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Biomedical subjects

I Harvey

Publications and source records attributed to I Harvey.

At least 73 records · Page 4Linked to original sources
PubMed1999

Effect of a primary-care-based epilepsy specialist nurse service on quality of care from the patients' perspective: quasi-experimental evaluation.

Initiatives to improve epilepsy care have emphasized the role of specialist nurses. Formal evaluation of these initiatives are scarce. Further evaluative studies are required to ascertain the optimal means of providing epilepsy care. This study aimed to assess the effect of a primary-care-based epilepsy specialist nurse service on patients' reported health status, perceived quality of life, health care use, attitudes to health care, and provision of information. A quasi-experimental follow-up questionnaire survey was sent to all 574 patients aged 16 years or over and receiving antiepileptic drugs for epilepsy, registered in 14 general practices in north-west Bristol. Patients in seven practices who received the new service (intervention patients) were compared with patients in seven practices who did not (control patients). Follow-up comparisons between intervention and control patients were adjusted for baseline differences. Response rates to the first, second and both surveys were 66.2%, 68.6% and 50.9%, respectively. Intervention patients were more likely than control patients to have discussed most epilepsy topics with general practitioners and/or hospital doctors. and were significantly more likely to have categorized general practitioner care as excellent (odds ratio (OR) 2.30, 95% confidence intervals (CI) 1.12-4.70). Intervention patients were significantly less likely than controls to have reported never missing taking their anti-epileptic drugs (OR 0.48, 95% CI0.24-0.94). There were no significant changes in measures of health status, use of other health care services, and perceived quality of life between intervention and control patients. This study provides evidence of an improvement, after 1 year, in communication and satisfaction but not health status resulting from the introduction of a primary-care-based epilepsy service.

Adult↗
PubMed1999

Is single-wavelength anomalous scattering sufficient for solving phases? A comparison of different methods for a 2.1 A structure solution.

The structure of rusticyanin is the largest unknown structure (M(r) = 16.8 kDa) which has been recently solved by the direct-methods approach using only single-wavelength anomalous scattering (SAS) data from the native protein [Harvey et al. (1998). Acta Cryst. D54, 629-635]. Here, the results of the Sim distribution approach [Hendrickson & Teeter (1981). Nature (London), 290, 107-113] and of the CCP4 procedure MLPHARE [Collaborative Computational Project, Number 4 (1994). Acta Cryst. D50, 760-763] are compared with those from direct methods. Analysis against the final refined model shows that direct methods produced significantly better phases (average phase error 56 degrees ) and therefore significantly better electron-density maps than the Sim distribution and MLPHARE approaches (average phase error was around 63 degrees in both cases).

Azurin↗
PubMed1999

A randomised controlled trial. Shifting boundaries of doctors and physiotherapists in orthopaedic outpatient departments.

OBJECTIVE: To evaluate the effectiveness and cost effectiveness of specially trained physiotherapists in the assessment and management of defined referrals to hospital orthopaedic departments. DESIGN: Randomised controlled trial. SETTING: Orthopaedic outpatient departments in two hospitals. SUBJECTS: 481 patients with musculoskeletal problems referred for specialist orthopaedic opinion. INTERVENTIONS: Initial assessment and management undertaken by post-Fellowship junior orthopaedic surgeons, or by specially trained physiotherapists working in an extended role (orthopaedic physiotherapy specialists). MAIN OUTCOME MEASURES: Patient centred measures of pain, functional disability and perceived handicap. RESULTS: A total of 654 patients were eligible to join the trial, 481 (73.6%) gave their consent to be randomised. The two arms (doctor n = 244, physiotherapist n = 237) were similar at baseline. Baseline and follow up questionnaires were completed by 383 patients (79.6%). The mean time to follow up was 5.6 months after randomisation, with similar distributions of intervals to follow up in both arms. The only outcome for which there was a statistically or clinically important difference between arms was in a measure of patient satisfaction, which favoured the physiotherapist arm. A cost minimisation analysis showed no significant differences in direct costs to the patient or NHS primary care costs. Direct hospital costs were lower (p < 0.00001) in the physiotherapist arm (mean cost per patient = 256 Pounds, n = 232), as they were less likely to order radiographs and to refer patients for orthopaedic surgery than were the junior doctors (mean cost per patient in arm = 498 Pounds, n = 238). CONCLUSIONS: On the basis of the patient centred outcomes measured in this randomised trial, orthopaedic physiotherapy specialists are as effective as post-Fellowship junior staff and clinical assistant orthopaedic surgeons in the initial assessment and management of new referrals to outpatient orthopaedic departments, and generate lower initial direct hospital costs.

