Acknowledging the expertise of patients and their organisations.
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Attitude of Health Personnel↗
Biomedical subjects
J Wilson
Publications and source records attributed to J Wilson.
Reducing the risk of major elective surgery: randomised controlled trial of preoperative optimisation of oxygen delivery.
OBJECTIVES: To determine whether preoperative optimisation of oxygen delivery improves outcome after major elective surgery, and to determine whether the inotropes, adrenaline and dopexamine, used to enhance oxygen delivery influence outcome. DESIGN: Randomised controlled trial with double blinding between inotrope groups. SETTING: York District Hospital, England. SUBJECTS: 138 patients undergoing major elective surgery who were at risk of developing postoperative complications either because of the surgery or the presence of coexistent medical conditions. INTERVENTIONS: Patients were randomised into three groups. Two groups received invasive haemodynamic monitoring, fluid, and either adrenaline or dopexamine to increase oxygen delivery. Inotropic support was continued during surgery and for at least 12 hours afterwards. The third group (control) received routine perioperative care. MAIN OUTCOME MEASURES: Hospital mortality and morbidity. RESULTS: Overall, 3/92 (3%) preoptimised patients died compared with 8/46 controls (17%) (P=0.007). There were no differences in mortality between the treatment groups, but 14/46 (30%) patients in the dopexamine group developed complications compared with 24/46 (52%) patients in the adrenaline group (difference 22%, 95% confidence interval 2% to 41%) and 28 patients (61%) in the control group (31%, 11% to 50%). The use of dopexamine was associated with a decreased length of stay in hospital. CONCLUSION: Routine preoperative optimisation of patients undergoing major elective surgery would be a significant and cost effective improvement in perioperative care.
Aged↗
Combretastatin A-4 phosphate as a tumor vascular-targeting agent: early effects in tumors and normal tissues.
The potential for tumor vascular-targeting by using the tubulin destabilizing agent disodium combretastatin A-4 3-0-phosphate (CA-4-P) was assessed in a rat system. This approach aims to shut down the established tumor vasculature, leading to the development of extensive tumor cell necrosis. The early vascular effects of CA-4-P were assessed in the s.c. implanted P22 carcinosarcoma and in a range of normal tissues. Blood flow was measured by the uptake of radiolabeled iodoantipyrine, and quantitative autoradiography was used to measure spatial heterogeneity of blood flow in tumor sections. CA-4-P (100 mg/kg i.p.) caused a significant increase in mean arterial blood pressure at 1 and 6 h after treatment and a very large decrease in tumor blood flow, which-by 6 h-was reduced approximately 100-fold. The spleen was the most affected normal tissue with a 7-fold reduction in blood flow at 6 h. Calculations of vascular resistance revealed some vascular changes in the heart and kidney for which there were no significant changes in blood flow. Quantitative autoradiography showed that CA-4-P increased the spatial heterogeneity in tumor blood flow. The drug affected peripheral tumor regions less than central regions. Administration of CA-4-P (30 mg/kg) in the presence of the nitric oxide synthase inhibitor, N(omega)-nitro-L-arginine methyl ester, potentiated the effect of CA-4-P in tumor tissue. The combination increased tumor vascular resistance 300-fold compared with less than 7-fold for any of the normal tissues. This shows that tissue production of nitric oxide protects against the damaging vascular effects of CA-4-P. Significant changes in tumor vascular resistance could also be obtained in isolated tumor perfusions using a cell-free perfusate, although the changes were much less than those observed in vivo. This shows that the action of CA-4-P includes mechanisms other than those involving red cell viscosity, intravascular coagulation, and neutrophil adhesion. The uptake of CA-4-P and combretastatin A-4 (CA-4) was more efficient in tumor than in skeletal muscle tissue and dephosphorylation of CA-4-P to CA-4 was faster in the former. These results are promising for the use of CA-4-P as a tumor vascular-targeting agent.
