Biomedical subjects

L Wright

Publications and source records attributed to L Wright.

At least 37 records · Page 2Linked to original sources

PubMed2000

Integrating primary and secondary care: the case of Christchurch South Health Centre.

AIMS: To study health services utilisation linkages and methodological issues in integrating primary and secondary care services for a defined general practice population (Christchurch South Health Centre, CSHC). METHODS: The Centre supplied national health index (NHI) linked data on date of birth, gender and community services card (CSC) status for 10,174 patients, and data on primary care. Secondary care providers supplied NHI linked data on specialist outpatients, emergency department usage for 1996 to 1998, and waiting lists. The Health Funding Authority (HFA) supplied NHI linked data on inpatient/daypatients for 1996 and 1997. Data were also obtained relating to community support services and long-term care. Rates of hospital utilisation for the Centre's population were standardised for comparison with national and Christchurch figures using age, gender and CSCs. Overall per capita expenditure was calculated for this population. RESULTS: Patients with CSCs constituted 31.2% of the practice population, but generated 60.8% of bed-days. Patients with high use health cards (HUHCs) constituted 8.6% of the population, but generated 42.4% of bed-days. This group was at high risk of hospitalisation over a wide range of disease categories. Standardised rates of hospital utilisation were significantly lower for the Centre's older patients, especially for bed-days, than both national and Christchurch figures. Only a small proportion of referrals to specialist outpatients, 28.2% in 1998, was from the Centre's general practitioners (GPs), the remainder being generated internally within the specialist services. The overall expenditure per capita on the Centre's population was $1012, which was substantially less than expected in comparison with national figures. CONCLUSION: The study demonstrates the importance of primary care factors in the utilisation of secondary care, especially acute hospitalisation in older patients. This needs further study as it could provide important insights into ways of reducing acute admissions. If there is to be more effective management of the primary/secondary care interface, more research and development effort is needed into the characteristics of patients at high risk of referral and admission, and how inappropriate secondary care can be averted.

Adolescent↗

PubMed2000

Laboratory expenditure in Pegasus Medical Group: a comparison of high and low users of laboratory tests with academics.

AIMS: To determine, through the use of clinical vignettes, whether low and high cost users of laboratory tests in Pegasus Medical Group (Pegasus) differed in their choice of laboratory tests from academics as a means of further investigating issues relating to quality and cost in laboratory testing. METHODS: Seven clinical vignettes were drawn up and sent to 30 selected members in Pegasus whose actual laboratory expenditure per consultation ranged from a mean of $2.3 in a low cost group (15 members) to $12.2 in a high cost group (15 members). The vignettes were also sent to 15 general practitioner academics. Respondents were requested to complete a laboratory form as to which tests they would use for each individual scenario. The answers were analysed for overall cost as well as numbers of laboratory tests requested. RESULTS: There were 14 academic responses and 13 each from the bottom and top laboratory users. Overall results for the seven vignette cases showed that low cost laboratory users would spend a total of $176.3, the academics $188.8, and the high cost users $219.5 on the cases. The mean per case costs were $25.2, $27.0 and $31.4 respectively. There was a clear tendency for high volume users of tests in each vignette to be high in others suggesting that doctor rather than patient factors were the main explanation of the variation. CONCLUSIONS: Clinical vignettes do not appear to be a useful strategy in clarifying issues related to quality and cost in laboratory utilisation. Test ordering behaviour appears, from the international literature and this study, to be determined more by personal doctor factors than by objective evidence and clinical need. Further work is needed to clarify the relationship between quality and the wide variation observed in utilisation and expenditure.

Adult↗

PubMed2000

Emerging clinical governance: developments in independent practitioner associations in New Zealand.

