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Biomedical subjects

M G Bramble

Publications and source records attributed to M G Bramble.

At least 19 recordsLinked to original sources
PubMed1995

Reasons for variations in the use of open access gastroscopy by general practitioners.

This study aimed to investigate the wide variation between general practitioners (GPs) in their use of open access gastroscopy by assessing (i) their partnership share, workload, and the aggregated practice request rate; (ii) correlations with their professional and practice characteristics; and (iii) a comparison with referral rates to medicine, surgery, and all specialties. All 145 GPs and their practice managers were sent a questionnaire and hospital held data on all requests for open access gastroscopy over one year were reviewed. During the year, the 145 GPs made 1210 requests for open access gastroscopy, varying from one to 44 per GP. There were 987,880 practice consultations altogether, an average of 22,451 per practice or 7127 per whole time practitioner. Requests for open access gastroscopy formed 2.4% of all referrals, an average of one per 1000 consultations, or eight per GP. Of a total of 49,123 referrals to all specialties (371 per GP) 4218 (8.5%) were to medicine, and 6444 to surgery (13.1%). The following factors did not correlate with requests: vocational training, a concurrent hospital post, length of service, or receipt of the deprivation allowance by the practice. When the open access gastroscopy referral rate was aggregated for each practice the variation between practices was narrowed to essentially twofold. Requests for open access gastroscopy form a small proportion of all referrals (2.4%). Aggregated practice request rates are relatively uniform compared with the wide variation between individual GPs, suggesting a disproportionate gastroenterology workload between partners. The open access gastroscopy service does not seem to be subject to misuse from most GPs if a variation in practice usage is used as a measure.

Family Practice↗
PubMed1994

Non-steroidal anti-inflammatory induced diaphragm disease of the small intestine: complexities of diagnosis and management.

A 52-yr-old lady with RA on long term NSAIDs developed an iron-deficiency anaemia and subsequently presented with subacute intestinal obstruction. After intensive investigation, a diagnosis of diaphragm disease of the small intestine was made at laparotomy. The features of diaphragm disease and the difficulties with diagnosis and management of the condition are discussed.

Adult↗
PubMed1994

What happens to patients following open access gastroscopy? An outcome study from general practice.

BACKGROUND: Open access gastroscopy allows general practitioners to request a gastroscopy without prior referral to a specialist. The effect of open access gastroscopy upon patient management is poorly explored. Most studies have been hospital based and have focused on diagnostic yields and on means of tightening requests to reduce inefficient use. A user evaluation can only be made by measuring outcomes in primary care. AIM: A study was undertaken to determine the impact of open access gastroscopy in general practice and in particular, the value of a normal result. METHOD: All general practices in South Tees District Health Authority were asked to participate. Any of their patients who had had open access gastroscopy in the year prior to July 1990 were identified from the hospital computer and their general practitioner notes examined. Patient management during the year prior to the open access gastroscopy was compared with the year after. The main outcome measures were: detection rate and grade of lesion, change in graded score of prescribed drugs, consultation rate for dyspepsia and non-dyspepsia problems, and further hospital referral and investigations. Outcomes among those with normal and abnormal gastroscopy results were compared. RESULTS: The study sample comprised 715 patients, 36% of whom had a normal gastroscopy result, 34% a major abnormality and 26% a minor abnormality (4% of patients had miscellaneous diagnoses). It was found that 39% of all patients, and 60% of those with normal findings on open access gastroscopy had their drug treatment stopped or reduced in grade after the investigation. Of those with a major endoscopic abnormality 58% increased their treatment score. Consultations for dyspepsia in the year before and after gastroscopy fell by 57% overall among those with a normal gastroscopy result, by 37% among those with a minor finding and by 33% in those with a major finding. There was a 21% fall in consultations for all reasons among those with a normal gastroscopy result but those with a minor abnormality had a 23% increase in non-dyspepsia consultations. Of all patients 19% were referred to hospital subsequently. CONCLUSION: Open access gastroscopy has a major effect upon patient management in general practice, and a normal endoscopy result has an important an impact as an abnormal one. Open access gastroscopy is associated with a rationalization of drug therapy, reduced consultations and a low hospital referral rate.

