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Biomedical subjects

A Macdonald

Publications and source records attributed to A Macdonald.

At least 19 recordsLinked to original sources
PubMed2007

The birth of a specialty: the first ten thousand patients of an old age psychiatry service.

BACKGROUND: Old age psychiatry as a clinical specialty emerged in the 1970s and modern, open-access multidisciplinary services started in the mid-1980s in South London. There are few accounts of referrals to old age psychiatry services and no quantitative accounts of the referral patterns to such teams. We report on the first 10,000 patients newly referred to the first such service in the world. METHODS: Observational study on routinely gathered data on age, gender, referral source, discipline of team member involved, diagnosis and duration of contact. Data validation was by iterative feedback to clinicians. RESULTS: Ten thousand patients were referred between December 1983 and March 2000. Missing data rates were low. The overall referral rate was 21.0 per 1000 population over 65 per annum, with the highest rate in those 85+ years old, in whom there was a marked rise over time. The rise in referral rate compensated for a decline in the population over 65 so that the numbers of referrals rose. Although there was a rise in the rate of referral of people with an organic diagnosis over time, this was not statistically significant. Organic patients constituted 50-60% of referrals but had shorter contact times than functional ones. Cause for concern included a low rate of referral from care homes, and a high proportion of possibly inappropriate referrals from medical and general psychiatry services. We were pleased to see no excess of such referrals from open-access sources, confirming earlier work. CONCLUSIONS: Descriptive data on referrals and workload of the first open-access multidisciplinary old age psychiatry service have generated cause for both celebration and concern.

Aged↗
PubMed2006

Histological processing variability in the determination of lateral resection margins in rectal cancer.

BACKGROUND: Involvement of the lateral resection margin (LRM) has been shown to be a reliable predictor of local recurrence of rectal cancer. Accurate determination of the LRM status is crucial in selecting patients for postoperative radiotherapy. However, variability in processing factors may affect the measurement of the LRM. AIM: To investigate how formalin fixation and laboratory processing affects the measurement of the LRM. METHODS: For this study, rectal cancer specimens (n = 9) were fixed in formalin for 4 days and then sectioned transversally, and one half of the specimen was sent for processing. The effacing tumours were placed back in formalin for another 3 days. At day 7, the effacing tumour block (mirror image) was sent for processing. The longest and the shortest perpendicular resection margins for each of the day 4 and day 7 specimens were measured. In a second experiment, control tissue (colon; n = 40), length 10 (0.05) mm, was also processed from a normal sigmoid colon. Specimens were retained in formalin for 24 h (n = 12), 48 h (n = 12), 72 h (n = 9) and 96 h (n = 7). The degree of tissue shrinkage was then recorded. Variations in the recorded LRM and length of colonic tissue are presented as a median (interquartile range) and data were compared using analysis of variance. RESULTS: In the cases of rectal cancer, the variation in measured LRM between day 4 and day 7 specimens was 3.2 (1.5-5) mm. In 30 of the 37 comparisons, the day 7 LRM increased in length, whereas in the remaining 7 it decreased. In the second experiment, control tissue of the original length 10 (0.05) mm increased in length to 10.9 (8.9-13.0) mm, p<0.01. CONCLUSION: These results suggest that the fixation period/laboratory processes result in measurable differences in the reported LRM. This degree of variation has implications for the reliable reporting of the LRM, predicting local recurrence rates and planning subsequent adjuvant radiotherapy.

Formaldehyde↗
PubMed2006

Randomised controlled trial of essential fatty acid supplementation in phenylketonuria.

