consultants' replies. Using standardised categories to state the reason for referral was not endorsed: 102 (89%) general practitioners and 132 (83%) consultants preferred referrers to use their own words. Using referral communications to provide feedback was less popular with consultants (54; 34%) than general practitioners (72; 63%). Finally, a majority of doctors (179; 65%) were in favour of using written communications as a topic for professionally led audit. CONCLUSIONS: A high degree of consensus exists among clinicians about the content of referral communications. Although doctors may still reject the concept of standardised communications, they have unambiguously endorsed a standard for communication that they can aspire to, and they are prepared to use it as a yardstick for their actual performance.

Communication↗
PubMed1992

Continuous arteriovenous haemofiltration and respiratory function in multiple organ systems failure.

OBJECTIVE: To determine what change in respiratory function occurred following prolonged and efficient continuous arteriovenous haemofiltration (CAVH) in a group of patients with multiple organ systems failure (MOSF). DESIGN: A retrospective assessment using patient notes and ICU charts. SETTING: The Intensive Care Unit of a large University Teaching Hospital. PATIENTS: All ICU patients satisfying the following criteria: (i) Failure of more than one organ system; (ii) Treatment with CAVH; (iii) Removal of more than 10 l of ultrafiltrate per day; (iv) Continuous haemofiltration for at least 5 days. Thirteen patients satisfied these criteria and 14 episodes of CAVH were analyzed. MEASUREMENTS: All data were recorded from the patient notes and ICU charts apart from the A-aDO2 and PaO2/FiO2 (PF) ratio which were calculated from available values. A mean of 3.5 different organ systems failed during the period of stay. The mean daily ultrafiltrate volume obtained was 23.7 (SD 0.95) l and the mean duration of treatment 9.6 (SD 4.3) days. Significant improvements occurred in the values for the PF ratio and ventilatory modality (p < 0.05), and the FiO2 and A-aDO2 (p = 0.001). The mean PEEP value remained unchanged at 4.8 cmH2O. Ten of the 13 patients subsequently died (77% mortality). CONCLUSIONS: A significant improvement in respiratory function occurred in patients with MOSF who had undergone a prolonged period of intensive CAVH. Haemofiltration may therefore be a useful treatment for respiratory failure in this patient group. Unfortunately the overall mortality of the group remained high.

Adolescent↗
PubMed1992

Outcome measures for primary health care: what are the research priorities?

A Delphi technique was used to ask general practitioners for their opinions as to which clinical problems and types of measure they thought most appropriate for the development of outcome measures for use in primary health care. The study comprised two rounds of postal questionnaires, targeted at general practitioners in academic departments throughout the United Kingdom and at trainers in the northern region, with the second questionnaire feeding back opinions from the first. Ninety eight participants suggested one or more areas in which outcome measures could be developed, giving a total of 451 suggestions. Consensus produced in the second round indicated that three clinical conditions were preferred for the development of outcome measures: asthma, diabetes and hypertension. Six categories of outcome measures were developed from the responses given in the first round--level of function, level of clinical control, incidence of complications, iatrogenic problems, patient understanding of a condition, and quality of life. Participants gave these measures different levels of importance according to the clinical problem in question. This Delphi study of doctors' opinions is a first step in the development process of appropriate, practicable measures of outcome for use in primary care and has achieved a degree of consensus among general practitioners.

Attitude of Health Personnel↗
PubMed1991

Calcium homeostasis in Trypanosoma brucei. Identification of a pH-sensitive non-mitochondrial calcium pool.

