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Biomedical subjects

G Watt

Publications and source records attributed to G Watt.

At least 19 recordsLinked to original sources
PubMed2001

Pragmatic randomised controlled trial to evaluate guidelines for the management of infertility across the primary care-secondary care interface.

OBJECTIVE: To investigate the effect of clinical guidelines on the management of infertility across the primary care-secondary care interface. DESIGN: Cluster randomised controlled trial. SETTING: General practices and NHS hospitals accepting referrals for infertility in the Greater Glasgow Health Board area. PARTICIPANTS: All 221 general practices in Glasgow; 214 completed the trial. INTERVENTION: General practices in the intervention arm received clinical guidelines developed locally. Control practices received them one year later. Dissemination of the guidelines included educational meetings. MAIN OUTCOME MEASURES: The time from presentation to referral, investigations completed in general practice, the number and content of visits as a hospital outpatient, the time to reach a management plan, and costs for referrals from the two groups. RESULTS: Data on 689 referrals were collected. No significant difference was found in referral rates for infertility. Fewer than 1% of couples were referred inappropriately early. Referrals from intervention practices were significantly more likely to have all relevant investigations carried out (odds ratio 1.32, 95% confidence interval 1.00 to 1.75, P=0.025). 70% of measurements of serum progesterone concentrations during the midluteal phase and 34% of semen analyses were repeated at least once in hospital, despite having been recorded as normal when checked in general practice. No difference was found in the proportion of referrals in which a management plan was reached within one year or in the mean duration between first appointment and date of management plan. NHS costs were not significantly affected. CONCLUSIONS: Dissemination of infertility guidelines by commonly used methods results in a modest increase in referrals having recommended investigations completed in general practice, but there are no detectable differences in outcome for patients or reduction in costs. Clinicians in secondary care tended to fail to respond to changes in referral practice by doctors. Guidelines that aim to improve the referral process need to be disseminated and implemented so as to lead to changes in both primary care and secondary care.

Cost-Benefit Analysis↗
PubMed2001

Lay constructions of a family history of heart disease: potential for misunderstandings in the clinical encounter?

BACKGROUND: Family history is recognised as a risk factor for coronary heart disease (CHD) by epidemiologists, health professionals, and the public, and could act either as a spur or barrier to changing health behaviour. However, there has been no systematic investigation of which factors affect whether people regard themselves as having a family history of CHDor not. METHODS: We used purposive sampling to select 61 men and women who were middle class or working class from a large cross-sectional survey. Half the respondents had indicated in this previous survey that they had heart disease in their family. The range of understanding of the meaning of having a family history was explored in detailed qualitative semistructured interviews. FINDINGS: Perception of a family history of heart disease depended on knowledge of the health of family members, the number and closeness of relatives with heart conditions, the age of affected relatives, and the respondent's sex and social class. Men, particularly working-class men, required a greater number of close relatives to be affected to perceive that they had a family history. Even when respondents judged that heart disease ran in their family, they did not always perceive themselves as at increased risk because they felt different in crucial ways from affected relatives. INTERPRETATION: The factors that people and epidemiologists judge as relevant to establish presence of a family history can differ. We suggest that these differences could lead to misunderstandings between doctor and patient, which could undermine advice on CHD risks and associated behavioural changes.

Adult↗
PubMed2001

Hand rash in trichinosis.

Trichinosis patients may develop peri-orbital oedema, conjunctival haemorrhages, splinter haemorrhages of the fingernails, and nonspecific skin rashes. Here, we describe an unusual hand rash noted in several patients enrolled in a treatment study for trichinosis.

Adult↗
PubMed2001

Foot problems in Turner's syndrome.

In a randomized, prospective study, data were collected on 23 girls with Turner's syndrome (TS) and an age- and sex-matched control group of 47 girls in order to document foot problems and to establish their cause. History revealed that 6 (26%) girls with TS had problems with ingrowing toenails compared with none of the control subjects. Compared with the control subjects, girls with TS showed a significantly increased incidence of short, broad feet; hyperextension of the great toes at the interphalangeal joint; toe nail involution; inflammation of the periungual tissues; and intermittent lymphedema. These features in combination with excessive subtalar joint pronation predispose to an increased risk of ingrowing toenails. We conclude that foot care problems are common in TS because of a number of predisposing factors and that foot examination should be part of routine surveillance.

Adolescent↗
PubMed2001

Passive transfer of scrub typhus plasma to patients with AIDS: a descriptive clinical study.