OBJECTIVE: The long-chain polyunsaturated fatty acids (LC-PUFA) status of children with PKU is often compromised. LC-PUFA, which are important fatty acids in the development of the CNS, can be synthesised endogenously from the parent essential fatty acids (EFA) provided dietary intakes are adequate. This study was designed to assess the biochemical effect over a 20-week period of a phe-free protein substitute that has been supplemented with a balanced blend of n-3 and n-6 EFAs on LC-PUFA status of children with PKU. DESIGN, SETTING AND SUBJECTS: Fifty three community-living children aged 1-10 years diagnosed with PKU in the newborn period were recruited from seven tertiary centres in the UK and France and randomised to a fat-free control formula or the EFA-supplemented test-treatment formula in an open, prospective study. Forty four children completed the study (20 controls, 24 test-treatments). Fatty acid status was assessed at entry and 20-weeks follow-up. Three day dietary diaries were recorded at 20 weeks' follow-up. The safety, efficacy and palatability of the test-treatment formula were also assessed. RESULTS: The test-treatment group had significantly higher intakes of fat and EFA than the control group. There was a significant between group difference (P=0.04) in increases in median docosahexaenoic acid (DHA) concentrations in erythrocyte phospholipids, which increased by 19% in the test-treatment group and by 0.5% in the control group over the study period. Growth and phe control were satisfactory in all subjects. CONCLUSIONS: Supplementing the diets of children with PKU with a balanced blend of n-6 and n-3 EFA improves DHA status without compromising AA status.

Child↗
PubMed2006

The Robinson-Hooper connection*.

The search for a connection between James Robinson, the dental surgeon who on 19 December 1846 administered the first general anaesthetic in England by the inhalation of the vapour of ether, and William Hooper, the pharmaceutical chemist who produced the best publicised and most widely used of the early commercial ether vaporisers, has revealed hitherto unrecognised aspects of the early history of general anaesthesia.

Anesthesia, Inhalation↗
PubMed2006

Should high-energy infant formula be given at full strength from its first day of usage?

OBJECTIVE: To evaluate the feeding tolerance of a high-energy (1 kcal mL(-1)) infant formula (HEIF) for infants with faltering growth, weighing 2.5-8 kg, when administered at full strength from day 1 compared with stepwise introduction. METHODS: Thirty infants (aged 2-43 weeks) from a supraregional children's hospital requiring a high-energy formula for faltering growth were randomly allocated to receive either a 1 kcal mL(-1) ready to feed infant formula at full strength from day 1 or the same formula in diluted form, graded to full strength over 3 days. Bowel actions, vomits and volume of feed taken were recorded daily for 2 weeks. Weight, length, head circumference and mid-upper arm circumference were recorded at recruitment and after 2 weeks. RESULTS: The number of bowel actions in the first 2 days was significantly higher for the full strength group than for the stepwise group (P = 0.02); younger infants (<12 weeks) had more bowel actions over the first 2 days on the HEIF at full strength (Spearman's correlation = -0.5; P = 0.04); and infants with a total higher energy intake (kJ kg(-1)) had more frequent bowel actions over the first 4 days (Spearman's correlation = 0.48; P = 0.01). There was no significant difference between groups for growth or vomiting. CONCLUSIONS: High-energy infant formula was generally well tolerated in infants under the age of 12 months with faltering growth when administered at full strength from day 1. However, younger infants (<12 weeks of age) may benefit from a graded introduction in order to avoid increased bowel frequency.

Double-Blind Method↗
PubMed2006

The determination of phenylalanine content of foods suitable for phenylketonuria.

BACKGROUND: A low phenylalanine diet for people with phenylketonuria (PKU) is very restrictive. Natural foods allowed are based chiefly on fruits and vegetables but there is limited analysis on the phenylalanine content of newer and exotic fruit and vegetables. The assumption that 1 g protein yields 50 mg phenylalanine does not apply to fruits and vegetables. METHODS: The National Society for Phenylketonuria Medical Advisory Panel commissioned the phenylalanine analysis of 172 foods, which emphasis on fruit and vegetables. The foods were purchased from retail outlets and analysed by LGC Limited (67 foods) and the LFI (105 foods). RESULTS: There was a strong correlation between this phenylalanine and UK analyses published in 1980, but previous analysis included only a limited range of fruits and vegetables (r = 0.8746; P < 0.0001). There was also correlation between phenylalanine and UK protein analyses (r = 0.7976; P < 0.0001). CONCLUSION: This new phenylalanine data have enabled a wider range of fruits and vegetables to be safely incorporated into the diet of people with PKU.