Dyspepsia↗
PubMed1993

Organising unrestricted open access gastroscopy in South Tees.

Increasing demand for upper gastrointestinal endoscopy has forced many clinicians to reconsider the policy of seeing all patients in a specialist clinic before gastroscopy. The following are considered essential in setting up an open access gastroscopy service. (1) Assessment of the need by examination of waiting times for the outpatient clinic and the proportion of patients requiring upper gastrointestinal endoscopy, and consultation with colleagues in general practice. During the first 2 years of the service the average waiting time for a medical gastrointestinal outpatient appointment has fallen from over 120 days to 37 days in this area. (2) An adequately staffed and equipped gastrointestinal unit with well motivated nurses (the workload will increase) and sufficient clinical support to allocate patients to the next available gastroscopy list is vital. A safe mechanism for relaying information back to the GP (including histology reports) is essential otherwise medicolegal problems could arise. Open access gastroscopy now accounts for 29% of the total endoscopy workload in South Tees. (3) Close cooperation between medical and surgical gastroenterologists must be achieved to ensure a uniform approach to the provision of this service and equal distribution of the endoscopy workload. This will require close examination of the potential numbers and may necessitate appointment of a clinical assistant or additional consultant. Clinical assistants perform just over 50% of the open access gastroscopies in South Tees and the waiting time has been kept short (average 17 days). (4) A comprehensive request form with guidelines for GPs and a specific box identifying whether the GP requires a report and brief advice only or follow up at the discretion of the endoscopist (often a clinical assistant) is required. (5) Management must be involved in identifying adequate resources. (6) Methods of monitoring requests and outcome measures to ensure effective audit must be established.

Endoscopy, Gastrointestinal↗
PubMed1992

Open access endoscopy--a nationwide survey of current practice.

In a postal survey of 450 members of the Endoscopy Section of the British Society of Gastroenterology carried out during 1990, 47% of respondants stated that they were offering some form of open access endoscopy. Virtually all of these were offering open access gastroscopy, but one in three were also performing open access flexible sigmoidoscopy. Those units that offered open access endoscopy had significantly more endoscopists sharing the workload, including a greater number of clinical assistants. Only 10% of those who replied, however, were offering 'true' open access endoscopy, the remainder used some form of 'censoring'. There were also important differences in consultants' attitudes to the investigation and management of patients referred with dyspepsia, which may account for the patchy availability of the service. Some 71% of those who did not offer open access endoscopy cited an inability to cope with numbers as their main reason for not doing so. Support for these concerns is gained from the finding that 52% of those that offered the service have had a waiting list exceeding six weeks at some time. Nevertheless, open access endoscopy is becoming more widely available with a large increase in participating units during the past 12 months.

Attitude of Health Personnel↗
PubMed1988

Loop diuretics cause less postural hypotension than thiazide diuretics in the frail elderly.

Seventy frail elderly patients attending a day hospital were studied to investigate the incidence of postural hypotension in control patients on no diuretic treatment (n = 30), patients on loop diuretics (frusemide) for mild cardiac failure (n = 20) and patients on thiazide diuretics for mild cardiac failure (n = 20). The results showed that patients on thiazide diuretics had a higher incidence of postural hypotension (reduction in systolic blood pressure greater than 20 mmHg on standing after 2 minutes) than patients on loop diuretics (12 out of 20 vs 4 out of 20, p less than 0.05). Mean plasma potassium levels were lower in the thiazide group than in the frusemide group (p less than 0.05) and this correlated significantly with change in systolic blood pressure from supine to standing position (r = -0.56, p less than 0.01). These findings indicate that a loop diuretic (frusemide) is as safe if not safer than thiazides in older patients and the latter have an unjustified reputation of being safer first-line drugs for the treatment of cardiac failure.

Aged↗
PubMed1986

Glucose turnover in compensated hepatic cirrhosis.