We examined the HIV-inhibitory effects previously found to be associated with scrub typhus infection. Individual 500 ml units of plasma from donors with mild scrub typhus were safety-tested, subjected to virucidal heat treatment, and administered to 10 HIV-1-infected recipients who were not receiving antiretroviral drugs. HIV-1 copy number fell three-fold or more in two recipients, and virus burden was reduced for 8 weeks in 70% (7/10) of recipients of a single plasma infusion, compared with the mean of three pre-infusion measurements. Scrub typhus donor plasma inhibited HIV-1 in vitro compared with normal human plasma and media controls. In the clearest in vivo response, reduction in viral load was accompanied by clinical improvement, a switchback from the syncytia-inducing to the non-syncytia-inducing phenotype, and decreases in CD8 cells and IL-6 levels. Scrub typhus infections can generate heat-stable, transferable plasma factors that exert prolonged anti-HIV effects. Whether variability in the results is due to different scrub typhus infections, different HIV infections or different individual responses, is unclear.

Acquired Immunodeficiency Syndrome↗
PubMed2001

Comparative pharmacokinetics and effect kinetics of orally administered artesunate in healthy volunteers and patients with uncomplicated falciparum malaria.

The single-dose pharmacokinetics of 100 mg of orally administered artesunate (AS) were studied in 6 patient volunteers with uncomplicated falciparum malaria and in 6 healthy volunteers. Plasma concentrations of both the parent drug, AS, and its major metabolite, dihydroartemisinin (DHA), were measured simultaneously by high-performance liquid chromatography (HPLC) with electrochemical detection (ECD). The antimalarial activity of each plasma sample measured by an in vitro bioassay (BA) was used to derive activity concentrations. Artesunate was absorbed rapidly and then almost completely hydrolyzed to DHA in patients, whereas hydrolysis was incomplete in healthy volunteers. The mean +/- standard deviation (SD) maximum concentration (Cmax) of AS was 296+/-110 nmol/L, the time to peak blood level (tmax was 0.71+/-0.66 hr, the half-life (t1/2,z) was 0.41+/-0.34 hr, and the bioavailability over 12 hr (area under the curve [AUC](0-12)) was 253+/-185 nmol hr/L. Measured by HPLC, the Cmax and AUC(0-12) values of DHA in patients with malaria were significantly greater than in volunteers (1,948+/-772 and 1,192+/-315 nmol/L; 4,024+/-1,585 and 1,763+/-607 nmol hr/L, respectively; P < or = 0.05). These differences were even greater when measured by BA. The Cmax for patients with malaria was 2,894+/-2,497 and 795+/-455 nmol/L for volunteers, and AUC(0-12) was 5,970+/-3,625 and 1,307+/-391 nmol hr/L, respectively (P < or = 0.05). In contrast, DHA parameter estimates for t1/2,z and tmax were similar between patients and healthy volunteers, with values of 0.80+/-0.30 versus 0.87+/-0.06 hr and 1.50+/-0.55 versus 1.13+/-0.52 hr, respectively (P > 0.5). Both drug metabolism and tissue protein binding could contribute to the differences between the antimalarial activity of artemisinin drugs in healthy volunteers and malaria infected patients.

Administration, Oral↗
PubMed2001

Orientia tsutsugamushi in peripheral white blood cells of patients with acute scrub typhus.

Scrub typhus, caused by Orientia tsutsugamushi, is an acute illness that occurs in many parts of Asia. Clinical manifestations range from inapparent to organ failure. Organisms disseminate from the skin to target organs, suggesting that they may enter the peripheral circulation. Here, peripheral blood cell smears from patients with acute scrub typhus were obtained before treatment and for 2 days after treatment and reacted with antibodies specific for O. tsutsugamushi. White blood cells from 3 of 7 patients with acute scrub typhus stained positively for O. tsutsugamushi. Cells containing O. tsutsugamushi were mononuclear and were detected on each day of sampling. The presence of O. tsutsugamushi in peripheral white blood cells of patients with acute scrub typhus is a new finding with clinical and pathogenic implications.

Adult↗
PubMed2001

Realising the value of primary care.

The immediate task in primary care is to respond to patient demand. In the absence of other influences, the resulting system of care tends to be both inefficient and inequitable. Primary care has been shown to be increasingly capable of making important contributions to public health, however, by delaying or reducing the complications of established conditions, and by reversing risks in people who are otherwise well. Increasingly, quality of care depends on continuity of care with better communication and cooperation between all concerned. Whether such possibilities are realised depends on the nature and volume of publicly funded support for education and training in primary care, and the types of support given for decisions taken at many levels. Greater integration is needed within primary care to improve its internal effectiveness and efficiency, and as a basis for better integration with secondary care. Primary care needs to be cultivated rather than managed, because of the complexity and importance of clinical decision-making at this level, and because of variations in the needs of individual patients, and local populations.

Delivery of Health Care↗
PubMed2000

Doxycycline and rifampicin for mild scrub-typhus infections in northern Thailand: a randomised trial.