Databases, Factual↗
PubMed2006

Ileostomy rod--is it a bridge too far?

OBJECTIVE: Defunctioning loop ileostomies are used commonly to protect low colorectal anastomoses and thereby reducing the serious complications of leakage. However, they are associated with specific complications such as retraction. Traditionally, a supporting rod is placed as a bridge to support both limbs of the stoma in the hope of reducing the incidence of stomal retraction. There is little evidence in the published literature to support this practice. The aim of this study was to determine whether using an ileostomy rod would reduce the incidence of stomal retraction. METHOD: A prospective, randomised controlled trial was performed in 60 consecutive patients who required a defunctioning loop ileostomy. Patients were allocated to either a 'bridge' or 'bridge-less' protocol. All the patients were assessed by dedicated stoma nurses for at least 3 months and until their stomas were closed. Their postoperative symptoms, including stoma activity and retraction rate, were recorded. RESULTS: Between May 2001 and June 2004, 57 patients completed the study (28 bridge; 29 bridge-less). There were no significant differences in the retraction rate between the groups. No clinical anastomotic leakage was recorded and none of the patients required early closure. CONCLUSIONS: If a loop ileostomy is constructed properly, stomal retraction is uncommon and routine use of a bridge is unnecessary.

Aged↗
PubMed2006

Do supervised colorectal trainees differ from consultants in terms of quality of TME surgery?

OBJECTIVE: The quality of surgical excision is held to be a major determinant of outcome following surgery for rectal cancer. Macroscopic examination of the excised mesorectum allows for reproducible assessment of the quality of surgery. We aimed to determine whether quality of excision undertaken by colorectal trainees under supervision was comparable with that performed by consultants, as measured using mesorectal grades. METHOD: A total of 130 consecutive patients undergoing potentially curative resection for primary adenocarcinoma of the rectum in our centre from 2001 to 2003 were included in the study. The pathologists graded the excised mesorectum according to staged classification proposed by Quirke. The outcome (quality of mesorectal excision and secondary outcomes including local recurrence and overall recurrence) of operations performed by consultants was compared with that of trainees. Statistical significance was tested using Pearson chi(2) test. RESULTS: Eighty-nine operations were performed by consultants and 41 by senior colorectal trainees with consultant supervision. Forty-four patients (49%) had good mesorectum when operated by consultants in comparison with 17 (41.5%) by the trainees. There was no statistically significant difference (P = 0.717) between the two groups in terms of quality of mesorectum excised after potentially curative resection. Furthermore, there were seven local recurrences in patients operated by consultants (7.8%) when compared with four in the trainee group (9.5%) and once again there was no statistical significance between the two groups (P = 0.719). CONCLUSION: We conclude that the quality of rectal cancer excision, as defined by mesorectal grades, achieved by supervised colorectal trainees is comparable with that achieved by consultants.

Aged↗
PubMed2005

'They're all depressed, aren't they?' A qualitative study of social care workers and depression in older adults.

Statutory and voluntary social services provide care and support for vast numbers of vulnerable older adults, yet little is known about how social care practitioners respond to depression in this high risk population. This study elicited the perceptions and conceptualizations of this condition among social care staff, and views on how the response of social care and other agencies might be improved. Qualitative interviews were conducted with 20 social care practitioners working in generic services for older adults in south London. Depression was perceived to be remarkably common among clients, a phenomenon largely attributed to the adverse circumstances of old age, particularly social isolation. A key message from participants was that social causes indicate a need for social interventions. While primary care was criticised for not taking depression seriously in older people, mental health services were generally praised. Expansion of social, recreational and psychological interventions was advocated.

Aged↗
PubMed2005

Fat intakes of children with PKU on low phenylalanine diets.

