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Biomedical subjects

J Allen

Publications and source records attributed to J Allen.

At least 163 records · Page 9Linked to original sources
PubMed1998

Simulated surgery in the summative assessment of general practice training: results of a trial in the Trent and Yorkshire regions.

BACKGROUND: General practice registrars are now required to undertake a summative assessment of their consulting skills. Simulated surgeries have been developed as an alternative to the existing method of assessing video-recorded consultations. AIM: To evaluate the simulated surgery assessment method, developed in the General Practice Postgraduate Education Department in Leicester, for use in assessing general practice consultation skills. METHOD: General practice registrars in Leicester performed two eight-patient simulated surgeries separated by four weeks. Assessment outcomes were compared to demonstrate the consistency of the method. Pilot surgeries in Yorkshire were videotaped, and then rated by video-raters trained for summative assessment. RESULTS: The method consistently identified those registrars who were competent and those who were not yet competent in consulting skills. It proved acceptable to candidate doctors and has fewer resource requirements for both examiners and candidates than other consulting skills assessment methods. CONCLUSION: The method developed in Leicester and successfully transferred to Yorkshire is feasible on a large scale, and offers an acceptable alternative to other consulting skills assessment methods. In this study it consistently identified competent from incompetent candidate doctors.

Clinical Competence↗
PubMed1998

What determines competence within a general practice consultation? Assessment of consultation skills using simulated surgeries.

A method for assessing the consultation skills required in general practice using patient simulators within a simulated surgery has been developed in Leicester, aimed at registrars coming to the end of their three-year training programme. This paper addresses the issues of validity, describing the technique as it has evolved over the past three years, and paying particular attention to ways in which the consultation was made to feel 'real' for candidates. As well as testing clinical issues during consultations, simulated surgery incorporates the views of the patient into the assessment process. Feedback from registrars has been positive and the method presents an alternative to video-recording the consultation for the purpose of assessment.

Clinical Competence↗
PubMed1998

The use of APACHE II scores to select candidates for left ventricular assist device placement. Acute Physiology and Chronic Health Evaluation.

BACKGROUND: The growth in left ventricular assist device (LVAD) use has been hampered by high morbidity and mortality rates and cost. The purpose of this study was to help improve patient selection for LVAD placement by determining whether the Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring system, a multiparameter, physiology-based predictor of outcome, could be used to predict outcome after LVAD placement and thus help determine optimum timing of LVAD placement. METHODS: This was a retrospective analysis of a prospective cohort observational study consisting of 2 groups: (1) 50 patients with severe heart failure who did not receive LVAD placement after initial evaluation and (2) 31 patients who did receive LVAD placement. Patients included in the study were in severe heart failure on the basis of 3 of the following: lung crackles, S3, peripheral edema, ejection fraction < 0.30, systolic blood pressure < 80 mm Hg, progressive prerenal azotemia, altered level of consciousness, gastrointestinal ischemia or congestion, or persistent although reversible pulmonary hypertension in spite of maximal medical therapy, including intravenous inotropes. The decision for LVAD placement was at the discretion of the attending physician. RESULTS: Both LVAD- and non-LVAD-treated patients were similar in cause of heart failure, APACHE II scores, and other baseline laboratory parameters. Survival time with a log-logistic model was better for LVAD-treated patients, p=.0266. Although Kaplan Meier analysis showed a trend toward better survival rates in the LVAD-treated patient, the Cox proportional hazards revealed that LVAD-treated patients had better survival (relative risk ratio, 95% confidence interval=0.305, 0.110 to 0.892; p=.0219) after adjustment for APACHE II score. Each unit increase in APACHE II independently predicted death (relative risk ratios, 95% confidence interval=1.139, 1.055 to 1.231; p=.0009). Patients with medium APACHE II (11 to 20) scores in particular benefitted from LVAD treatment. CONCLUSION: LVAD placement for severe heart failure (not restricted to cardiogenic shock) improves survival. APACHE II can aid in deciding the timing of LVAD placement in patients with heart failure who may not have attained conventional hemodynamic criteria for LVAD placement. Patients who had APACHE II scores between 11 and 20 derived the greatest benefit from LVAD placement.

APACHE↗
PubMed1997

Deliberate self-harm: developing clinical guidelines.