Adolescent↗
PubMed1999

General practitioners' use of guidelines in the consultation and their attitudes to them.

BACKGROUND: There is concern about the apparent lack of uptake of management and referral guideline information by general practitioners (GPs) in their day-to-day consultations with patients. Little is understood about the barriers to the uptake of guidelines as perceived by GPs. AIMS: To explore how GPs gain access to and use guidelines, including computer-based guidelines, in day-to-day consultations with their patients; and to identify the perceived problems and barriers to the use of guidelines in such situations. METHOD: Postal questionnaires enquiring about the practices and attitudes towards the use of guidelines in general practice were completed by 391 of 600 randomly selected GPs in the South and West NHS region. RESULTS: GPs found guidelines a useful method of accessing expert information. Key factors in their uptake were brevity, an authoritative and unbiased source of evidence, and resonance with the GP's usual practices; they also needed to be flexible enough to incorporate individual viewpoints. Guidelines were perceived as being valuable to enable safe delegation of care to other health professionals and for sharing decision-making with patients. Dissemination of guidelines through the medium of computers was acceptable to the majority of GPs. Virtually all (93%) responders reported adapting guidelines to the needs of individual patients. Older GPs from non-fundholding practices were least likely to show a positive attitude towards guidelines. CONCLUSION: In principle, there is a very positive attitude towards the use of guidelines in general practice. However, those developing guidelines for use by GPs in the consulting room need to be aware of the factors that facilitate their use in practice. Educational strategies aimed at increasing the use of guidelines need to take into account the significant proportion who show negative attitudes towards guidelines, whose characteristics have been identified in this study.

Attitude of Health Personnel↗
PubMed1999

General practitioners' use of computers during the consultation.

This study documents the extent of reported computer use by general practitioners (GPs) in consultations with patients, and identifies barriers to their use. There was a 65% response rate from a random sample of 600 GPs in the South and West National Health Service (NHS) region who were sent a questionnaire. Ninety-one per cent (357) had a desktop computer terminal in their consulting rooms. Of these, 98% used the computer to look up information or prescribe medication, 75% entered details about selected problems presented by patients, and 36% entered information about the patient's presenting problem at every consultation. Only 18% used computers to access reference information. Use of the computer for anything other than looking up patient information or prescribing was positively associated with fundholding status and use of a personal computer at home, and was independent of number of years in practice. Sixty-five per cent of responders had positive attitudes to the inclusion of management guidelines on the computer software, and 45% of responders held positive views towards the idea of integrating management guidelines with the patient's personal computerized medical record. Consideration should be given to targeting training at those GPs who appear to be reluctant to use computers during the consultation.

Attitude to Computers↗
PubMed1999

The patient-centredness of consultations and outcome in primary care.

BACKGROUND: There is general support for general practitioners (GPs) using patient-centred styles. However, there is limited British evidence of beneficial outcomes for patients from such styles. AIM: To explore whether, for patients presenting for new episodes of care, the GP's consulting style, specifically the patient-centredness of the consultation, is related to five generic outcomes. METHOD: General practitioners in South Wales were recruited, and one surgery consulting session was audiotape recorded for each participating clinician. Questionnaires were given to consenting patients before their consultations, immediately afterwards, and, by post, at two weeks to measure the following outcomes: doctor-patient agreement (on the nature of the problem and management), patient satisfaction, resolution of symptoms, resolution of concerns, and functional health status. From the patients consulting for a new episode of care and completing all three questionnaires, one patient was selected at random for each GP and the audiotape of their consultation rated for patient-centredness. Statistical analysis employed correlation coefficients and t-tests, followed by multiple regression and logistic regression to control for potential confounders. RESULTS: In total, 143 patients consulting 143 GPs were studied. The patient-centred score was positively and statistically significantly associated with patient satisfaction (Pearson correlation = 0.28; P = 0.002). No other associations were found with the other outcomes measured. CONCLUSION: The study presents evidence that patient-centred styles of consulting produce benefits in terms of increased patient satisfaction for patients consulting for new episodes of care in Britain.

Adolescent↗
PubMed1998

Modulating the redox potential and acid stability of rusticyanin by site-directed mutagenesis of Ser86.