The objective of this study was to characterize mechanisms which maintain intracellular calcium homeostasis in bloodstream forms of Trypanosoma brucei. The identification of homeostatic pathways is required to understand signal transduction in these organisms. The fluorescent probes Fura-2, 2',7'-bis(carboxyethyl)-5(6)-carboxyfluorescein, and bisoxonal were used to measure intracellular calcium ([Ca2+]i), intracellular pH (pHi), and membrane potential, respectively. Homeostatic pathways maintained [Ca2+]i at 98 +/- 12 nM in the presence of 1.8 mM extracellular calcium despite a steady leak of calcium into the cell. The addition of 2.7 microM nigericin acidified the cytosol, depolarized the plasma membrane, and induced an approximate 3-fold increase in [Ca2+]i. The rise in [Ca2+]i could not be induced with valinomycin or gramicidin D under conditions where membrane depolarization occurred. By contrast, the proton ionophore, carbonyl cyanide p-trifluoromethoxyphenylhydrazone, elevated [Ca2+]i in a manner that was not additive with nigericin. Changes in pHi appeared to regulate [Ca2+]i since: 1) stepwise addition of K+ to nigericin-treated cells generated and incremental increase in pHi and concomitant decrease in [Ca]i; 2) addition of serum to nigericin-treated cells allowed simultaneous recovery of pHi and [Ca2+]i; and 3) addition of NH4Cl to untreated cells resulted in a biphasic change in pHi with corresponding biphasic change in [Ca2+]i. The rise in [Ca2+]i was derived from an intracellular pool which was not dependent on functional cytochrome oxidase, mitochondrial alternative oxidase, or the F0F1-ATPase. These data demonstrate that large quantities of calcium are reversibly stored in a non-mitochondrial pH-sensitive intracellular pool in T. brucei. We conclude that changes in pHi can serve to trigger calcium signals in these organisms.

Animals↗
PubMed1991

Factors influencing general practitioners' referral decisions.

This paper presents some findings from a small scale qualitative study of referral decision making conducted in south-east Northumberland in 1988-89. The study was prompted by an interest in variability in referral rates and the view that existing studies had not attempted to understand referral from the perspective of those involved in making the decisions. Our findings suggest that such understandings are crucial in the analysis of referral decisions and in any policy making initiatives designed to influence the pattern of referring.

Clinical Competence↗
PubMed1991

Case mix measures for ambulatory care.

Resource management in Ambulatory Care is recognized as an increasingly important area for development by many countries, and there has been much interest in the part that Case Mix Measures (CMMs) can play in this. There are a number of possible approaches to case mix, and several measures already exist. However, these are at present mainly still at the development stage and all are North American in origin. This paper reviews the role and state of the art of ambulatory CMMs and reports on an initial evaluation of the Ambulatory Visit Group (AVG) methodology using European data. Although the AVG grouper works under limited conditions, important questions remain concerning its validity and usefulness.

Ambulatory Care↗
PubMed1990

Self-help materials for anxiety: a randomized controlled trial in general practice.

The efficacy of a self-help package in treating chronic anxiety was evaluated in a randomized controlled trial in which the intervention group received self-help materials in the form of an audiotape and booklet, in addition to their current treatment. The intervention was successful in terms of mean depression scores (P = 0.01), anxiety scores (P = 0.04) and general health questionnaire scores (P = 0.02) which were significantly lower for the intervention group than for the controls. In addition, the depression scores fell faster for the intervention group than for the controls. The overall mean reduction in three months in adjusted depression scores was approximately two points greater for the intervention group than for the controls (P = 0.02). Clinicians welcomed the package as a valuable addition to the therapies available for managing chronic anxiety problems. Further studies should include larger sample sizes, taking into account the non-response to postal questionnaires over time.

Adolescent↗
PubMed1989

Comparison of two scores for allocating resources to doctors in deprived areas.

Current proposals in the general practitioner contract include additional payments to doctors working among deprived populations. The underprivileged area score will be used to identify local authority wards with the greatest levels of deprivation, thus acting as the basis for distributing considerable resources. Two methods of identifying deprived populations--the underprivileged area score and the material deprivation score--were compared to determine whether they result in similar allocation of resources to regions. Financial allocations to regions based on figures derived from the contract differed considerably if the material deprivation score was used instead of the underprivileged area score: Northern and Mersey regions gained over 50% of their allocation whereas East Anglia, Oxford, and South West Thames regions lost more than 30% of theirs. Such differences have considerable implications for doctors working among deprived populations as up to 60m pounds each year might be distributed by these payments.

