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Biomedical subjects

J Dale

Publications and source records attributed to J Dale.

At least 73 records · Page 4Linked to original sources
PubMed1997

Visualization of flumes from pharmaceutical delivery devices.

For the treatment of some diseases, drugs are delivered suspended in sprays that are administered either intranasally or by inhalation. The characteristics of these sprays or flumes have an influence on the effectiveness of the drug and some of these characteristics are best understood if the emerging flumes can be visualized. At GlaxoWellcome we have developed a multi-exposure photographic system whereby individual flumes can be recorded at pre-set intervals over their entire time period, typically 250 ms. It may also be desirable to visualize the flume within the nasal passage and this may be achieved by the use of a glass model nose. In this paper I will summarize pre-existing photographic methods and describe in detail the new technique.

Medical Illustration↗
PubMed1997

Wound dressings.

Wound healing is a complex rebuilding process that may be easily disrupted if dressings and topical applications are chosen unwisely. There is now a consensus of opinion on the attributes of an ideal dressing. There are many dressings available, each possessing certain of these attributes. There is a shortage of clinical trials in this area.

Bandages↗
PubMed1996

Cost effectiveness of treating primary care patients in accident and emergency: a comparison between general practitioners, senior house officers, and registrars.

OBJECTIVES: To compare outcome and costs of general practitioners, senior house officers, and registrars treating patients who attended accident and emergency department with problems assessed at triage as being of primary care type. DESIGN: Prospective intervention study which was later costed. SETTING: Inner city accident and emergency department in south east London. SUBJECTS: 4641 patients presenting with primary care problems: 1702 were seen by general practitioners, 2382 by senior house officers, and 557 by registrars. MAIN OUTCOME MEASURES: Satisfaction and outcome assessed in subsample of 565 patients 7-10 days after hospital attendance and aggregate costs of hospital care provided. RESULTS: Most patients expressed high levels of satisfaction with clinical assessment (430/562 (77%)), treatment (418/557 (75%)), and consulting doctor's manner (434/492 (88%)). Patients' reported outcome and use of general practice in 7-10 days after attendance were similar: 206/241 (85%), 224/263 (85%), and 52/59 (88%) of those seen by general practitioners, senior house officers, and registrars respectively were fully recovered or improving (chi2 = 0.35, P = 0.840), while 48/240 (20%), 48/268 (18%), and 12/57 (21%) respectively consulted a general practitioner or practice nurse (chi2 = 0.51, P = 0.774). Excluding costs of admissions, the average costs per case were 19.30 pounds, 17.97 pounds, and 11.70 pounds for senior house officers, registrars, and general practitioners respectively. With cost of admissions included, these costs were 58.25 pounds, 44.68 pounds, and 32.30 pounds respectively. CONCLUSION: Management of patients with primary care needs in accident and emergency department by general practitioners reduced costs with no apparent detrimental effect on outcome. These results support new role for general practitioners.

Consultants↗
PubMed1996

Creating a shared vision of out of hours care: using rapid appraisal methods to create an interagency, community oriented, approach to service development.

OBJECTIVES: To undertake a district wide review of out of hours primary health care services and identify the views of users and providers about current arrangements and options for development. DESIGN: A range of qualitative and quantitative survey methods based on rapid appraisal methods, modified to apply to an inner city district. SETTING: Socially deprived, multiethnic district in south east London with a population of over 700,000. MAIN OUTCOME MEASURES: Strengths and weaknesses of current out of hours services and suggestions for developments. RESULTS: Widespread dissatisfaction with current arrangements was identified, with specific problems relating to access, availability, demand for services, and interagency communication. Several areas for development were identified, including the establishment of an out of hours cooperative, multiagency primary care emergency centres, and telephone advice-triage. Many of these are now being planned or piloted. CONCLUSIONS: Rapid appraisal provided a helpful method, enabling partnerships to be established between local agencies and users in relation to service development. The shared understanding and commitment to improving services that resulted is now having a major impact on out of hours care in the district.

Attitude of Health Personnel↗
PubMed1996

Preoperative concurrent chemoradiotherapy for unresectable Stage III nonsmall cell lung cancer.