The expression of rusticyanin in Escherichia coli and a number of mutants for Ser86 is reported. Mutations of Ser86 to Asn, Asp, Gln, and Leu were undertaken as this is an Asn residue in other structurally characterized cupredoxins, and it has been suggested that this may be partly responsible for the high redox potential (680 mV) and extreme acid stability of rusticyanin. N-Terminal sequence analysis, together with other biochemical and spectrochemical characterization, shows that the recombinant wild-type protein is indistinguishable from native rusticyanin. All four mutants retain the rhombic nature of the EPR spectra and a significant absorption maximum at approximately 450 nm, thus confirming that the overall geometry of the Cu ligands is essentially maintained. The oxidized form of all four mutants is less acid stable than the wild-type protein, although the detailed mechanism of lability varies. Ser86Leu readily loses copper as the pH is reduced from 4.0, but the protein does not denature. A significant proportion (approximately 30%) of Ser86Gln is denatured at lower pH values, whereas Ser86Asn and Ser86Asp are stable as the reduced (CuI) protein. The redox potential also varies by approximately 110 mV (590-702 mV) upon these single point mutations, thus providing direct experimental support to the idea that this residue is at least in part responsible for the acid stability and the highest redox potential of rusticyanin in the cupredoxin family.

Amino Acid Sequence↗
PubMed1998

Structure determination of a 16.8 kDa copper protein at 2.1 A resolution using anomalous scattering data with direct methods.

The structure of rusticyanin, an acid-stable copper protein, has been determined at 2.1 A resolution by direct methods combined with the single-wavelength anomalous scattering (SAS) of copper (f" = 3.9 e-) and then conventionally refined (Rcryst = 18.7%, Rfree = 21.9%). This is the largest unknown protein structure (Mr approximately /= 16.8 kDa) to be determined using the SAS and direct-methods approach and demonstrates that by exploiting the anomalous signal at a single wavelength, direct methods can be used to determine phases at typical (approximately 2 A) macromolecular crystallographic resolutions. Extrapolating from the size of the anomalous signal for copper (f" approximately 4 e-), this result suggests that the approach could be used for proteins with molecular weights of up to 33 kDa per Se (f"max++ = 8 e- at the 'white line') and 80 kDa for a Pt derivative (f"max = 19 e- at the 'white line', L3 edge). The method provides a powerful alternative in solving a de novo protein structure without either preparing multiple crystals (i.e. isomorphous heavy-atom derivative plus native crystals) or collecting multi-wavelength anomalous diffraction (MAD) data.

Azurin↗
PubMed1998

Use of guidelines in primary care--practitioners' perspectives.

BACKGROUND AND OBJECTIVES: Concern about the inadequate take-up of guidelines in general practice has concentrated on problems arising from the process of their development and implementation. However, these perspectives fail to take account of the needs, attitudes and problems of GPs themselves. In this study we aimed to identify barriers to the use of guidelines and opportunities for tackling them, from the point of view of the GP, so that future guideline development and policy could be more sensitive to the needs of GPs in the environment in which they work. METHOD: Twenty in-depth semi-structured interviews were audiotaped with GPs from within the Avon Health Authority area, representing GPs with different backgrounds and working environments. The transcribed data collected were analysed using a grounded theory approach. RESULTS: Utilization of guideline information is complex. GPs' appraisals of the value of guidelines interact with prior knowledge and beliefs, practicalities of existing information storage and retrieval systems, and individual working practices. Conditions where guidelines are most likely to be referred to may be those either very rarely or very commonly presenting in general practice. Key issues for the uptake of guidelines in the consultation are: general preference for certain formats of presentation; reputability and ownership; use of guidelines in shared decision-making; scope for computer-based systems; and GPs' attitudes to time pressures on information-seeking in relation to tolerance of uncertainty. CONCLUSION: Local initiatives might usefully explore the possibilities of supporting development of guideline-retrieval systems customized for individual GPs or practices. Novel means of stimulating 'ownership' and demonstrating reputability should be sought. The analysis provides a framework for understanding the complexities of the processes of GPs' use of guidelines in practice which can be useful in explaining the results of trials of guideline effectiveness. Guideline implementation occurs in the context of conflicting pressures for clinical autonomy and professional standardization and quality improvement.

Attitude of Health Personnel↗
PubMed1998

Formal consensus and consultation: a qualitative method for development of a guideline for dementia.

