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Biomedical subjects

J Munro

Publications and source records attributed to J Munro.

At least 55 records · Page 3Linked to original sources
PubMed1999

Quality of life four years after acute myocardial infarction: short form 36 scores compared with a normal population.

OBJECTIVES: To assess the impact of myocardial infarction on quality of life in four year survivors compared to data from "community norms", and to determine factors associated with a poor quality of life. DESIGN: Cohort study based on the Nottingham heart attack register. SETTING: Two district general hospitals serving a defined urban/rural population. SUBJECTS: All patients admitted with acute myocardial infarction during 1992 and alive at a median of four years. MAIN OUTCOME MEASURES: Short form 36 (SF 36) domain and overall scores. RESULTS: Of 900 patients with an acute myocardial infarction in 1992, there were 476 patients alive and capable of responding to a questionnaire in 1997. The response rate was 424 (89. 1%). Compared to age and sex adjusted normative data, patients aged under 65 years exhibited impairment in all eight domains, the largest differences being in physical functioning (mean difference 20 points), role physical (mean difference 23 points), and general health (mean difference 19 points). In patients over 65 years mean domain scores were similar to community norms. Multiple regression analysis revealed that impaired quality of life was closely associated with inability to return to work through ill health, a need for coronary revascularisation, the use of anxiolytics, hypnotics or inhalers, the need for two or more angina drugs, a frequency of chest pain one or more times per week, and a Rose dyspnoea score of >/= 2. CONCLUSIONS: The SF 36 provides valuable additional information for the practising clinician. Compared to community norms the greatest impact on quality of life is seen in patients of working age. Impaired quality of life was reported by patients unfit for work, those with angina and dyspnoea, patients with coexistent lung disease, and those with anxiety and sleep disturbances. Improving quality of life after myocardial infarction remains a challenge for physicians.

Aged↗
PubMed1999

Shifting services from secondary to primary care: stakeholders' views of the barriers.

OBJECTIVES: To identify the barriers to shifting services from secondary to primary care perceived by the involved stakeholders. METHODS: Forty-five semi-structured interviews with stakeholders from primary care, acute and community hospitals, purchasers (health authorities) and other agencies involved in two contrasting initiatives to shift services. RESULTS: Stakeholders perceived similar barriers in the two initiatives: disinvesting from existing providers; lack of information on activity and costs; uncertainty over the quality of the proposed alternative service; concern about an increasing workload in primary care; diversity of views within primary care; difficulties in communication between the many agencies involved; and lack of leadership by purchasers. CONCLUSIONS: Service shifts which involve disinvestment from existing providers and collaboration between agencies with different views and interests will inevitably face a range of barriers. Attempts to shift services by disinvesting from secondary care are likely to encounter the greatest difficulties. Attempts to shift without concomitant disinvestment may also be slow because of the difficulties of multi-agency collaboration. Frustration will be reduced if those involved have a realistic understanding of the difficulties rather than being surprised and overwhelmed by them.

Attitude of Health Personnel↗
PubMed1999

Active monitoring of 12,760 clozapine recipients in the UK and Ireland. Beyond pharmacovigilance.

BACKGROUND: People prescribed clozapine for treatment-resistant schizophrenia have mandatory haematological monitoring through a case register for identifying reversible neutropenia. AIMS: To quantify risk factors for agranulocytosis in subjects receiving clozapine. METHOD: Data from 12,760 subjects registered to receive clozapine from January 1990 to April 1997 were analysed. Risk factors for agranulocytosis were quantified using a Cox proportional-hazards regression analysis. RESULTS: The risk for agranulocytosis in Asian subjects was 2.4 times that in Caucasians (P = 0.03). There was an age-related increase in risk of 53% per decade (P = 0.0001). CONCLUSIONS: The case register yielded valuable information for guiding research into the causes of the haematological reactions.

Adolescent↗
PubMed1998

Meta-analysis of studies on genetic variation in 5-HT2A receptors and clozapine response.

Serotonin (5-HT) neurotransmitter receptors are targeted by atypical antipsychotic drugs. We hypothesized that genetic variation in these receptors may affect clinical response to the drugs targeting them. This hypothesis has been tested by several studies in which the correlation between polymorphic variants in the 5-HT2A receptor gene and clinical response to the atypical antipsychotic clozapine was investigated. The results of these studies either found association between 5-HT2A genetic variants and clozapine response or found differences in the same direction which did not reach statistical significance. Meta-analysis of these studies including 373 patients who responded to the treatment and 360 non-responders showed association between two 5-HT2A polymorphisms, 102-T/C and His452Tyr, and clozapine response. Statistical analysis of extreme responders showed a clearer association of the 102-T/C with clozapine response. These results reinforce the hypothesis and strengthen the candidacy of these receptors as important therapeutic targets.

