Current proposals in the U.K. envisage a reduction in both junior staff numbers and the hours which they work. The proponents of change argue that this will improve patient care, although there are also opposing arguments, based mainly on the need to maintain continuity of care and ensure juniors gain sufficient clinical experience. By means of a literature review and interviews with junior doctors, this paper examines the effect of the existing system of hospital medical staffing on quality of care. There is evidence that the existing system reduces the quality of care, principally through mistakes associated with inadequate supervision, and lowered humanity of care due to tiredness. The training value of night-time and weekend work is low, and many doctors find it unsatisfying. In contrast, many doctors value providing continuity of care and a few appreciate the opportunity to gain unsupervised experience. Overall, the disadvantages of the existing system outweight the advantages, and change is required to improve the quality of care. There are, however, several obstacles to change, and there are doubts about the extent to which the current proposals will be implemented.

Continuity of Patient Care↗

PubMed1992

Laboratory assessment of feeding behavior in bulimia nervosa and healthy women: methods for developing a human-feeding laboratory.

We have designed a human-feeding laboratory to be used to study feeding behavior in patients with eating disorders. Twenty-one normal-weight bulimic subjects consumed 29.711 +/- 39.940 MJ (range 0.862-178.632 MJ; 7101 +/- 9546 kcal, range 206 to 42,694 kcal) in 24 h. In comparison, 11 healthy volunteer women, when instructed to eat ad lib for 48 h, ate 7.715 +/- 2.590 MJ (1844 +/- 619 kcal) during the first 24 h and 7665 +/- 1828 MJ (1832 +/- 437 kcal) during the second 24 h. Bulimics and control subjects had a similar number of eating intervals (6.6 +/- 2.6 vs 5.0 +/- 1.7); 72% of the bulimic subjects' meals were similar in size to the meals of the controls [167-4100 kJ (40-980 kcal)] but these meals were higher in carbohydrate and lower in fat in bulemic patients. Excessive caloric intake by bulimic subjects was because 28% of their meals were very large [range 4.427-28.150 MJ (1058-6728 kcal)]. Data gathered in a laboratory setting appears to be a reasonable replication of naturalistic feeding and suggest that such a laboratory may prove useful for future studies of feeding behaviors in humans.

Adult↗

PubMed1992

Adherence and entry of Borrelia burgdorferi in Vero cells.

Adherence to and entry of the parasite into the host is one of the essential elements of microbial pathogenicity. We investigated the adherence to and entry into primate kidney epithelial (Vero) cells of Borrelia burgdorferi by radiolabelling techniques, immunofluorescence and electronmicroscopy. The attachment to and subsequent entry of both untreated and heat (50 degrees C)-treated B. burgdorferi into Vero cells occurred at cell-surface sites associated with aggregated coated pits. In contrast, there was minimal attachment of spirochaetes heated at 60 degrees C. Radiometric studies showed that, with untreated cells, there was incorporation of both 14C-glucose-1-phosphate and 14C-thymidine, whereas with the 50 degrees C-treated spirochaetes only glucose-1-phosphate was incorporated, and with the 60 degrees C-treated spirochates neither radionuclide was incorporated. Spirochaetes heated at 50 degrees C or 60 degrees C did not grow at 35 degrees C in culture medium. These results suggest that the presence of certain metabolic activities of the spirochaete but not viability (ability to grow) are necessary for the attachment process. After entry of untreated B. burgdorferi, most of the spirochaetes were either free in the cytoplasm or tightly bound to the host membrane. In contrast, 50 degrees C-treated spirochaetes remained bound to host membrane in large phagosome-like vesicles.

Animals↗

PubMed1992

Which tasks performed by pre-registration house officers out of hours are appropriate?

This paper seeks to identify tasks performed out of hours by pre-registration house officers and to determine whether they could be performed by someone other than a doctor. It was conducted in two parts: a descriptive study in four hospitals using diaries and interviews and a consensus panel consisting of four consultants, three junior doctors, and two nurses. The panel agreed that one-third of the tasks performed by house officers at night could be done by someone other than a doctor. The work-load of house officers could be reduced considerably by providing additional clerical and administrative support and a more widespread adoption of an extended role for nurses. However, the greater professional independence of nurses which may result might require doctors to redefine some of their roles.

Humans↗

PubMed1992

Can out-of-hours work by junior doctors in obstetrics be reduced?