Animals↗
Sterilization-in-place of concentrated nutrient solutions
Sterilization-in-place (batch sterilization) behavior of concentrated nutrient solutions was quantified for various nutrient solutions of fermentation processing interest. Experimental observations of sterilization temperatures and corresponding pressures suggested that sterilization pressures were substantially lower for concentrated nutrient solutions than for water. This effect was believed to be directly related to the lower vapor pressure and lower activity coefficient of these concentrated nutrient solutions. Using thermodynamic data for the specific nutrient, pressures and temperatures, calculated as a function of nutrient concentration, compared favorably with observed values. This method permits estimation of the expected sterilization pressure for concentrated nutrients for which no experimental observations have yet been made at the sterilization temperature of interest. Estimate accuracy, ranging from 0.006 to 0.06 bar, can be enhanced if one set of experimental temperature/pressure values is known at the expected sterilization scale. The potential impact of the nature of concentrated nutrient solutions on steam-in-place vessel headspace temperature distributions, D-values of B. stearothermophilus, and overall sterilization effectiveness is also discussed. The low vapor pressure of concentrated nutrient solutions was hypothesized to directly impact air removal effectiveness and sterilization performance during batch sterilization. Copyright 1999 John Wiley & Sons, Inc.
Journal Article↗
Aerosol route enhances the contamination of intact eggs and muscle of experimentally infected laying hens by Salmonella typhimurium DT104.
Commercial laying hens were infected with Salmonella typhimurium DT104 strain 16 alternatively via the crop (10(7) cfu per bird) or by an aerosol delivered directly to the beaks using a Collison nebuliser and Henderson apparatus (2 x 10(2) or 2 x 10(4) cfu per bird). Infection by both routes caused systemic infection and prolonged contamination of faeces. Contamination rates of eggs and muscle were much higher following the aerosol challenges despite the much lower doses given by this route. The frequency of Salmonella isolation from eggs rose from 1.7% following oral challenge to 14% and 25%, for each of the aerosol challenges respectively, and the frequency of isolation from muscle rose from 0% following the oral challenge to 27% following each of the aerosol challenges.
Aerosols↗
Comparative bone growth behavior in granules of bioceramic materials of various sizes.
Various bioceramic materials were implanted into 6-mm-diameter holes made in the femoral condyles of mature Japanese white rabbits using different-sized granules to find an optimal material and granule diameter for use as a bone graft. Bioceramics include a bioinert ceramic (Alumina), surface-bioactive ceramics [hydroxyapatite (HAp) and Bioglass(R)], and resorbable bioactive ceramics [alphatricalcium phosphate (alpha-TCP), beta-TCP, tetracalcium phosphate (TeCP), Te. DCPD, Te. DCPA, and low-crystalline HAp]. Granule sizes were 100-300, 10, and 1-3 microm. Bone growth behavior varied with the kind of bioceramic and the size used. For surface-bioactive ceramics, 45S5 Bioglass(R) led to more rapid bone proliferation than synthetic HAp. In resorbable bioactive ceramics, the order of resorption was: low-crystalline HAp and OCP > TeCP, Te DCPD, Te DCPA > alpha-TCP, beta-TCP. In terms of biocompatibility, alpha-TCP was better than beta-TCP.
Aluminum Oxide↗
The NAC proton treatment planning system.
A three-dimensional proton treatment planning system called PROXELPLAN has been used at the National Accelerator Centre (NAC) since October 1994. This system is entirely based on the VOXELPLAN planning system, developed at the Deutches Krebsforschungszentrum (DKFZ), Heidelberg, Germany. The VOXELPLAN system provides the treatment planning infrastructure while the proton dose distributions are calculated using a software module that was initially developed at the Royal Marsden Hospital, UK. The proton module has been extensively modified and refined. It uses a rayline-tracing algorithm which is suitable for planning current treatments but is not sufficiently dynamic to accommodate the use of compensators. A sophisticated pencil beam algorithm is currently under development.
Algorithms↗
Status report of the NAC particle therapy programme.