AIMS: To document and analyse the development of independent practitioner associations and similar groups in New Zealand. METHODS: A questionnaire was sent to the 30 independent practitioner associations in August 1998 and followed-up by a number of reminders. RESULTS: The 28 respondents (93%) represent 97% coverage of the estimated membership of independent practitioner associations and similar groups. Membership of the 28 responding organisations ranged between seven and 340, with an average of 74 members and a total of 132 employed staff. Twenty-one had appointed a chief executive officer or general manager. The respondents' most important goals were "achieving better health outcomes for patients" and "making better use of primary care resources". They reported almost total implementation of computerised age/sex registers in their practices. There was strong support for independent practitioner associations to manage the clinical activity of members, to move from historical to equitable, needs-based funding and for formal patient enrolment. The majority of respondents supported integrated and capitated primary care budgets but few supported capitated budgets for separate general medical services, laboratory and pharmaceutical services. Important recent initiatives include a wide range of integration projects and increasing involvement of local communities. CONCLUSION: Independent practitioner associations have made significant progress in increasing membership levels, in establishing a framework for managing clinical activity of members and in developing their infrastructure, including information systems. They have established a wide range of new relationships within primary care, with their communities and with primary and secondary care providers. In managing increasing amounts of public money to achieve public goals, these groups may be developing a new model of clinical governance, which could be of international importance.

Humans↗

PubMed2000

Reassessment of the corneal endothelial cell organisation in children.

AIM: To assess uniformity of the corneal endothelial cell mosaic in children. METHODS: 36 healthy children (5-11 years old, 16 boys, 20 girls) were assessed by specular microscopy. Endothelial cell density (ECD) was calculated from measured cell areas, and the number of sides/cell noted. RESULTS: Average values for ECD and cell areas were 3987 cells/mm(2) (95% CI 3806 to 4168 cells/mm(2)) and 278 (SD 85) mm(2) respectively, with normal distribution (COV 28. 2%, range 17.4 to 39.2%) and with the average percentage of six sided cells being 66.6% (8.8%). Cell area was positively correlated to number of cell sides (p <0.01, r(2)=0.993), but the percentage of six sided cells was negatively correlated to ECD (p <0.01, r=0.493). CONCLUSION: A high ECD occurs in children, but this does not mean there is a high percentage of "hexagons".

Cell Count↗

PubMed2000

Mentorship programs for transplant patients.

The concept of mentoring has been used successfully in numerous settings, but only in the past decade have mentoring programs been used with organ transplant recipients. This paper describes how the Toronto Multi Organ Transplant Mentor Programme works, is administered, augments patient care, is evaluated, and has been adapted to meet the needs of various transplant patient populations.

Humans↗

PubMed1999

Neisseria canis infection: a case report.

The third case report, which is the first in Australia, of human infection with Neisseria canis is documented. This is the first case report in which the pathogenicity of this organism for humans is unequivocally demonstrated.

Animals↗

PubMed1999

An evaluation of pharmaceutical management and budget holding in Pegasus Medical Group.

AIMS: To describe and evaluate pharmaceutical management, including budget holding, in Pegasus Medical Group (Pegasus), to determine savings being achieved, to analyse variation in prescribing behaviour and to compare the findings with national and international experience. METHODS: Trends in pharmaceutical expenditure of the 150 Pegasus' 208 members who had a continuous prescribing record for the three years ending December 1996 were compared with national trends. Expenditure per member, per consultation and per item were also analysed. RESULTS: Pegasus has implemented a comprehensive and classical pharmaceutical management strategy. This includes active personalised feedback, information sharing, peer review groups and information system development, all within an incentive framework of retained savings for new services. Although about 5% savings of total pharmaceutical expenditure were identified by the above method, the real level may be higher. Wide variation between members in their prescribing behaviour was explained almost entirely by the volume rather than the price of the drugs prescribed. Targeting of the volume issue is therefore likely to have a much more significant effect in reducing inappropriate variation. CONCLUSION: The results indicate that the achievements of Pegasus, as for other independent practitioner associations, go far beyond the modest level of pharmaceutical savings achieved. These include the development of a substantial infrastructure, peer review processes, new internal and external relationships and accountability for the management of both quality and cost in what may be styled clinical governance. Such achievements put Pegasus and other independent practitioner associations into a strong position to take on new initiatives including integration with secondary care.