Nurses in an acute admissions psychiatric ward are using reflective practice to develop clinical guidelines for the management of patients who deliberately self-harm. In this article, they describe the cyclical learning processes and reflective techniques involved.

Clinical Nursing Research↗
PubMed1997

Genetic tagging of humpback whales.

The ability to recognize individual animals has substantially increased our knowledge of the biology and behaviour of many taxa. However, not all species lend themselves to this approach, either because of insufficient phenotypic variation or because tag attachment is not feasible. The use of genetic markers ('tags') represents a viable alternative to traditional methods of individual recognition, as they are permanent and exist in all individuals. We tested the use of genetic markers as the primary means of identifying individuals in a study of humpback whales in the North Atlantic Ocean. Analysis of six microsatellite loci among 3,060 skin samples collected throughout this ocean allowed the unequivocal identification of individuals. Analysis of 692 'recaptures', identified by their genotype, revealed individual local and migratory movements of up to 10,000 km, limited exchange among summer feeding grounds, and mixing in winter breeding areas, and also allowed the first estimates of animal abundance based solely on genotypic data. Our study demonstrates that genetic tagging is not only feasible, but generates data (for example, on sex) that can be valuable when interpreting the results of tagging experiments.

Animals↗
PubMed1997

Thyroid dysfunction as a late effect in survivors of pediatric medulloblastoma/primitive neuroectodermal tumors: a comparison of hyperfractionated versus conventional radiotherapy.

BACKGROUND: Primary hypothyroidism is a common sequela of craniospinal radiotherapy in the treatment of pediatric brain tumors. METHODS: The authors compared the incidence of primary hypothyroidism after hyperfractionated radiotherapy (HFRT) (n = 14 patients) versus conventionally fractionated radiotherapy (CRT) (n = 34 patients) in a group of pediatric patients with medulloblastoma/primitive neuroectodermal tumors (MB/PNET). RESULTS: The mean age at the time of tumor diagnosis was 7.9 years in the HFRT group and 8.4 years in the CRT group. The patients were followed for a mean of 4.6 years (HFRT) and 8.3 years (CRT) after diagnosis. Mean radiation doses to the thyroid were similar in both radiotherapy groups (29 gray [Gy] [HFRT] vs. 24 Gy [CRT]). Approximately 14% of the HFRT and 62% of the CRT patients developed primary hypothyroidism within a similar period after irradiation (3.2 years [HFRT] vs. 3.0 years [CRT]). Analysis by cumulative incidence function demonstrated a significant difference in the risk of developing thyroid dysfunction between these two groups of patients (P = 0.02). CONCLUSIONS: The current study findings suggest that the use of HFRT in the treatment of pediatric patients with MB/PNET is associated with a lower risk of these patients developing primary hypothyroidism.

Adolescent↗
PubMed1997

Salmonella typhimurium infections in mice deficient in interleukin-4 production: role of IL-4 in infection-associated pathology.

Mice harboring mutations in the IL-4 gene (IL-4(-/-)) were infected with a range of Salmonella typhimurium HWSH derivatives using different routes of infection. Compared with IL-4(+/+) mice, IL-4(-/-) mice exhibited a delayed time to death following infection with wild-type S. typhimurium HWSH. Groups of IL-4(+/+) mice infected with S. typhimurium HWSH purE, a less virulent derivative, showed sporadic deaths and harbored micro- or macroabscesses in their tissues, particularly associated with the liver. However, IL-4(-/-) mice infected with similar doses of S. typhimurium HWSH purE bacteria were resistant to killing and failed to develop detectable abscesses. Abscess formation in IL-4(-/-) mice could be induced by i.v. administration of rIL-4 during the S. typhimurium HWSH purE infection. The immune response in both IL-4(-/-) and IL-4(+/+) mice was of the Th1-type. Viable salmonella bacteria could be found associated with abscesses. Both IL-4(-/-) and IL-4(+/+) mice were resistant to killing by S. typhimurium aroA.

Animals↗
PubMed1997

Cloning and sequencing of the mouse Gli2 gene: localization to the Dominant hemimelia critical region.