The 200 MeV cyclotron facility at the National Accelerator Centre has been operational since 1987. Between September 1988 and December 1997 a total of 973 patients (26,916 fields) had been treated on the 66 MeV p+Be isocentric neutron therapy system. Patients are currently being treated according to several protocols, including tumors of the head and neck, salivary gland and breast and soft tissue sarcomas, uterine sarcomas and paranasal sinuses. A multiblade post-collimator trimmer has recently being installed. This device provides improved neutron beam shaping capability. Between September 1993 and December 1997 a total of 243 patients (4008 fields) had been treated (mainly intracranial stereotactic irradiations) on the fixed horizontal 200 MeV proton therapy facility. The facility incorporates an innovative automatic patient positioning system. Two new fixed beam lines for proton therapy are presently being designed (horizontal and 30 degrees to the vertical) for an existing unused treatment vault. Spot scanning systems will be developed for both beam lines.
Head and Neck Neoplasms↗
Low alcohol preference among the "high alcohol preference" C57 strain of mice; preference increased by saline injections.
RATIONALE AND OBJECTIVE: This study investigated individual alcohol preference among the "high alcohol preferring" strain of C57BL10 (line ScSn) mice. METHODS: Alcohol preference was assessed in free choice two-bottle preference tests, using 8% ethanol and tap water, under various conditions. RESULTS: Between 15 and 40% of the mice, bred in house, showed a low preference for alcohol with ethanol/water ratios of 0.4 or less. There was a biphasic distribution of preference, and no relationship between alcohol preference and gender. Mice of the C57BL/6 strain from an outside breeder also contained animals with low preference for alcohol. Selective breeding from "in house" stock did not demonstrate evidence of a simple genetic link. Ethanol preference showed no correlation with locomotor activity or the effects of alcohol on such activity. Daily intraperitoneal injections of saline increased the preference of low preference mice, an effect prevented by the CCK(B) antagonist, CAM1028. The preference of "low preference" mice was significantly increased when the effects of saline injections were compared with those of handling alone. Diazepam, at 1 mg/kg, did not affect the low preference, compared with Tween vehicle. This demonstration of C57 strain mice with low preference for alcohol may provide a valuable model for the effects of stress on alcohol consumption.
Alcohol Drinking↗
Validating the Ontario Child Health Scale in a UK population.
The Ontario Child Health Scale (OCHS) was one of the first scales to seek to assess a broad range of formally defined psychiatric disorders using a checklist format. The performance of the teacher version of this instrument is reported in a UK population of children attending a special educational provision for emotionally and behaviourally disordered (EBD) pupils. Against DSM-IV criteria the instrument proved to have retained its convergent and discriminant validity, although it was somewhat less effective in detecting internalizing disorders and discriminating oppositional defiance from other behavioural disorders. Overall the results confirm the usefulness of this instrument as a screening tool in a UK population.
Adolescent↗
Management of labor in Eisenmenger syndrome with inhaled nitric oxide.
Administration of nitric oxide by means of inhalation during the labor of a woman with Eisenmenger's syndrome caused by an atrial septal defect resulted in improved oxygenation and initial pulmonary arterial pressure. She gave birth to a live infant at 34 weeks' gestation but died of worsening pulmonary hypertension and heart failure 21 days post partum.
Administration, Inhalation↗
Surgical teaching quality makes a difference.
BACKGROUND: This study examined the influence of the quality of faculty members' teaching on student performance in a third-year surgery clerkship. METHODS: Eighty-nine third-year students on a surgery clerkship completed preceptor evaluation forms. The faculty member's overall score was the mean of ratings from all the third-year students for whom that faculty member served as preceptor during the year. We examined associations between these ratings and student performance on the National Board of Medical Examiners (NBME) surgery subject examination and clerkship Objective Structured Clinical Examination (OSCE) by using an analysis of covariance that controlled for prior academic achievement [United States Medical Licensure Examination (USMLE) Part I]. RESULTS: The average mean teaching evaluation score was associated with the scores on the NBME surgery subject examination (P = 0.0005). Students with attendings who received poor teaching evaluations performed more poorly on OSCE data-gathering stations than did students with attendings rated as average or good. CONCLUSIONS: The study results indicate that the teaching quality of surgery faculty appears to have an impact on student performance.
Adult↗
Inadequate career advice for students.
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Career Choice↗
Staged surgical treatment of obstructive sleep apnea syndrome: a review of 35 patients.