Glucose turnover and recycling from glucose derived 3-carbon intermediates were examined in overnight fasted patients with compensated hepatic cirrhosis and in age- and weight-matched normal control subjects. Fasting blood concentrations of glucose, lactate and glycerol were similar in both groups but blood pyruvate (60 +/- 10 vs. 80 +/- mumol/l, P less than 0.05), blood alanine (0.23 +/- 0.02 vs 0.34 +/- 0.02 mmol/l, P less than 0.01) were decreased and serum insulin increased (19 [13-24]v 7 [4-11] mU/l, P less than 0.01) in cirrhotic subjects. Absolute glucose turnover, assessed by analysis of decay of [3H]-3-glucose specific activity was decreased in cirrhotic patients (8.1 +/- 0.6 v 12.1 +/- 0.7 mol/kg-1 min-1). Glucose "recycling", assessed by the difference between absolute glucose turnover and that given by [14C]-1-glucose data, was normal in cirrhotic patients suggesting that Cori cycle (glucose-lactate-glucose) activity was normal. These data support previous findings of decreased peripheral glucose utilisation and insulin resistance in cirrhotic patients.

Adult↗
PubMed1985

Acute gluten challenge in treated adult coeliac disease: a morphometric and enzymatic study.

Using a Quinton hydraulic biopsy tube, jejunal biopsies were obtained from 10 patients with adult coeliac disease in remission and four healthy volunteers before and after administration of gluten fraction III into the proximal duodenum. The biopsies taken at hourly intervals for four hours, were analysed for changes in brush border enzymes, light microscopic appearances, and villous and crypt population counts. The results indicate that mucosal damage occurs within three to four hours of gluten administration with significant falls in brush border enzyme concentrations and villous population counts. The absence of any change in control biopsies indicates that gluten sensitivity is specific to the mucosa of patients with coeliac disease, the timing of the changes being consistent with a type III immune response or direct toxicity. Some recovery of the brush border enzymes but not the villous population was evident 24 hours after gluten administration while the crypt population showed evidence of a compensatory hyperplastic reaction.

Adult↗
PubMed1985

An analysis of plasma levels and 24-hour ECG recordings in tricyclic antidepressant poisoning: implications for management.

Twenty-seven patients with confirmed tricyclic antidepressant (TCA) self-poisoning were studied for 24 h following admission to hospital. Ten patients were judged to be severely poisoned on clinical grounds, whilst 14 patients had initial plasma levels above 1 mg l-1, indicating severe poisoning. Plasma levels were generally maximal on admission to hospital and fell quickly thereafter. Clinical and ECG data showed patients to be most at risk in the casualty department and three patients sustained cardiac arrest. Initial management must be speedy as these patients present with acute toxicity.

Adolescent↗
PubMed1981

Flexible sigmoidoscopy in outpatients with suspected colonic disease.

One hundred and fifteen patients attending a gastroenterology clinic were investigated by flexible sigmoidoscopy as outpatients. There were asked to fast before the examination and give a high-volume enema and sedated before the examination. A standard long colonoscope was used rather than the 60-cm sigmoidoscope, which limits the distance that can be examined and forces the operator to work very close to the patient. Preparation was considered good in 95 patients and 49 were examined as far as the hepatic flexure or beyond. Sixty-one patients were found to have lesions of the colon, 25 of them ulcerative colitis, 16 a poly, and nine carcinoma. Despite the fact that these patients were selected (some of them had already had ulcerative colitis diagnosed), flexible sigmoidoscopy proved to be a valuable initial outpatient investigation. The proximal colon was well visualised in 46 patients and a subsequent barium enema was considered unnecessary. There were no complications and the procedure seemed to be well tolerated.

Ambulatory Care↗
PubMed1981

The effect of the topical steroid clobetasone butyrate on coeliac mucosa maintained in organ culture.

The effect of the topical corticosteroid clobetasone butyrate on enzyme activity and morphology of duodenal mucosa was studied in 9 patients with coeliac disease and 10 controls using organ culture techniques. There was significant increase in mucosal alkaline phosphatase, lactase and maltase activities, but inclusion of a soluble extract of gluten reduced this effect. When clobetasone butyrate was also included in the culture medium significant elevations in enzymes were again observed. Enterocyte height was not affected by incorporation of gluten into the medium. Intra-epithelial lymphocyte counts fell significantly during the culture period. This improvement was also inhibited by gluten and overcome by addition of steroid.

Adult↗