Budgets↗

PubMed1999

Randomized trial of "slow" versus "fast" feed advancements on the incidence of necrotizing enterocolitis in very low birth weight infants.

OBJECTIVE: To determine whether the rate of feed advancement affects the incidence of necrotizing enterocolitis (NEC). STUDY DESIGN: Prospective randomized controlled trial involving 185 formula-fed infants with birth weight 501 to 1500 g and gestational age </=34 weeks. Infants were randomized into 2 groups: "slow" (n = 98), who received 15 cc/kg/d increments (a 10-day schedule to full feeds) and "fast" (n = 87), who received 35 cc/kg/d increments (a 5-day schedule to full feeds) of Similac Special Care 20 cal/oz. Feeds were increased only if well tolerated as defined by a protocol. RESULTS: The incidence of NEC (Bell stage >/=II) was similar in both groups (slow 13% and fast 9%, P =.5). The incidence of perforation (Bell stage III) was also similar in both groups (slow 4% and fast 2%, P =.8). Feeds were started at a comparable postnatal age in both groups (median age: slow 5 days and fast 4 days, P =.9). Although the neonates in the fast group attained full enteral intake earlier (median days [25th and 75th percentiles]: slow 15 [12, 21] and fast 11 [8, 15], P <.001) and regained their birth weight earlier (slow 15 [11, 20] and fast 12 [8, 15], P <.05), their ages at discharge were not statistically different (slow 47 [31, 67] and fast 43 [29, 62], P =.3) CONCLUSIONS: A greater than twofold difference in the rate of feed advancement from 15 cc/kg/d to 35 cc/kg/d did not affect the incidence of NEC >/= stage II. Factors other than feed advancement appear to be more important in the pathogenesis or progression of NEC.

Age Distribution↗

PubMed1999

Verbal communication: what do critical care nurses say to their unconscious or sedated patients?

The importance of using verbal communication in the care of critically ill patients has long been known. Both qualitative and quantitative studies have presented evidence of the benefits of effective communication. This non-participant observational study aimed to explore how much and what types of verbal communication critical care nurses use when caring for unconscious or sedated patients. Sixteen critical care nurses were observed in 4-hour episodes and their verbal communication was transcribed and timed at source. Seven categories of verbal communication and a 'core concept' emerged on analysis of the raw data. Medical investigations/interventions performed on the patients increased the amount of communication used. The participants in this study were found to use a greater variety and amount of verbal communication than participants in other studies. The findings of this study highlight the need for formal support systems and continued education for nurses about the benefits of verbal communication.

Analgesia↗

PubMed1999

The success of an integrated care programme for patients with ischaemic heart disease: the practice nurses' perspective of SHIP.

Follow-up care of patients with angina and myocardial infarction after hospital discharge is known to be suboptimal across the UK. The employment of cardiac liaison nurses ensured timely notification of hospital discharge and good communication of each patient's current and planned care. The direct ongoing support of the liaison nurse was valued by more practice nurses than educational support meetings and the initial counselling skills course. The most important factor which enabled practice nurses to expand their role to provide post-hospital follow-up care was the support of the doctors in the practice. After the conclusion of the Southampton Heart Integrated Care Project (SHIP) and the withdrawal of cardiac liaison nurses, the lack of hospital discharge notification was the most important reason for practice nurses discontinuing follow-up care.

Aftercare↗

PubMed1999

Do people who apply sunscreens, re-apply them?

Little is known about Australians' practices regarding sunscreen re-application, yet it is routinely advised and has recently been shown to increase the protective efficacy of sunscreens. A baseline survey of sunscreen application and re-application behaviour was therefore conducted in a Queensland community using a standard self-administered questionnaire. Other sun protection methods were also assessed. Of a total of 669 adult respondents, 76% reported using sunscreen and of those, 61% reported re-applying sunscreen. Significantly more women (66%) than men (55%) reported re-applying sunscreen and re-application was inversely related to age (79% of those aged less than 45, 57% of those 45-59 years old and 46% of those over 60 years). Increased rates of re-application were reported during times of increased sun exposure, as well as by those with greater knowledge of the benefits of sunscreen re-application. A recent personal history of non-melanoma skin cancer did not lead to improved rates of sunscreen application, sunscreen re-application, or most forms of physical sun protection.