BACKGROUND: Some strains of scrub typhus in northern Thailand are poorly responsive to standard antirickettsial drugs. We therefore did a masked, randomised trial to compare rifampicin with standard doxycycline therapy for patients with scrub typhus. METHODS: Adult patients with strictly defined, mild scrub typhus were initially randomly assigned 1 week of daily oral treatment with 200 mg doxycycline (n=40), 600 mg rifampicin (n=38), or doxycycline with rifampicin (n=11). During the first year of treatment, the combined regimen was withdrawn because of lack of efficacy and the regimen was replaced with 900 mg rifampicin (n=37). Treatment outcome was assessed by fever clearance time (the time for oral temperature to fall below 37.3 degrees C). FINDINGS: About 12,800 fever patients were screened during the 3-year study to recruit 126 patients with confirmed scrub typhus and no other infection, of whom 86 completed therapy. Eight individuals received the combined regimen that was discontinued after 1 year. The median duration of pyrexia was significantly shorter (p=0.01) in the 24 patients treated with 900 mg daily rifampicin (fever clearance time 22.5 h) and in the 26 patients who received 600 mg rifampicin (fever clearance time 27.5 h) than in the 28 patients given doxycycline monotherapy (fever clearance time 52 h). Fever resolved in a significantly higher proportion of patients within 48 h of starting rifampicin (900 mg=79% [19 of 24], 600 mg=77% [20 of 26]) than in patients treated with doxycycline (46% [13 of 28]; p=0.02). Severe gastrointestinal events warranted exclusion of two patients on doxycyline. There were two relapses after doxycycline therapy, but none after rifampicin therapy. INTERPRETATION: Rifampicin is more effective than doxycycline against scrub-typhus infections acquired in northern Thailand, where strains with reduced susceptibility to antibiotics can occur.

Adolescent↗
PubMed2000

HIV-1 suppression during acute scrub-typhus infection.

BACKGROUND: In HIV-1-infected individuals, viral load has been reported to rise transiently if an acute infection with another organism occurs. Our study was prompted by the unexpected finding that HIV-1 copy number fell during an acute infection with Orientia tsutsugamushi, the causative agent of scrub typhus. METHODS: Serial HIV-1 viral load determinations were made in ten Thai adults with scrub typhus, who were not receiving antiretroviral therapy, and in five HIV-1-infected patients who had other infections (four malaria, one leptospirosis), during and after acute infections. Sera from HIV-1-infected patients with scrub typhus and from mice immunised with O. tsutsugamushi were examined for HIV-1-suppressive activity. FINDINGS: Median viral load 3 days after admission was significantly lower in the scrub-typhus group than in patients with other infections (193% vs 376% of day 28 values, p=0.03). In four O. tsutsugamushi-infected patients HIV-1 RNA copy number fell by three-fold or more compared with day 28 values, and HIV-1 copy numbers were below the assay threshold in two patients with scrub typhus. Five of seven HIV-1 isolates from non-typhus patients with CD4 lymphocytes less than 200 cells/microL were syncytia-inducing variants, whereas all ten isolates from O. tsutsugamushi-infected individuals matched by CD4-cell count were non-syncytia inducing (p=0.03). Sera from an HIV-1-negative patient with scrub typhus had potent HIV-1-suppressive activity in vitro. Sera from typhus-infected mice inhibited HIV-1 syncytia formation and bound by immunofluorescence to HIV-1-infected lymphocytes. INTERPRETATION: HIV-1-suppressive factors are produced during some scrub-typhus infection and should be investigated further in the search for novel strategies for the treatment and prevention of AIDS.

Acute Disease↗
PubMed2000

Blinded, placebo-controlled trial of antiparasitic drugs for trichinosis myositis.

There is no consensus on the benefits of treatment with any specific anthelminthic compound on muscle-stage trichinosis. A double-blind, placebo-controlled comparison was done of 3 antiparasitic drugs during an outbreak of trichinosis in Chiangrai Province, northern Thailand. Forty-six adults were randomized to receive 10 days of oral treatment with mebendazole (200 mg twice a day), thiabendazole (25 mg/kg twice a day), fluconazole (400 mg initially, then 200 mg daily), or placebo. All patients received treatment to eradicate adult intestinal worms. Trichinella spiralis infection was proved parasitologically in 19 (41%) of 46 patient and by serodiagnosis in all cases. Significantly more patients improved after treatment with mebendazole (12/12) and thiabendazole (7/7) than after treatment with placebo (6/12; P<.05) or fluconazole (6/12). Muscle tenderness resolved in more patients treated with thiabendazole and mebendazole than in those treated with placebo (P<.05). However, 30% of volunteers could not tolerate the side effects of thiabendazole. In summary, Trichinella myositis responds to thiabendazole and to mebendazole.

Adolescent↗