PURPOSE: We carried out a Phase II trial in an attempt to improve resectability and survivability of inoperable Stage III A and III B nonsmall cell lung cancer (NSCLC) patients by implementing a neoadjuvant chemoradiotherapy treatment program. METHODS AND MATERIALS: Thirty-six patients with locally advanced Stage III NSCLC received neoadjuvant therapy consisting of 50.4 Gy in 5.5 weeks concurrent with two cycles of chemotherapy, using cisplatin and etoposide. No postsurgical consolidation therapy was given. RESULTS: Assessment at 3 to 6 weeks after treatment suggested that 26 (72%) patients had been rendered resectable. Toxicities were common but usually tolerable; however, one toxic death occurred. Of 24 patients who proceeded to thoracotomy, complete resection was achieved in 20 (56%). There were two surgically related deaths. Surgical-pathological staging showed downstaging in 18 patients, including complete sterilization of the tumor in 3 (8%). The median survival for all 36 patients is 15 months, but at the time of analysis, median survival of resectable patients had not been reached. The actuarial 2-year survival is 39% for all study groups, 57% for resectable patients, and 16% for the remaining (p < 0.005). CONCLUSIONS: While this preoperative neoadjuvant appears to improve survival of patients with Stage III NSCLC, comparison with previous reports of other similar trials indicate a superior survival advantage in association with higher doses of radiotherapy.

Adult↗
PubMed1996

Postradiotherapy hypothyroidism: radiation dose response and chemotherapeutic radiosensitization at less than 40 Gy.

To analyze our experience with iatrogenic hypothyroidism, we prospectively followed 84 patients, seen from 1984 to 1990, who had been diagnosed with either Hodgkin's disease (HD) or head and neck (H&N) carcinoma and subsequently treated with radiotherapy. Within these two diagnostic groups were subgroups whose treatment differed as to dose of therapeutic irradiation received or adjunctive use of chemotherapy. Approximately 50% of all patients and of each subgroup developed either clinical or subclinical hypothyroidism during follow-up. However, among the HD patients who received irradiation plus chemotherapy, a dose-response relationship below a threshold limit of dose received, probably 40 Gy, was observed.

Adolescent↗
PubMed1996

Paediatric calls to an inner city accident and emergency department: service demand and advice given.

Patients routinely call both Accident and Emergency (A & E) departments and General Practice for advice. Many of these calls concern children. In the UK, telephone calls for advise made to A & E departments are usually dealt with by nursing staff in an informal manner. This paper focuses on telephone calls concerning children received in a busy inner city department. Data were collected using a Telephone Consultation Record proforma (TCR) developed to document all calls to the A & E department. There were a total of 597 calls to the A & E department documented during the study period of which 218 (37%) concerned paediatric patients. The majority of calls were concerning children under the age of 5. One-third of callers were given self-care advice. This paper reports on the volume of calls, the nature of patients' problems and the outcome in terms of the advice given to the caller. The implications of the findings are discussed. Given the current demand for telephone advice, A & E departments should examine the nature and demand for telephone advice and explore methods of providing training and support to staff carrying out this role.

Adolescent↗
PubMed1996

Prothrombin time: one tube or two.

This study compares the prothrombin times (PTs) and calculated international normalized ratios (INRs) from first and second evacuation blood tubes to determine the clinical importance of using a second tube specimen for protime coagulation studies. The National Committee for Clinical Laboratory Standards (NCCLS) currently recommends that all coagulation studies be done on a second or later drawn blood tube. For patients on long-term anticoagulation therapy, this often requires that first blood tubes be drawn and discarded at each prothrombin evaluation. In this prospective study, a first and second evacuation blood tube was drawn from 343 outpatients who had a physician-ordered prothrombin time test performed. There was no statistically significant difference in the paired PT or calculated INR from any of the first and second tubes. The average difference in the INR from tube 1 to tube 2 was 2% (standard deviation [SD] 1.1%). In this sample of outpatients, the use of a second tube for PT testing was not clinically justified.

Ambulatory Care↗
PubMed1996

Simple clinical data are useful in predicting effect of exercise training after myocardial infarction.