Alleles↗
PubMed1998

Evidence for association between polymorphisms in the promoter and coding regions of the 5-HT2A receptor gene and response to clozapine.

Clozapine is a potent atypical antipsychotic which binds to a variety of neurotransmitter receptors including serotonin (5-HT) receptors. However, the precise neurochemical site of clozapine's therapeutic action is unknown. We hypothesize that genetic variation in the neurotransmitter receptors to which the drug binds may influence clozapine response. To test this hypothesis we genotyped a novel -1438-G/A polymorphism detected in the promoter region, and a His452Tyr polymorphism described in the coding region of the 5-HT2A receptor gene in two independent samples of clozapine-treated patients including responders and non-responders. Although the strong association between these polymorphisms and clozapine response observed in the first sample (sample I) was not statistically significant in the second sample (sample II), the results in both samples were in the same direction. Homozygosity for the allele G-1438 was higher among non-responders (56% in sample I, 43% in sample II) than in responders (28% in sample I and 32% in sample II) in both samples. Similarly, the frequency of allele Tyr452 was higher in non-responders (11% in sample I, 16% in sample II) than in responders (6% in sample I and 10% in sample II). A combined analysis of both samples showed association between both polymorphisms and clozapine response. These results provide further evidence suggesting that genetic variation at 5-HT2A receptors may influence clozapine response and strengthen the candidacy of these receptors as important therapeutic targets.

Alleles↗
PubMed1998

Lack of association between a polymorphism in the promoter region of the dopamine-2 receptor gene and clozapine response.

Dopamine receptors are strong candidates for involvement in schizophrenia and are targeted by a wide variety of antipsychotics. We hypothesized that genetic variation in these neurotransmitter receptors may influence clinical response to clozapine, an antipsychotic which displays high affinity for dopamine D2 receptors in the limbic system. To test this hypothesis, we studied a functional polymorphism in the promoter region of the D2 receptor gene (-141C Ins/Del) in a sample of 151 clozapine treated patients of British origin. In addition, the influence of this polymorphism on antipsychotic response in general was investigated on a sample of 146 Han Chinese schizophrenic patients treated with a variety of antipsychotics. No association was found between this polymorphism and clinical response in either of the two samples suggesting that genetic variation in D2 receptors does not play a major role in determining clinical response to antipsychotic treatment.

Antipsychotic Agents↗
PubMed1998

Efficacy of speech and language therapy for particular speech sounds in children.

At the present time there is a demand for research into the efficacy of speech and language therapy. This study aims to assess the efficacy of therapy provided in South Tees for children who do not use word-initial velar plosives. The study is in progress at the time of writing and it is expected that therapy will be completed by July 1998. Subjects are split randomly into an 'immediate treatment' and a 'deferred treatment' group. All subjects are reassessed after treatment of each group. It is of course possible that analysis of the results will not show a significant difference between pre- and post-treatment scores. Some children may acquire target sounds before entering therapy, whilst others may fail to learn them within the treatment period. Various factors are being noted to determine whether they appear to correlate with the outcome of therapy.

Child, Preschool↗
PubMed1998

Unwelcome customers? The epidemiology of removal from general practitioner lists in Sheffield.

BACKGROUND: The 1990 contract and the 1991 fundholding scheme encouraged speculation that general practitioners (GPs) may remove patients from their lists for financial reasons. Despite assertions that patient removals are increasing, little evidence exists on the number or trends in removals. AIM: To describe the epidemiology of removals by time, place, and person, and to determine whether removals have increased in recent years. METHOD: Descriptive analysis of routine data relating to all removals of Sheffield residents from GP lists during 1991-1996. RESULTS: Removal from a doctor's list was a rare event (2.4 per 1000 patients per year) that did not become more common over the period examined. Removal rates varied by age, sex, and practice, with relatively high rates among children, young women, and the over-75s. There was a significant tendency for higher removal rates in more deprived parts of the city. CONCLUSION: Removal rates have not increased in Sheffield. The reasons for the variation in rates by age, sex, and practice are unknown. The higher rates noted in the under-fives and young women are consistent with the possibility that the 1990 target payment scheme may have increased removal rates in these age groups.