BACKGROUND: As part of a study on the effects of a fat-supplemented phenylalanine (phe)-free protein substitute on the fatty acid status of children with phenylketonuria (PKU), the adequacy of the diets of children aged 1-10 years for fat and essential fatty acids (EFA) was assessed. METHODS: Subjects randomized in a 1 : 1 ratio to a phe-free protein substitute supplemented with EFA (test-treatment group) or a phe-free, fat-free protein substitute (control group) for 20 weeks. 3-day semi-weighed records of food intakes collected at the end of the study period. RESULTS: Total fat and alpha-linolenic acid (alpha-LA) intakes were found to be poor in the control group (n = 19). Those in the test-treatment group (n = 24) had higher fat and EFA intakes (P < 0.05), bringing intakes closer to population norms. The youngest children (<5 years of age) in the control group appeared to be especially vulnerable to poor fat intakes because of the restricted diversity of their diets and, regardless of age, alpha-LA intakes by this group were poor compared with the non-PKU population. CONCLUSIONS: The quantity and quality of fat in the diets of children with PKU, in particular young children, should be given careful consideration in trying to optimize the ratio of linoleic acid: alpha-LA in their diets and in satisfying the requirements of this group for fat and alpha-LA.

Child↗
PubMed2005

Thirty-day mortality from colorectal cancer surgery within a deprived population.

OBJECTIVE: A recently published model for predicting 30-day mortality has been devised using data from 73 hospitals in the UK. Deprivation category was not one of the data sets used in predicting mortality and was not included in formulating this model. We wished to assess if the model was applicable to a population with high deprivation category scores. METHODS: Data on all colorectal cancer operations included in the model (age, ASA, cancer resected, Dukes stage and urgency) had been collected prospectively since January 1999. This data was applied to the model. RESULTS: Two hundred and thirty patients were included in analysis. Overall predicted mortality was 8.2% and actual mortality 7.8%. Within different categories of deprivation, predicted and actual mortality are similar and not significantly different. 137 patients lived in areas of deprivation category 3-5. Predicted and actual mortality were 8.4% and 8.0%, respectively. In areas of deprivation category 6-7, 91 patients had a predicted and actual mortality of 8.0% and 7.7%. CONCLUSION: Although deprivation data was not included in the production of the mathematical model to predict postoperative death, the model appears to predict well in the deprived population. It is likely that poorer socio-economic status is accounted for by increased ASA and cancer stage.

Adult↗
PubMed2005

Prospective analysis of stoma-related complications.

BACKGROUND: Stoma-related complication rates vary between 10% and 70%, possibly because of varying lengths of follow-up. It is thought that most of the complications improve with time. Furthermore, little is known about the commonly neglected but potentially quite distressing complications such as leakage, soiling and night-time emptying. The aim of this audit was to examine prospectively whether there was any difference in the complication rates at different time-points during the postoperative follow up period. METHOD: A prospective study on 408 consecutive patients with either colostomy or ileostomy was conducted over a period of at least 2 years. Both emergency and elective procedures were included. Stoma related complications were analysed at 10 days, 3 months, 6 months, 1 year and 2 years postoperatively. RESULTS: Both elective and emergency stomas had similar complication rates. The percentage of patients who had stenosis (1-2%), retraction (8-22%), prolapse (1-3%) or odour (6-9%) did not significantly change with time. The complication rates for skin excoriation, leakage, soiling or night-time emptying were higher amongst the ileostomy patients, and these rates did not improve with time. The proportion of patients who had parastomal hernias increased with time (from 0 to 40% in the colostomy and 0 to 22% in the ileostomy group). Daytime leakage, night-time leakage, soiling and night-time emptying were more problematic in the ileostomy group. CONCLUSIONS: The proportion of patients who had postoperative stoma-related complications did not improve with time, but the rate of parastomal hernias in both groups and night-time emptying in the ileostomy group was worse with time. Ileostomy patients had a higher incidence of skin excoriation, leakage, soiling, and night-time emptying, and they should receive additional support.

Colorectal Neoplasms↗
PubMed2004

Protein substitutes for PKU: what's new?