OBJECTIVES: The aim of the present study was to determine whether simple clinical variables can predict the effect of intensive exercise training in an unselected population early after myocardial infarction. METHODS: Starting 5 weeks after the qualifying myocardial infarction, 105 patients, 68 years old or younger, completed a 4 week period of intensive exercise training. The training effect was defined as an absolute increase in cumulative work at bicycle ergometry. Using univariate and multivariate analysis, 28 variables were tested against the training effect. RESULTS: The mean exercise capacity increased from 46.7 +/- 22.7 kJ to 69.5 +/- 31.1 kJ (P = 0.0001). Multivariate analysis identified five independent predictors of the training effect. Myocardial infarct size was associated with a better training effect (P = 0.0018), as was male gender (P = 0.0042) and ability to exercise to exhaustion at the baseline exercise test (P = 0.0124). Older age (P = 0.0017) and treatment with beta-adrenergic blocking agents (P = 0.0241) were associated with a lower effect from training. These five variables explained 33% of the variations in effect from training. Patients suffering in-hospital cardiac complications or congestive heart failure achieved a training effect at least as great as patients without cardiac complications. CONCLUSIONS: Five simple clinical variables, including infarct size, can assist in the selection of patients for exercise training after myocardial infarction.

Aged↗
PubMed1996

Do patients use minor injury units appropriately?

BACKGROUND: This study aimed to examine the extent to which patients make appropriate use of Accident and Emergency and Minor Injury Unit services. The outcomes used included the proportion of Minor Injury Unit patients referred to an Accident and Emergency department, comparison between the proportions admitted from patients attending Minor Injury Units and Accident and Emergency departments directly, and the diagnoses and lengths of stay of those requiring admissions from Minor Injury Units. METHODS: Patients were identified who were resident in the vicinity of Deal and Folkestone and in January 1994 attended local Minor Injury Units in these towns or nearby Accident and Emergency departments at times when the Minor Injury Units were open. The following details were documented from their hospital notes: presenting problem, time and date of attendance, mode of arrival at/referral to the facility, postcode of residence, age, sex, diagnosis and referral/discharge. A sub-sample of 448 patients were interviewed while waiting to be seen at the Minor Injury Units. RESULTS: The criteria for inclusion in the study were met by 1891 patients. Of these, 188 (9.9 per cent) were referred by a general practitioner (GP). A total of 1472 patients attended the Minor Injury Units without referral from a GP, of whom 28 [1.9 per cent; 95 per cent confidence interval (CI) 1.2-2.6 per cent] were referred for further assessment and care to a general hospital. Whereas 71 (29.5 per cent; 95 per cent CI 23.7-35.3 per cent) of the 241 who went directly to an Accident and Emergency department without GP referral required admission, this was true for only eight (0.5 per cent; 95 per cent CI 0.2-0.9 per cent) self-referred patients attending Minor Injury Units. Four of the latter admissions were for trauma-related problems and required stays of less than 24 hours. Of the patients attending the Deal and Folkestone Minor Injury Units who were interviewed, only 195 (47.0 per cent) said that they would have attended an Accident and Emergency department had the facility not been available; the remainder said that they would have either gone to their own GP or self treated. The latter were more likely to be female patients, to have problems of longer duration, and/or to have attended the facilities by public transport or taxi. CONCLUSION: The results support the view that patients choose appropriately between attending a Minor Injury Unit or an Accident and Emergency department. However, there was evidence that the availability of an intermediate tier of health care for minor injuries appears likely to result in increased overall workload. This small-scale study leaves unanswered questions in terms of clinical outcomes and the quality of care provided by different facilities.

Adolescent↗
PubMed1996

Treatment of thyrotoxicosis resistant to carbimazole with corticosteroids.

We report two patients whose thyrotoxicosis failed to respond to conventional treatment with carbimazole. The patients remained persistently hyperthyroid, both clinically and biochemically, despite several months of carbimazole therapy at the maximum recommended doses. Prednisolone 20 mg per day was then given in addition to the antithyroid drug and a dramatic response observed in both cases. They were then successfully treated with radioiodine. Prednisolone has not been previously used to treat patients with hyperthyroidism who have not responded to thionamide drugs. Our experience suggests that corticosteroids may be potentially useful for controlling thyrotoxicosis in combination with carbimazole before definite treatment can be instituted.

Adult↗
PubMed1996

An analysis of telephone calls to an inner-city accident and emergency department.