Adolescent↗
PubMed1997

Physical activity for the over-65s: could it be a cost-effective exercise for the NHS?

BACKGROUND: There is increasing interest in the health-promoting potential of physical activity in older adults. The objective of this study was to estimate the likely costs, health benefits and consequences for the National Health Service which might result from a publicly funded programme of regular exercise made available to a population of 10,000 people over the age of 65. METHODS: Risk education data from observational studies were used to calculate the possible impact of a community-based programme of activity on hospital admissions and deaths from coronary heart disease, stroke, diabetes, femoral neck fractures and mental disorders. The avoided costs of health care and net cost per life-year saved were estimated. RESULTS: Providing twice-weekly exercise classes for 10,000 participants would cost approximately 854,700 pounds per year, but would prevent 76 deaths and 230 in-patient episodes, avoiding annual health care costs of approximately 601,000 pounds. Assuming the mean expectation of life after 65 to be ten years, the programme would cost about 330 pounds per life-year saved. Under a range of more extreme assumptions, the cost per life-year saved would vary from 100 pounds to 1500 pounds. CONCLUSIONS: A publicly funded programme of regular moderate exercise for over-65-year-olds could achieve important health benefits at relatively low cost. The estimates provided by this analysis should now be tested in a rigorous randomized trial, and health commissioners should begin to think of purchasing exercise programmes alongside other health-promoting measures.

Aged↗
PubMed1997

Routine preoperative testing: a systematic review of the evidence.

OBJECTIVES. To review the available evidence on the value of routine preoperative testing in healthy or asymptomatic adults. To assess the completeness of existing reviews of preoperative testing and how applicable their conclusions are to the UK. To identify areas for further research. HOW THE RESEARCH WAS CONDUCTED. The databases Medline, Embase, Biological Abstracts, Science Citation Index and HealthSTAR were thoroughly searched for relevant articles which were then classified and appraised. The databases of the Centre for Reviews and Dissemination (DARE and NHS Economic Evaluations Database) and the Cochrane Collaboration (the Cochrane Library) were also used to verify the completeness of the search. In this review, 'routine' tests are defined as those ordered for an asymptomatic, apparently healthy individual in the absence of any specific clinical indication, to identify conditions undetected by clinical history and examination. RESEARCH FINDINGS. No controlled trials of the value of the following routine preoperative tests have been published. All available evidence reports the results of case-series. CHEST X-RAY. Few studies allow the outcome of routine chest X-rays to be distinguished from those of indicated chest X-rays, and fewer have gone beyond abnormality yields to examine the impact on clinical management. Findings from routine preoperative chest X-ray are reported as abnormal in 2.5-37.0% of cases, and lead to a change in clinical management in 0-2.1% of patients. The effect on patient outcomes is unknown. Both abnormality yield and impact on patient management rise with age and poorer American Society of Anesthesiologists (ASA) status. The limited evidence on the value of a chest X-ray as a baseline measure suggests that it will be of value in less than 9% of patients. ELECTROCARDIOGRAPHY. The findings from routine preoperative electrocardiograms (ECGs) are abnormal in 4.6-31.7% of cases, and lead to a change of management in 0-2.2% of patients. The effect on patient outcomes is unknown. The proportion of abnormal tests rises with age and worsening ASA status. The predictive power of preoperative ECGs for postoperative cardiac complications in non-cardiopulmonary surgery is weak. There is no evidence to support the value of recording a preoperative ECG as a 'baseline.' HAEMOGLOBIN MEASUREMENT AND BLOOD COUNTS. Routine preoperative measurement shows that the haemoglobin level may be lower than 10-10.5 g/dl in up to 5% of patients, but that it is rarely lower than 9 g/dl. The routine test leads to a change of management in 0.1% to 2.7% of patients. Routine preoperative measurement shows that the platelet count is abnormally low in less than 1.1% of patients, and that platelet count results rarely if ever lead to change in management of patients. Routine preoperative white blood cell count is abnormal in less than 1% of patients, and rarely if ever leads to change in management of patients. TESTS OF HAEMOSTASIS. Abnormalities of bleeding time, prothrombin time and partial thromboplastin time are found in up to 3.8%, 4.8% and 15.6% of routine preoperative tests, respectively. The results of these tests very rarely lead to change in the clinical management of patients. BIOCHEMISTRY. In routine preoperative tests of serum biochemistry, abnormal levels of sodium or potassium are found in up to 1.4% of patients, and abnormal levels of urea or creatinine are found in up to 2.5% of patients. Abnormal levels of glucose are found in up to 5.2% of patients. These abnormalities rarely lead to change in clinical management of patients. URINE TESTING. Routine preoperative urinalysis finds abnormal results in 1-34.1% of patients, and leads to a change of management in 0.1-2.8% of patients. The only abnormality that leads to a change in management of patients is the finding of white blood cells in the urine. There is no good evidence that preoperative abnormal urinalysis is associated with any postoperative complication in non-urinary tract surgery. (ABSTRACT TRUNCATED)