OBJECTIVES: To use a formal consensus method--the nominal group technique--for developing a clinical practice guideline to improve the diagnosis, needs assessment, and management of dementia at the primary/secondary care interface. To assess the usefulness of this method in an area where there is a dearth of clinical trials thus precluding an evidence-based approach. DESIGN: A qualitative and iterative method was used. The guideline was developed by an expert panel using the nominal group technique, incorporating the deliberations of a Primary Care Professionals' Task Group, recent reviews in the scientific literature, information from semistructured interviews with local specialists, and a local questionnaire survey. SETTING: Mainly Bristol but incorporating other parts of the United Kingdom especially the south and west. SUBJECTS: Expert panel group (including users and non-statutory organisations), local general practitioners (GPs), professionals carrying out the health check for people over 75, local geriatricians and psychogeriatricians, and primary care professionals with an interest in dementia. MAIN MEASURES: Items important in dementia from the nominal group in response to three questions on diagnosis, needs assessment, and management, ranked into a series of top 10 items for each area and allocated a score according to relative importance to each member; summary outputs from the questionnaire survey, semistructured interviews, and primary care professionals' task group. RESULTS: A clinical practice guideline covering diagnosis, needs assessment, and management of dementia in primary care was produced in the form of an algorithm and a management sheet. CONCLUSIONS: A formal consensus method can be used as an acceptable alternative to the evidence-based approach when developing guidelines in situations in which evidence is scarce, in which the guideline is intended as an aid in linking different stages of care, and in which practical and political considerations--such as the links between agencies--are important.

Consensus Statements as Topic↗
PubMed1998

A randomized controlled trial and economic evaluation of counselling in primary care.

BACKGROUND: Counselling in primary care settings remains largely unevaluated. Such evaluation has been strongly recommended. AIM: To determine the relative effectiveness and cost-effectiveness of generic counselling and usual general practitioner (GP) care for patients with minor mental health problems. METHOD: A randomized controlled trial and health economic evaluation were carried out in nine general practices. Access to generic counselling (brief counselling, generally involving up to six 50-minute sessions) was compared with usual GP care. A total of 162 patients aged 16 years and over with diverse mental health problems (excluding phobic conditions and psychoses) were randomized. The Hospital Anxiety and Depression (HAD) scale, COOP/WONCA (World Organization of Family Doctors) functional health assessment charts, and the delighted-terrible faces scale were used to assess outcome four months after randomization. RESULTS: The two groups were similar at baseline. There were significant improvements in both groups between randomization and follow-up for most outcome measures, but no significant differences between the study arms. The 95% confidence limits were narrow and excluded clinically significant effects. Under various assumptions concerning the cost of secondary care referrals and of counselling time, no clear cost advantage was associated with either intervention. CONCLUSIONS: This pragmatic trial demonstrates no difference in functional or mental health outcome at four months between subjects offered access to counselling and those given usual care by their GP. There is no clear difference in the cost-effectiveness of the two interventions. Purchasers should take account of these findings in allocating resources within primary care.

Adult↗
PubMed1997

Focal signal hyperintensities in schizophrenia.

The presence of focal signal hyperintensities on MRI images of the brain was compared in 48 schizophrenic patients, 26 patients with bipolar disorder and 34 healthy controls. Significantly larger areas of brain were affected by focal signal hyperintensities, particularly in the frontal lobes, in the schizophrenic group compared to the bipolar group and the controls. Although the bipolar group had more such foci than controls, this difference did not reach statistical significance.

Adult↗
PubMed1997

Factor-derived subsyndromes of schizophrenia and familial morbid risks.

Factor analysis was performed on OPCRIT checklist ratings from 66 patients with RDC schizophrenia. Eight substantive factors were found, characterised respectively by: positive formal thought disorder; first rank delusions; first rank hallucinations; inappropriate affect/bizarre behaviour; negative symptoms; grandiose/bizarre delusions; delusions of influence/persecution; and other hallucinations. A history of schizophrenia and other non-affective psychoses was ascertained in the probands' first-degree relatives using a family history approach. Illness in relatives was best predicted by probands' scores on subsyndromes derived from the inappropriate affect/bizarre behaviour and positive formal thought disorder factors.

Adult↗
PubMed1997

Crystallization and preliminary crystallographic data of a neutrophil migration-inducing lectin (KM+) extracted from the seed of Artocarpus integrifolia.

The tetrameric KM+ lectin from the seeds of Artocarpus integrifolia has, when compared to other plant lectins, the singular property of directly inducing neutrophil migration into the peritoneal cavity or into the air pouch of rats. This protein crystals have been grown and they belong to the orthorhombic system with space group C222(1). The unit cell parameters are a = 54.4 A, b = 127.9 A and c = 99.8 A. A native diffraction dataset to 2.8 A was collected and an analysis of the self-rotation function has shown the presence of only one independent non-crystallographic 2-fold axis orthogonal to the crystal b-axis, compatible with a dimer in the asymmetric unit.

Animals↗