OBJECTIVE: Against a background of concerns about the hours of work of junior doctors, this study examines how the night-time work of junior staff in obstetrics may be reduced by giving greater responsibility to midwives. DESIGN: In the first phase of the study, the tasks undertaken at night in four hospitals were identified. In the second phase a nominal group technique was used to seek the extent of agreement among professionals about the appropriateness of postponing surgery to the following day in certain circumstances. RESULTS: There were considerable variations between hospitals in the rate of obstetric intervention and the division of tasks between doctors and midwives. The panel concluded that many tasks currently performed by senior house officers could be undertaken by midwives. CONCLUSION: This study suggests that there scope for reducing the workload of junior obstetricians at night through the adoption of an extended role by midwives.

Attitude of Health Personnel↗

PubMed1992

Can out-of-hours operating in gynaecology be reduced?

Against a background of concerns about future hospital medical staffing and the safety of unsupervised operations at night, this study examines which gynaecological operations now undertaken at night may be safely postponed until the following day. In the first phase of the study, the operations taking place at night in four hospitals were identified. In the second phase a nominal group technique was used to seek the extent of agreement among professionals about the appropriateness of postponing surgery to the following day in certain circumstances. There were considerable variations between hospitals in the volume of work and the grade of staff involved. The panel concluded that most operations now performed at night should not be postponed. This study suggests that there is limited scope for postponing gynaecological operations currently undertaken at night.

Female↗

PubMed1992

Achieving consensus on out-of-hours laboratory tests.

Many reports on guidelines for investigation describe either the guidelines themselves or their implementation. Implicitly these assume that there has been general agreement about the guidelines, whereas there may be uncertainty about the appropriateness of a particular investigation in a given situation. We report the use of a technique for developing guidelines which explicitly seeks to identify areas of agreement and disagreement, and focuses on the reasons that particular decisions were made and the causes of disagreement.

Clinical Laboratory Techniques↗

PubMed1992

Criteria for audit of annual reports on the public health: do they exist?

Production of an annual report is a statutory duty of the Director of Public Health; its production uses significant resources. Audit of reports may help in the effective use of these resources. For audit to be performed criteria need to be agreed upon which to set standards. The present study investigated whether Directors of Public Health agree on suitable criteria for the audit of annual health reports. Districts within North East Thames Regional Health Authority were paired; Directors of Public Health, who had produced the most recent report, interviewed each other using a semi-structured questionnaire. Reports were examined for the presence of the 'key indicators' from the common data set. The results show that there was little agreement on what were suitable criteria to evaluate reports. The criteria in the Toolbox produced by the Faculty of Public Health Medicine were thought to be unsuitable because of the diversity of Districts. Effective audit requires agreed criteria and standards but these were not identified. The Faculty criteria were not considered suitable. Directors of Public Health may develop criteria that they consider suitable for audit of their annual report in discussion, focusing upon their objectives in producing an annual report. This should be the first step in the audit process and an integral part of producing an annual report.

Annual Reports as Topic↗

PubMed1991

Circadian patterns of cortisol, prolactin, and growth hormonal secretion during bingeing and vomiting in normal weight bulimic patients.

Women who are of normal weight and have bulimia nervosa exhibit multiple neuroendocrine disturbances. We hypothesized that bingeing and vomiting behavior could be contributory because food consumption in healthy volunteers increases plasma cortisol and prolactin secretion and suppresses growth hormone secretion. Thus, we investigated the effects of bingeing and vomiting on the circadian pattern (measurements every 20 min for 24 hr) of these hormones in comparison to healthy control women eating normally. Bingeing and vomiting were associated with modest increases in cortisol and prolactin and reductions in growth hormone secretion. However, this bingeing or purging did not alter mean 24-hr pattern of cortisol and growth hormone secretion as values for bulimics were similar to controls. While mean daytime patterns of prolactin secretion were similar in bulimics and controls, bulimic patients had a significant reduction of nocturnal prolactin levels. In summary, bingeing and vomiting does not appear to have a substantial influence on hormonal secretion. However, bulimic women have blunted nocturnal prolactin patterns.

Adolescent↗

PubMed1991

Cervical spondylopathy.

Explore the source record for details and available documents.

Animals↗

PubMed1991

Subacute exposure to low concentrations of toluene affects dopamine-mediated locomotor activity in the rat.