England↗
PubMed1989

Etomidate infusions for the control of refractory status epilepticus.

Etomidate was used in eight patients to control status epilepticus which had been refractory to previous anticonvulsant therapy. Cortical activity was measured using a Cerebral Function Analysing Monitor and etomidate administered to achieve a 5 microV mean amplitude, avoiding burst suppression if possible with obliteration of any paroxysmal increase in amplitude. Neuromuscular blockade facilitated endotracheal intubation and mechanical ventilation, and corticosteroid replacement was provided. Rapid control of seizure activity, with cardiovascular stability, was obtained in all cases. Initially the mean infusion rate of etomidate required to achieve adequate suppression of cortical activity was 25 micrograms kg-1 min-1, but several patients exhibited tachyphylaxis. Weaning from the infusion presented difficulties in four patients due to recurring seizures. Adrenocortical function returned to normal within 96 hrs of stopping the infusion. At six month follow up, two patients had died, and two patients had significant reduction in cerebral function compared with their pre-morbid state.

Adult↗
PubMed1989

Influence of induced hypotension and spinal distraction on feline spinal somatosensory evoked potentials.

Spinal cord injury may occur during surgical correction of spinal deformity, which is performed frequently under hypotensive anaesthesia. We have investigated the interaction between pharmacologically induced hypotension and distraction on feline spinal cord function. Twelve anaesthetized cats were subjected to hypotension (mean arterial pressure (MAP) 60 mm Hg) using a mixture of sodium nitroprusside and trimetaphan (1:5). No significant changes were observed in somatosensory evoked potentials recorded at T11. In six cats distraction was applied at L2-3 in 2.5-mm increments up to 1 cm, while MAP was maintained at 100 mm Hg (normotensive group). The remaining cats were subjected to the same distraction procedure at an MAP of 60 mm Hg (hypotensive group). In the hypotensive group, a reduction in amplitude of evoked response occurred at significantly less distraction than in the normotensive group. These data indicate that the feline spinal cord is more sensitive to spinal distraction under hypotensive conditions.

Animals↗
PubMed1989

Placental transfer of alfentanil at caesarean section.

Twenty-one women about to undergo elective Caesarean section were given intravenous alfentanil 10 micrograms kg-1 1 min prior to induction of anaesthesia in order to obtund the pressor response to laryngoscopy and endotracheal intubation. Compared with a control group of 16 patients, alfentanil significantly reduced the pressor response to endotracheal intubation (P less than 0.01), without any detectable adverse effect upon the neonate. At delivery, mean maternal alfentanil plasma concentration was 23.5 ng ml-1 (SD 7.5, range 9.8-41.2 ng ml-1) and the mean maternal venous plasma alpha 1-acid glycoprotein (alpha 1-AGP) was 576 mg l-1 (SD 208, range 230-1200 mg l-1). Mean neonatal umbilical venous alfentanil plasma concentration was 7.5 ng ml-1 (SD 1.8, range 3.6-10.6 ng ml-1), while the mean umbilical venous alpha 1-AGP concentration was 189 mg l-1 (SD 76, range 80-410 mg l-1). At delivery, the calculated unbound maternal and foetal plasma alfentanil concentrations were similar.

Alfentanil↗
PubMed1988

Gastric exocrine "failure" in critically ill patients: incidence and associated features.

Following the observation that many critically ill patients cannot maintain their gastric juice pH below 4 without treatment a study was performed to measure the gastric juice pH in such patients and relate it to other clinical data. The case notes of 64 patients who had been admitted to the intensive care unit and taken part in two trials of ranitidine treatment were reviewed. During those trials gastric juice was aspirated hourly and the pH and volume measured. In this study the values recorded during a six hour untreated control phase were used. Data on age, diagnosis, treatment, outcome, episodes of hypoxia, episodes of hypotension, and use of inotropic drugs were also reviewed. Full data were available for 61 patients: 27 had a mean baseline pH of greater than 5 during the control phase and 34 a mean baseline pH of less than 5. Significantly more of those with a high pH suffered hypotension (21/27 v 13/34) and received inotropic drugs (16/27 v 8/34). These findings suggest that hypotension in critically ill patients adversely affects gastric exocrine function; prophylaxis with drugs that can improve gastric mucosal blood flow may be more effective than with antacids.