Adolescent↗
PubMed1996

Analysis of a structural polymorphism in the 5-HT2A receptor and clinical response to clozapine.

Clozapine is an atypical antipsychotic with affinity for a broad range of receptors, including serotonin (5-HT) and dopamine receptors. It is successful in treating about 60% of patients refractory to other antipsychotic drugs. Since genetic variation in clozapine's neurotransmitter receptor targets may affect clinical response through altering drug binding or receptor expression, we have studied a His452Tyr polymorphism in the 5-HT2A receptor (HTR2A) in a sample of 153 schizophrenic patients undergoing clozapine treatment and 178 normal controls. An association was found between the allele Tyr452 and poor clinical response.

Alleles↗
PubMed1996

Detection of a cluster of hepatitis C infections in a renal transplant unit by analysis of sequence variation of the NS5a gene.

Hepatitis C virus (HCV) genotype 1 isolates from 31 patients on dialysis or with renal transplants were studied for evidence of patient-to-patient spread of infection. Nucleotide sequences from a variable region (NSSV) of the NSSa (nonstructural 5a) gene and the hypervariable region of the second envelope gene. (env2) were compared. Investigation of phylogenetically related isolates of HCV type 1a with identical derived amino acid sequences in the NS5V led to recognition of a cluster of 4 patients who had received renal transplants within an 8-day period in 1984. This demonstrates the value of molecular epidemiologic techniques in reconstructing routes of infection and adds to the evidence for nosocomial transmission of HCV by routes other than blood transfusion.

Amino Acid Sequence↗
PubMed1996

Beyond guidelines: promoting clinical change in the real world.

There is widespread recognition that simply publishing research findings is not enough to ensure that they are carried into clinical practice. One response to this has been the burgeoning "guidelines movement" of recent years, which has now reached the stage of generating guidelines for the production of guidelines. Argues that guidelines, and other forms of intervention to change clinical practice in an evidence-based direction, will succeed only to the extent that they engage actively with the real world of clinical decision making. This world is more complex than guidelines writers acknowledge, and includes economic, administrative, professional and personal incentives as well as those provided by research evidence. Engaging with this real world may be difficult, but it opens up new possibilities for understanding how clinicians act and how evidence may be used to inform clinical practice. Such possibilities include social influences, educational outreach, providing information to patients, negotiating local coalitions on specific issues and changing the administrative environment.

Education, Medical, Continuing↗
PubMed1996

Growth and physical outcome of children conceived by in vitro fertilization.

OBJECTIVE: To determine the growth and physical outcome at 2 years of age for children born after assisted reproductive techniques in the state of Victoria. DESIGN: Using a case-matched control study between January 1991 and July 1993, 314 children (196 singletons, 47 sets of twins, 8 sets of triplets) conceived after in vitro fertilization (IVF) and related techniques at the Monash IVF and Royal Women's Hospital Reproductive Biology Unit and 150 control children (113 singletons, 17 sets of twins, 1 set of triplets) randomly selected from the general population using the Victorian Perinatal Data Collection Unit records were enrolled to be examined for minor dysmorphic and major organ abnormalities. Singleton and twin cases were matched for plurality and gestation and date of birth. Triplets were not matched. RESULTS: IVF status was not a significant independent factor for physical outcomes, including malformation rates, nor for days of hospitalization postdischarge and operations. There was no significant interaction between IVF status and mean percentiles for weight and head circumference. The IVF group had a greater mean length percentile. Twins in both groups had significantly poorer physical outcomes than singletons on some measures. CONCLUSION: This study did not demonstrate an independent IVF effect on the growth and physical outcome of children at 2 years of age when matched for plurality and gestation. The poor outcomes where noted were related to the effects of multiple births. These findings must be viewed in context of the response rates and therefore representativeness of the data. The need for longitudinal studies is demonstrated.

Adult↗