Adult↗

PubMed1999

Minority enrichment programs at the New Jersey Medical School: 26 years in review.

In 1971 the New Jersey Medical School formed a task force to address the training of physicians from minority and disadvantaged backgrounds, and in 1972 the Students for Medicine Program (SMP) was launched. The program, one of the first of its kind, provided previews of college science courses to help minority students develop their noncognitive skills and make the transition to medical school. The school has also established other minority programs. The programs have been designed to form a health careers pipeline for college-bound students, beginning in the eighth grade. Grade-specific summer experiences, as well as year-round monthly workshops, are offered to all participants. The workshops for pre-college and college students and their parents are designed to strengthen students' academic skills, address issues such as self-esteem, provide exposure to health professions, and increase parents' knowledge and involvement. From 1972 to 1998, there had been 1,722 participants in the pre-college, 1,875 in the college, and 683 in the prematriculation programs, respectively. They were from the inner city, most of them African American, but with a growing number of Hispanics. From 1987 to 1994, 36% of the SMP participants entered health professions schools. In 1996, the medical school created the New Jersey Partnership for Health Professions Education, a collaboration of high schools, universities, community-based organizations, the federal government, and the health professions schools. It works to strengthen the medical school's "pipeline" for underrepresented minority students while eliminating competition among programs for the same students and simultaneously developing a larger pool.

Adolescent↗

PubMed1999

Prostacyclin synthase expression is decreased in lungs from patients with severe pulmonary hypertension.

Prostacyclin is a powerful vasodilator and inhibits platelet adhesion and cell growth. We hypothesized that a decrease in expression of the critical enzyme PGI2 synthase (PGI2-S) in the lung may represent an important manifestation of pulmonary endothelial dysfunction in severe pulmonary hypertension (PH). Immunohistochemistry and Western blot analysis were used to assess lung PGI2-S protein expression, and in situ hybridization was used to assess PGI2-S mRNA expression. In the normal pulmonary circulation (n = 7), PGI2-S was expressed in 48% of small, 67% of medium, and 76% of large pulmonary arteries as assessed by immunohistochemistry. PPH (n = 12), cirrhosis-associated (n = 4) and HIV-associated PH (n = 2) lungs exhibited a marked reduction in PGI2-S expression, involving all size ranges of pulmonary arteries. Vessels with concentric lesions showed complete lack of PGI2-S expression. Congenital heart (n = 4) and CREST (n = 2) cases exhibited a more variable immunohistological pattern of PGI2-S expression. These results were complemented by in situ hybridization and Western blots of representative lung samples. We conclude that the different sizes of the pulmonary arteries express PGI2-S differently and that the loss of expression of PGI2-S represents one of the phenotypic alterations present in the pulmonary endothelial cells in severe PH.

Adult↗

PubMed1998

Induction of phosphodiesterases 3B, 4A4, 4D1, 4D2, and 4D3 in Jurkat T-cells and in human peripheral blood T-lymphocytes by 8-bromo-cAMP and Gs-coupled receptor agonists. Potential role in beta2-adrenoreceptor desensitization.