Adolescent↗
PubMed1988

Dantrolene in severe tetanus.

In its most severe form tetanus is treated with prolonged use of neuromuscular blockade, and artificial ventilation. We report a case in which the use of dantrolene sodium shortened the period of artificial ventilation.

Aged↗
PubMed1988

Gastric fluid volume and pH in elective inpatients. Part I: Coffee or orange juice versus overnight fast.

In order to assess the effect of preoperative oral fluids, with and without ranitidine, on gastric fluid volume and pH, 300 elective surgical inpatients, ASA physical status I or II, were randomly assigned to one of six groups. The three groups that received placebo are discussed in this paper, Part I, and the three that received ranitidine in Part II. Between two and three hours before the scheduled time of surgery patients received either 150 ml coffee (Group 1), or 150 ml orange juice (Group 2), while the control group continued their overnight fast (Group 3). No opiate or belladonna premedication was given. Immediately following induction of anaesthesia the residual gastric fluid was obtained by suction on a nasogastric tube and its volume and pH measured. Residual gastric fluid volumes showed no statistically significant differences among the groups (Group 1: 24.5 +/- 21.6 ml; Group 2: 23.7 +/- 18.4 ml; Group 3: 23.2 +/- 17.3 ml; p greater than 0.1). Values for pH among the groups were also similar (Group 1: 2.18 +/- 1.58; Group 2: 1.95 +/- 1.24; Group 3: 1.95 +/- 1.62; p greater than 0.1).

Adolescent↗
PubMed1988

Gastric fluid volume and pH in elective inpatients. Part II: Coffee or orange juice with ranitidine.

In order to assess the effect of preoperative oral fluids, with and without ranitidine, on gastric fluid volume and pH 300 elective surgical inpatients, ASA physical status I and II, were randomly allocated to one of six groups. The three ranitidine groups (Groups 4, 5, and 6) are discussed in this paper (Part II), and the three placebo groups (Groups 1, 2, and 3) in Part I. Between two and three hours before the scheduled time of surgery, patients received 150 ml coffee with oral ranitidine 150 mg (Group 4), 150 ml orange juice with oral ranitidine 150 mg (Group 5), or oral ranitidine alone (Group 6). No opiate or belladonna premedication was given. Immediately following induction of anaesthesia a # 18 Salem sump tube was passed and its position in the stomach confirmed by auscultation of insufflated air. The volume of residual gastric fluid, which was aspirated into a 60 ml syringe, was recorded, and its pH was measured. There were no statistically significant differences between groups with respect to volume (Group 4: 14.3 +/- 15.4; Group 5: 14.8 +/- 17.0; Group 6: 9.7 +/- 12.6 ml). The mean pH in all groups was greater than 5.40 (Group 4: 5.65 +/- 2.12; Group 5: 5.41 +/- 2.12; Group 6: 6.21 +/- 1.51).

Adult↗
PubMed1988

Ranitidine--bolus or infusion prophylaxis for stress ulcer.

Stress ulcer is a dangerous complication for the critically ill patient. Prophylaxis with antacids can undoubtedly reduce this risk, if gastric pH is maintained above 3.5. Histamine receptor antagonists may achieve this more conveniently. We have studied the effects of ranitidine, given either as 50-mg boluses every 6 h or as one of two infusion regimes (125 or 250 micrograms/kg.h), in controlling pH in critically ill patients on a ventilator. The percentage of samples with a pH less than 4 fell in all groups during therapy; while there was no significant difference between groups, pH control was achieved more rapidly in the bolus group. Infusion therapy with ranitidine is an attractive concept but a loading dose must be used. The presence of occult blood in the gastric juice did not correlate with pH and was not affected by ranitidine therapy.

Adolescent↗