The GLI family of zinc finger genes has been implicated in both neoplastic and developmental disorders. We have cloned and sequenced the mouse homolog of the zinc finger gene Gli2 and demonstrated significant similarity to the human GLI3 gene. We have also localized Gli2 to mouse chromosome 1, in the vicinity of the morphogenetic mutation Dominant hemimelia (Dh), which is characterized by tibial hemimelia, poly/oligodactyly, and a number of visceral abnormalities, most strikingly absence of the spleen. Using a Gli2-associated microsatellite, we demonstrated no recombination between Dh and Gli2 in a Dh intraspecific backcross. Gli2 is expressed in Dh heterozygotes and homozygotes. However, using a combination of mismatch analysis and direct sequencing, we have failed to identify any mutations in the coding sequence of Gli2 from Dh. We have also demonstrated that it is unlikely that there are any Gli genes in the mouse genome in addition to the previously described Gli, Gli2, and Gli3.

Amino Acid Sequence↗
PubMed1997

European healthcare. Foreign exchange.

The European Union offers sources of funding, skills and experience, so why are health organisations not tapping into them? Carol Ludvigsen and Janet Allen recount one trust's experiences.

Europe↗
PubMed1997

Maternal serum interleukin-6 during pregnancy and during term and preterm labor.

OBJECTIVE: To determine the normal concentrations of maternal serum interleukin-6 during the second and third trimesters of pregnancy and the different stages of term and preterm labor, and to examine the clinical usefulness of measuring this cytokine in the serum of women in preterm labor to diagnose asymptomatic intrauterine infections. METHODS: Maternal serum interleukin-6 concentrations were measured cross-sectionally in 315 gravidas in their second and third trimesters and during term and preterm labor. Placentas from women who delivered preterm were examined for histologic chorioamnionitis. RESULTS: At term, women in labor had significantly elevated median maternal serum interleukin-6 concentrations compared with those at term not in labor (4.7 pg/mL versus 2.2 pg/mL, P < .001). Women admitted in preterm labor who delivered had significantly higher median interleukin-6 concentrations than did those in preterm labor who responded to tocolysis (9.3 pg/mL versus 1.9 pg/mL, P < .001). Women in preterm labor who delivered preterm with evidence of chorioamnionitis had significantly higher serum concentrations of interleukin-6 than did those in preterm labor who delivered in the absence of chorioamnionitis (15.9 pg/mL versus 4.6 pg/mL, P = .006). CONCLUSION: Compared with antepartum gravidas, those in term or preterm labor had significantly higher concentrations of maternal serum interleukin-6 concentrations; extremely elevated levels were found in patients whose preterm labor was associated with intrauterine infection.

Female↗
PubMed1997

Does low individual operator coronary interventional procedural volume correlate with worse institutional procedural outcome?

OBJECTIVES: To assess the relation between individual operator coronary interventional volume and incidence of complications, the in-hospital outcome at a single, moderate volume urban academic center was prospectively collected over a 3-year period. BACKGROUND: A minimum of 75 coronary interventions/operator per year may be required in the future to obtain formal certification. However, few data exist regarding individual operator volumes and procedural outcome. METHODS: Between January 1993 and December 1995, 1,389 consecutive procedures were performed or supervised by nine geographic full-time operators: 171 (12.3%) utilized various devices, and 350 (25.2%) involved multivessel coronary intervention. Left ventricular ejection fraction was 59 +/- 15% (mean +/- SD), and there were 1.7 +/- 0.7 vessels diseased (with > or = 70% stenosis). Clinical indications included stable angina in 22.5% of cases, unstable angina in 31.9%, acute myocardial infarction (MI) in 2.9%, post MI in 20.6%, shock or acute heart failure in 3.0% and restenosis in 19.1%. In the last consecutive 857 lesions in 655 cases, 20.7% type A, 55.5% type B and 23.8% type C lesions were categorized before coronary intervention. RESULTS: Average yearly operator volume ranged from 26 to 83 cases (mean 51 +/- 26). Each operator has performed a total of 590 +/- 268 coronary interventions, with 10.0 +/- 4.3 years of coronary interventional experience. The mean angioplasty volume rating for the nine operators was 180 +/- 37 (> 170 considered adequate). The in-hospital major complication rate was 1.4% (95% confidence interval 0.7% to 1.893%) for all coronary interventions, including death in 3 patients, bypass surgery in 13, arrhythmia in 3 and Q wave MI in 2. To ascertain how these outcomes compared with standard measures of coronary interventional outcome, four previously published registries were reanalyzed in a similar manner. The rate of complications in the present study was found to be significantly lower than that of the 1992-1993 Society for Cardiac Angiography and Intervention registry (1.9%, n = 19,594, p < 0.05 [excludes ventricular arrhythmias]), the 1994 American College of Cardiology database (3.9%, n = 38,963, p = 0.001), the Mid-America Heart Institute outcome in 1988 (2.3%, n = 5,413, p = 0.02) and the 1985-1986 National Heart, Lung, and Blood Institute Registry (7.2%, n = 1,801, p = 0.001). Odds ratios and 95% confidence intervals showed the outcome in the current study to be at least comparable to the standard registries. CONCLUSIONS: Despite individual operator volumes below those currently being considered for credentialing, the overall institutional outcome was excellent in a diverse and complex patient population.