In this study, a potential mechanism of beta2-adrenoreceptor desensitization has been explored that is based upon the enhanced degradation of cAMP by phosphodiesterase (PDE). Pretreatment of Jurkat T-cells with 8-bromo cAMP (8-Br-cAMP) or prostaglandin E2 increased PDE3 and PDE4 activity in an actinomycin D- and cycloheximide-sensitive manner. This effect was associated with increased expression of HSPDE3B, HSPDE4A4, HSPDE4D1, HSPDE4D2, and HSPDE4D3 mRNA transcripts. Western analysis reproducibly labeled a band of immunoreactivity in vehicle-treated cells that corresponded to HSPDE4A4 (125 kDa). Although the intensity of this band was unchanged in cells treated with 8-Br-cAMP, additional 68-72-kDa proteins (HSPDE4D2, HSPDE4D1) were labeled that were not detected after vehicle. Similar results were obtained with T-lymphocytes exposed to 8-Br-cAMP and fenoterol. However, in those experiments HSPDE4A4 and HSPDE4D1 appeared to be equally expressed in vehicle- and treated cells, whereas HSPDE4D2 (72 kDa) was detected only after 8-Br-cAMP. The up-regulation of PDE activity in Jurkat T-cells abolished the ability of isoproterenol to elevate cAMP, which was partially reversed by the non-selective PDE inhibitor, 3-isobutyl-1-methylxanthine, and by the PDE3 and PDE4 inhibitors, Org 9935 and rolipram, respectively. Collectively, these data suggest that chronic treatment of T-cells with cAMP-elevating agents compromises beta2-adrenoreceptor-mediated cAMP accumulation by increasing the expression of HSPDE3B and HSPDE4D gene products.

3',5'-Cyclic-AMP Phosphodiesterases↗

PubMed1998

Telephone or face-to-face interviews?: a decision made on the basis of a pilot study.

De Vaus (1991) highlights five main considerations that may be key factors in decisions about whether to use telephone or face-to-face interviews for survey work: response rates, ability to produce representative samples, effects on interview schedule design, quality of responses and implementation problems. De Vaus' discussion of these five issues is outlined at the start of this article. The five issues are then applied to the experiences of researchers conducting a study on continence care. Description and discussion of pilot interviews, which explored both interview modes, are followed by a similar examination of the main study which employed telephone interviews. Ideas in this discussion are supported and challenged by reference to other publications on the subject of telephone and face-to-face interviews. The success of the decision to use telephone interviews in the main study is evaluated and recommendations are made.

Humans↗

PubMed1998

Delayed external compression reduction of an omphalocele (DECRO): an alternative method of treatment for moderate and large omphaloceles.

BACKGROUND/PURPOSE: Standard treatment of large hepatoomphaloceles has been SILASTIC (Dow Corning, Midland, MI) silo placement followed by closure. This requires two operations, and complications from the silo may occur. The authors have looked for a safe and simpler alternate method of closure. Delayed external compression reduction of an omphalocele (DECRO), appears to have a low complication rate and a rapid time to closure. METHODS: The authors reviewed retrospectively the records of six patients with hepato-omphaloceles treated with DECRO from August 1993 to July 1997. All defects were evaluated by the attending surgeon and could not be closed primarily. All data are expressed as mean +/- SEM. RESULTS: The average gestational age was 36.5 +/- 0.67 weeks with mean weight of 2,780 +/- 256 g. Two patients had congenital cardiac disease. The mean size of the defects was 6.2 x 5.7 cm. All defects had the liver out of the abdomen. No patients required silo placement. The mean time to reduction and final closure was 5.6 +/- 0.49 days. The average postoperative time on the ventilator was 7.1 +/- 3.5 days. Mean time to full feeds was 18.8 +/- 3.4 days. One patient had superficial necrosis of the skin flap. Mean time to discharge was 30.5 +/- 5.5 days. All patients had DECRO completed without complications. CONCLUSIONS: This procedure decreases the number of operations needed from two to one. No complications were seen from the procedure and the time of mechanical ventilation required was low. The abdominal compartment syndrome developed in none of the patients. DECRO is a safe and very effective alternative to SILASTIC silo placement in moderate and large omphaloceles that cannot be closed primarily.

Bandages↗

PubMed1998

Composition and function of peripheral blood stem and progenitor cell harvests from patients with severe active rheumatoid arthritis.