Protein substitutes are an essential component in the management of phenylketonuria. A series of studies at Birmingham Children's Hospital have investigated their optimal dosage, timing and practical administration as well as the efficacy and tolerance of novel protein substitutes. The key findings are as follows. (1). Lower dosages of protein substitute (1.2 g/kg per day of protein equivalent) adversely affect blood phenylalanine control in children aged 1-10 years. (2). There is wide variability in 24 h blood phenylalanine concentrations. (3). Adjusting protein substitute timing during daytime does not reduce blood phenylalanine variability. (4). Repeated 4 h administration of protein substitute throughout 24 h markedly reduces phenylalanine variability and leads to lower phenylalanine concentrations. (5). The new, concentrated, low-volume protein substitutes and amino acid tablet preparations are efficacious and well tolerated by patients. (6). Administration of protein substitute as a gel or paste has reduced difficulties with administration of protein substitute in children. These findings are important in rationalizing treatment strategies, improving patient compliance and overall in improving blood phenylalanine control.

Dietary Proteins↗
PubMed2004

Home enteral feeding audit.

OBJECTIVE: To determine the main problems that families experience in the first month after their child is discharged from hospital on home enteral tube feeds (HETF) in terms of obtaining feed and equipment, managing tube feeding and accessing health professionals. METHODS: A multiple choice/short answer questionnaire was used to interview 81 parents/carers of children aged 0-16 years discharged from a supra regional children's hospital on HETF for the first time between December 2001 and August 2003. Questions addressed issues such as: contact with the home delivery company (HDC); delivery of feed and equipment; training; ability to access help; illnesses associated with tube feeding; and understanding of procedures post-discharge. RESULTS: The main problems identified were: delayed first deliveries (> or =7 days post-discharge; 47%); equipment missing from the first delivery (41%); difficulty obtaining a prescription from the general practitioner (GP) (17%); changing to different equipment post-discharge with minimal training on the new equipment (26%). CONCLUSIONS: There were many problems with delays in delivery of equipment, incorrect equipment and changing of equipment when patients were first discharged on HETF. Significant improvements are necessary in organization of home enteral feeding systems when patients are first discharged.

Adolescent↗
PubMed2003

An assessment of surgeons' abilites to site colostomies accurately.

AIMS: The ability of surgeons to site a colostomy is assessed in a clinical model. In addition, the tuition received by surgical trainees in stoma siting is also reviewed. MATERIALS AND METHODS: Eleven surgeons (trainees--six, colorectal subspeciality interest--two) were asked to site an end colostomy on nine patients using an adhesive disc (diameter--1cm). The position of the stoma was then measured on the 'x' and 'y' axis of a 2cm box grid, (maximum error--1cm) which was placed on the abdomen and centred on the umbilicus. The positions were then compared with that chosen by the stoma nurse who was taken as the gold standard. Results were compared using ANOVA and the Mann Whitney--U test. A telephone questionnaire was then undertaken to review the training of junior surgeons. RESULTS: There was variance present within the group of surgeons studied (p<0.01). Trainees and consultants had a similar accuracy in stoma-siting (p<0.2). Consultants with a colorectal subspeciality interest were better at placing stomas than those with a general interest (p<0.002). Badly placed stomas were three times more likely to be too low than too high (p<0.002). Thirty of 37 trainees reported receiving no undergraduate training from a specialist stoma nurse. Ninety per cent received postgraduate training from another surgeon while a specialist nurse trained only 35%. CONCLUSION: There was no difference between trainees and consultants in their ability to site a colostomy. However, surgeons with a subspeciality interest chose stoma sites that were more consistent with the specialist nurse than general surgeons. Training is haphazard and ability is frequently assumed rather than proven.

Clinical Competence↗
PubMed2002

The hourglass appearance of the neurofibroma on rectal ultrasound. A case report.

Colorectal manifestation of von Recklinghausen's disease is a rare entity. The typical dumbbell shape of the lesion has been described previously, but only from a resected cecal specimen. The authors present the endosonographic appearance of a rectal neurofibroma, which shows a similar hourglass shape, thus facilitating the diagnosis.

Adult↗