Academic Medical Centers↗
PubMed1997

Bullous pemphigoid evolving into cicatricial pemphigoid?

We describe three patients who initially presented with both clinical and immunological findings to support a diagnosis of bullous pemphigoid but whose subsequent course has been that of cicatricial pemphigoid. Mucosal scarring was accompanied by a fall in autoantibody titres in our three patients. These cases illustrate the difficulties clinicians may experience in assigning a specific diagnosis to patients. They also support the concept that bullous pemphigoid and cicatricial pemphigoid are part of a single disease spectrum. The most intriguing question is what specific factors determine the expression of a particular disease phenotype as bullous pemphigoid and cicatricial pemphigoid share target antigens and also the DQ7 allele.

Aged↗
PubMed1997

Assessing and managing risk of violence in the mentally disordered.

This review paper explored the concepts of risk assessment and management in relation to 'serious' violence by individuals with mental disorder. The paper highlighted the political context in which concern over serious violence by those with mental disorder is increasing. Government guidance on risk assessment was considered and identified as having an actuarial bias. Correlational studies, which provide actuarial indicators of risk, were explored and a picture was developed that demonstrated the difficulty of determining risk of violence to others simply on the basis of psychiatric symptomatology. The literature led to a conclusion that risk assessment for violence is an inexact science, and that actuarial indicators need to be supported by structured thorough clinical investigation. Legal concerns around the assessment and management of risk were also explored. The Health and Safety Executive model for risk management was explored in relation to the findings of the risk-assessment literature and the recommendations of reports into serious violent incidents. The model was shown to have potential utility in providing a legally sound framework for the assessment and management of risk of violence in mental disorder.

Bias↗
PubMed1997

Strengthening health promotion in Australian workplaces.

The Australian workplace has emerged as an important venue for influencing the health of employees through regulations and behaviour change programs. Recent surveys have highlighted a growth in this activity but the effectiveness of these programs in changing unhealthy work practices and policies is questionable. The need for strengthening programs by stronger designs and evaluation, and addressing organisational factors and employee participation in planning and implementation processes is documented. Efforts in that direction in Queensland are cited, Building on these existing foundations, redirecting existing resources, and building intersectoral cooperation in public-private partnerships hold a creative, exemplary vision of the future for Australian workplace programming.

Australia↗
PubMed1997

Linear IgA disease: a report of two dermal binding sera which recognize a pepsin-sensitive epitope (?NC-1 domain) of collagen type VII.

Linear IgA disease is a subepidermal blistering disease characterized by IgA autoantibody deposition at the basement membrane zone of skin and mucosa. The antigens targeted in linear IgA disease have been defined by their molecular weight and localization. It has been proposed that a minority of linear IgA disease sera that bind to the dermal aspect of salt-split skin target collagen type VII. We have identified two patients with linear IgA disease using dermal binding IgA autoantibodies on salt-split skin which recognize collagen type VII by immunoblot analysis. The reactive epitope was destroyed by the proteolytic enzymes pepsin, which destroys the NC-1 domain of collagen type VII, and protease type VIII. Localization studies compared the IgA autoantibodies from these patients with the monoclonal antibody LH7.2 to the NC-1 domain of collagen type VII and showed colocalization on a dermal cylindroma tumour tissue, and a similar distribution with immunogold electron microscopy, using purified blister fluid from one patient. We propose from these results that the IgA autoantibodies from these two patients recognize the NC-1 domain of collagen type VII, the classical immunodominant epitope for epidermolysis bullosa acquisita.

Adult↗