The general public in the UK often telephone accident and emergency (A&E) departments for medical advice. Such calls are usually dealt with by nursing staff in an informal manner (often with no written record of the call being made). The specific questions addressed in this study are who was calling for advice, when did they call, what were their presenting complaints, and what was the outcome of the call? In addition, the study provided an opportunity to test the implementation of a new system of record-keeping for telephone consultation. A telephone consultation record (TCR) was developed and used to record details of each call made to the A&E department for medical/health advice. An analysis of 597 consecutive documented calls is presented in this paper. The majority of calls were dealt with by 'E' grade nursing staff (42.7%); only four calls (0.7%) were recorded by medical staff. Two hundred and six (43.5%) calls related to patients aged up to 15 years. In 57% of the cases the call was made by a third party. In all, 149 different presenting complaints were recorded on the TCRs. The three most common presenting complaints were dental problems (7.4%), fever (4.3%), and concerns about drug reactions (23%). Seventy-three per cent of callers were advised that a visit to the A&E department was not immediately necessary. The study identifies several important issues for development of a more formal and effective system of telephone advice. The majority of calls made to the A&E department appeared to be of a primary care nature but the extent to which nurses are trained to assess and advise on these problems needs to be questioned. A reluctance to document the calls to A&E was identified, one reason being a concern about accountability. Training and support are clearly required.

Adolescent↗
PubMed1995

Primary care in the accident and emergency department: I. Prospective identification of patients.

OBJECTIVE: To compare patient characteristics and consultation activities for attenders at accident and emergency departments assessed by nurse triage as presenting with "primary care" or "accident and emergency" type problems. DESIGN: One year prospective study. SETTING: A busy, inner city accident and emergency department in south London. SUBJECTS: Of the 5658 patients treated for new problems during a stratified random sample of 204 three hour sessions between 10 am and 9 pm during June 1989 to May 1990, all "primary care" (2065 patients) and a 10% random sample of "accident and emergency" (291 patients) were included in the analysis. MAIN OUTCOME MEASURES: Patient's age, sex, duration of presenting problem, diagnosis, laboratory and radiographic investigations, treatments, and referrals. RESULTS: 40.9% of attenders with new problems were classified by triage as presenting with "primary care" problems (95% confidence interval 39.6% to 42.2%). Primary care attenders were more likely than accident and emergency patients to be young adults, to have symptoms with a duration of longer than 24 hours, and to present problems not related to injury (all P < 0.001). Accident and emergency patients were considerably more likely to be referred to on call teams and to be admitted. Even so, 9.7% of primary care patients were referred to on call teams and a further 8.9% were referred to the fracture clinic or advised to return to the accident and emergency department for follow up. CONCLUSION: Accident and emergency triage can be developed to identify patients with problems that are more likely to be of a primary care type, and these patients are less likely to receive an investigation, minor surgical procedure, or referral. Many patients in this category, however, receive interventions likely to support their decision to attend accident and emergency rather than general practice. This may reflect limitations in the sensitivity of triage practice or a clinical approach of junior medical staff that includes a propensity to intervene.

Adolescent↗
PubMed1995

Primary care in the accident and emergency department: II. Comparison of general practitioners and hospital doctors.

OBJECTIVE: To compare the process and outcome of "primary care" consultations undertaken by senior house officers, registrars, and general practitioners in an accident and emergency department. DESIGN: Prospective, controlled intervention study. SETTING: A busy, inner city accident and emergency department in south London. SUBJECTS: Patients treated during a stratified random sample of 419 three hour sessions between June 1989 and May 1990 assessed at nurse triage as presenting with problems that could be treated in a primary care setting. 1702 of these patients were treated by sessionally employed local general practitioners, 2382 by senior house officers, and 557 by registrars. MAIN OUTCOME MEASURES: Process variables: laboratory and radiographic investigations, prescriptions, and referrals; outcome variables: results of investigations. RESULTS: Primary care consultations made by accident and emergency medical staff resulted in greater utilisation of investigative, outpatient, and specialist services than those made by general practitioners. For example, the odds ratios for patients receiving radiography were 2.78 (95% confidence interval 2.32 to 3.34) for senior house officer v general practitioner consultations and 2.37 (1.84 to 3.06) for registrars v general practitioners. For referral to hospital specialist on call teams or outpatient departments v discharge to the community the odds ratios were 2.88 (2.39 to 3.47) for senior house officers v general practitioners and 2.57 (1.98 to 3.35) for registrars v general practitioners. CONCLUSION: Employing general practitioners in accident and emergency departments to manage patients with primary care needs seems to result in reduced rates of investigations, prescriptions, and referrals. This suggests important benefits in terms of resource utilisation, but the impact on patient outcome and satisfaction needs to be considered further.

Adolescent↗