The effects of low concentrations of toluene (40-80 ppm, 3 days, 6 h/day) were investigated on spontaneous and on apomorphine-induced locomotor activity in the rat, and were correlated to effects on S(-)[N-propyl-3H(N)]-propylnorapomorphine ([3H]NPA) binding in rat neostriatal membranes, on membrane fluidity, membrane leakage, and calcium levels in synaptosomes from the frontoparietal cortex, the neostriatum and the subcortical limbic area, and on serum hormone levels. Toluene exposure (80 ppm, post-exposure delay 18 h) alone did not affect locomotor activity, but attenuated apomorphine-induced (0.05 mg/kg, s.c.) suppression of rearing, and potentiated apomorphine-induced (1 mg/kg, s.c.) increases in locomotion and rearing. Toluene exposure increased the KD value of [3H]NPA binding without affecting the Bmax. All these effects were absent at 40 ppm of toluene or at a post-exposure delay of 42 h. Toluene exposure (80 ppm, post-exposure delay of 18 h) did not affect the serum levels of prolactin, TSH, corticosterone, or aldosterone, or synaptosomal membrane fluidity and calcium levels, whereas membrane leakage was increased in the neostriatum. The present study indicates that the reduction of D-2 receptor affinity by short-term, low-dose toluene exposure is accompanied by a reduced D-2 autoreceptor function and an enhanced postsynaptic D-2 receptor function.

Administration, Inhalation↗

PubMed1991

Disruption of the potential across the synaptosomal plasma membrane and mitochondria by neurotoxic agents.

The effect of a neurotoxic organo-metal, methyl mercuric iodide, and an aromatic solvent, toluene, upon the transmembrane potential (psi), across both the limiting membrane of isolated nerve terminals and their mitochondria, has been studied. Exposure of nerve endings to either of these toxicants in vitro resulted in a dose-dependent diminution of psi that was especially pronounced in the case of mitochondria. This was not prevented by a concurrent exposure to an antioxidant (alpha-tocopherol), or an iron chelator (deferoxamine), or ganglioside GM1. No significant changes were detected in synaptosomal potentials derived from cortices of rats exposed to methyl mercury or toluene at levels known to increase the rate of formation of reactive oxygen species within this region. The special vulnerability of mitochondrial psi to these agents may be due to the disruption of oxidative phosphorylation and may be related to the increase in intrasynaptosomal free ionic calcium that both of these chemicals can induce.

Animals↗

PubMed1991

How representative are members of expert panels?

A study was undertaken to test the hypothesis that consultants who are willing to participate in expert panels are similar, in terms of routinely available characteristics, to those who are not participating. All consultants in acute specialties in North-east Thames Region were asked to participate in a series of expert panels. Routinely available data was used to compare those who agreed to participate with those who declined or did not reply. Consultants who are willing to participate in expert panels are similar to those who are not in terms of years since qualification, specialty, sex, country of graduation, and possession of higher degrees. Consultants working in district general hospitals seem to be more likely to be willing to participate than those employed in teaching hospitals (37% versus 26%, p less than 0.02), although this difference may be accounted for by errors in the list of teaching hospital consultants.

Attitude of Health Personnel↗

PubMed1991

Soft-tissue blood flow after segmental osteotomy of the canine tibia.

The response of soft-tissue blood flow to a segmental osteotomy of the canine tibial diaphysis was investigated. Forty-three dogs underwent unilateral tibial osteotomies to create a 2.5-cm avascular diaphyseal segment, which was then rigidly stabilized with a plate. Blood flow measurements of the limbs that underwent surgery and control limbs were made using cerium 141 microspheres. One month after surgery, blood flow to the caudal musculature was increased 1.4-fold and at 2 and 3 months was twofold the value of the control side. The cranial musculature blood flow was 2.4-fold the control value at 1 month and 1.4-fold the control value at 2 and 3 months. Skin blood flow was significantly elevated at 1 month after surgery (p less than 0.0277), but by 2 and 3 months, skin flow had decreased to 1.4-fold and 1.3-fold of control values (p = 0.22). Bone marrow and cortical blood flows were still significantly elevated at 3 months after surgery. Muscle blood flow remains markedly elevated 3 months after surgery. This study demonstrates the importance of soft-tissue blood flow to the process of revascularization, remodeling, and incorporation of avascular cortical bone.

Animals↗