High-dose chemotherapy with autologous stem cell rescue has been proposed as an intensive therapy for severe rheumatoid arthritis (RA). In view of previous observations of abnormal haemopoiesis in RA patients, the composition and function of peripheral blood stem cell harvests (PBSCH) was investigated. Compared with PBSCH from healthy allogeneic donors mobilized with the same dose of G-CSF (filgrastim; 10 microg/kg/d, n = 14), RA PBSCH (n = 9) contained significantly fewer mononuclear cells (375 v 569 x 10(6)/kg, P = 0.03) and CD34+ cells (2.7 v 5.8 x 10(6)/kg, P = 0.003). However, there were increased proportions of CD14+ cells (P = 0.006) and CD14+ CD15+ cells (the phenotype of previously described 'abnormal' myeloid cells, P = 0.002) in the RA PBSCH which translated into 3.5- and 7-fold increases respectively on a per CD34+ cell basis. There were no differences in T-cell activation status as judged by proportions of CD4+ and CD8+ expressing CD45RA, CD45RO, HLA-DR and CD28 (RA PBSCH, n = 7, donor PBSCH, n = 5, P = 0.2-0.7). Phytohaemagglutinin responses determined fluorocytometrically with induction of CD69 expression were reduced in CD4+ and CD8+ cells following filgrastim administration in 3/3 RA patients tested. Compared with bone marrow as a potential source of CD34+ cells, PBSCH contained 11-fold more T cells (P < 0.0005), 8-fold more B cells (P < 0.0005) and 4-fold more monocytes (P = 0.02). In short-term methylcellulose culture there were no differences in colony counts (CFU-GM, CFU-GEMM, BFU-E) per CD34+ cell from PBSCH from RA patients (n = 11) and healthy donors (n = 10). Long-term culture initiator cells were cultured successfully from cryopreserved PBSCH from RA patients (n = 9). In conclusion, PBSCH from RA patients differed significantly in composition from normal individuals, but in vitro studies support normal stem and progenitor cell function. Changes in T-cell function occur during mobilization in RA patients. This work provides reassurance for the use of PBSCH as haematological rescue and baseline data for clinical trials of graft manipulation strategies in patients with RA.

Adult↗

PubMed1998

Factors affecting practice nurse involvement in follow-up care of patients following myocardial infarction.

BACKGROUND: Preventive care can reduce the morbidity and mortality of patients following myocardial infarction. Recent evidence has shown that such care is not being provided effectively. The involvement of practice nurses has been proposed as a means of improving the completeness of follow-up and the quality of preventive care. OBJECTIVES: We aimed to determine the extent to which follow-up care for people discharged from hospital after a myocardial infarction is currently being undertaken by practice nurses and to assess the factors influencing the provision of such care and the nurses' attitudes towards this extended role. METHOD: Postal questionnaires were sent to 183 practice nurses working in general practices in the Southampton and South-West Hampshire Health District; 121 nurses responded (66%), representing 58 out of 64 practices surveyed (91%). RESULTS: The majority of responding practice nurses (55%, 95% CI 47-64%) had hospital experience of caring for patients with ischaemic heart disease, and most (83%, 95% CI 76-89%) believed that they played a key role in follow-up care of patients following myocardial infarction. In the absence of external support from a cardiac liaison nurse, few nurses (26%, 95% CI 16-41%) provide such care at present and only 21% work in practices with a register of myocardial infarction patients. Factors predicting the provision of follow-up care are having adequate time (odds ratio 4.59, 95% CI 1.66-12.7), the support of a cardiac liaison nurse (odds ratio 3.07, 95% CI 1.28-7.34) and GP colleagues (odds ratio 3.38, 95% CI 1.38-8.23), training in consultation skills (odds ratio 7.25, 95% CI 2.08-25.3), fundholding (odds ratio 3.11, 95% CI 1.26-7.69) and the confidence and knowledge of the practice nurse (odds ratios and 95% CIs respectively: 2.84, 1.18-6.83 and 2.80, 1.13-6.89). CONCLUSION: Most practice nurses are enthusiastic and have some of the necessary experience to provide follow-up care for patients who have experienced a myocardial infarction. Yet few currently provide it. The most important organizational incentives for providing such care are further training and the support of GPs and the cardiac liaison nurse.

Adult↗