PURPOSE: The purpose of this study was to investigate the success of a staged surgical reconstruction of the upper airway for treatment of obstructive sleep apnea syndrome. PATIENTS AND METHODS: Thirty-five patients with obstructive sleep apnea syndrome documented by nocturnal polysomnography were treated surgically with a staged protocol for reconstruction of the upper airway. All patients were evaluated preoperatively by a history and physical examination, including fiberoptic nasopharyngoscopy, oropharyngoscopy, and hypopharyngoscopy; cephalometric analysis; and laboratory polysomnography. All patients included were diagnosed with type II obstruction, with collapse at the oropharyngeal and hypopharyngeal levels. Stage I reconstruction consisted of uvulopalatopharyngoplasty (UPPP) by the Fujita method and anterior mandibular osteotomy (AMO) or inferior sagittal osteotomy (ISO) with genioglossus muscle advancement. If stage I was unsuccessful, patients were advanced to stage II and stage III, if necessary. Stage II reconstruction consisted of bimaxillary advancement with rigid fixation. Stage III reconstruction consisted of hyoid myotomy and advancement. RESULTS: All patients underwent follow-up nocturnal polysomnography 4 to 6 months after the last surgical procedure. Most patients responded positively to stage I reconstruction (respiratory disturbance index [RDI] < 20, with O2 saturation 95+%). Twenty-four patients (69%) had postoperative RDIs of 20 or less. Of these, 11 patients (31%) had an RDI of five or fewer; seven patients (20%) had an RDI between 6 and 10, and six patients (17%) had an RDI between 10 and 20. The mean preoperative RDI was 53, and the mean postoperative RDI was 19. Of the three patients who elected to proceed to stage II reconstruction, all had a postoperative RDI of 10 or less (two patients [67%] had an RDI of 5 or less, and one patient [33%] had an RDI of 6 to 10). CONCLUSION: This study showed that properly selected patients with obstructive sleep apnea syndrome benefit from a staged reconstruction of the upper airway.
Adult↗
Clinical governance and the potential implications for tissue viability.
This article explores how clinical governance can and will impact on tissue viability specialists. It highlights the principles of governance and what it means for healthcare organizations, and the different processes of application, including responsibilities, that will be adopted. The dimensions of clinical governance have been applied to the quality of care expected and given by staff as well as ways of assessing performance and ensuring that quality is everybody's business. It is up to us all as healthcare practitioners to ensure that we keep professionally up-to-date, enhance our education, research and development, and have a mechanism for monitoring and safeguarding our performance. The paper should promote discussion and provide food for thought regarding the application and full utilization of clinical governance.
Decision Making, Organizational↗
Clinical supervision: practicalities for the supervisor.
The concept of clinical supervision is firmly taking root within the profession. This article draws on the author's experience of being a supervisor to link theory to practice. Types of supervision, models used and the essential skills needed are all discussed. The importance of reflection is stressed and a suggested format to facilitate this is described. For clinical supervision to be successful, both supervisee and supervisor need to attend relevant training sessions.
Clinical Competence↗
ERCP and stent therapy for progressive jaundice in hepatocellular carcinoma: which patients benefit, which patients don't?
Jaundice in hepatocellular carcinoma (HCC) can be due to biliary obstruction. Endoscopic retrograde cholangiopancreatography (ERCP) can be both diagnostic and therapeutic. Biliary stenting can relieve jaundice and allow further chemotherapy, but at additional expense and potential morbidity. We sought to determine whether CT scan or ultrasound (US) could identify which patients with HCC and jaundice would benefit from endoscopic stenting. We retrospectively analyzed 26 patients with HCC and jaundice who underwent ERCP after CT or US. We compared biliary dilation on CT or US with the dominant biliary stricture seen on ERCP, and with response to biliary stenting. Eleven of 26 patients had dominant biliary stricture on ERCP; 11 underwent stenting. Six of 11 (55%) stented patients had a significant decline in bilirubin; three became eligible for further chemotherapy. All six responders to stenting had biliary dilation on prior CT or US. Procedure-related complications occurred in 1/11 (9%) who underwent stent placement. In conclusion, in selected patients, stenting can safely relieve jaundice and allow subsequent chemotherapy. CT or US accurately predicted lesions that responded to stenting. ERCP and stenting provided no benefit in the absence of biliary dilation on CT or US.
Adult↗