Oestrogen replacement therapy after hysterectomy.
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Estrogen Replacement Therapy↗
Biomedical subjects
N Black
Publications and source records attributed to N Black.
Disruptions in intracellular membrane trafficking and structure preclude the glucocorticoid-dependent maturation of mouse mammary tumor virus proteins in rat hepatoma cells.
We have previously shown that glucocorticoids regulate the trafficking and processing of mouse mammary tumor virus (MMTV) proteins in viral-infected M1.54 rat hepatoma cells. To examine the role of intracellular membrane integrity on MMTV protein maturation, brefeldin A (BFA) was utilized to disrupt membrane flow between the endoplasmic reticulum and Golgi. Immunoprecipitation and immunofluorescence microscopy revealed that in the presence of dexamethasone, BFA inhibited the proteolytic processing, cell surface delivery, and externalization of MMTV glycoproteins. Glycosidase digestion and inhibitors of protein glycosylation confirmed that the observed differences in apparent sizes of MMTV glycoprotein products are due to BFA-induced changes in oligosaccharide processing. BFA treatment inhibited the proteolytic processing of the MMTV phosphoprotein precursor, which normally associates with the cytoplasmic face of intracellular membranes. Similarities in salt extraction efficiency revealed that BFA did not affect the membrane affinity of the uncleaved phosphorylated precursor. In a complementary approach, proteolytic processing of the phosphorylated polyprotein did not occur in glucocorticoid-treated HTC cells transfected with a mutant MMTV provirus encoding a normal phosphorylated precursor, but which express a truncated MMTV glycoprotein missing its transmembrane domain and cytoplasmic tail. These results suggest that the MMTV glycoproteins and phosphoproteins may interact at a late step in the transport pathway in a manner required for their mutual processing in response to glucocorticoids and establishes the importance of functional interactions with intracellular membranes for maturation of the cytoplasmic MMTV phosphoproteins.
Animals↗
Research, audit, and education.
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Costs and Cost Analysis↗
Day-case surgery.
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Ambulatory Surgical Procedures↗
Does the current use of junior doctors in the United Kingdom affect the quality of medical care?
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↗
The relationship between evaluative research and audit.
Evaluative research and audit are distinct activities with different goals. However, they are interrelated in four ways: research provides a basis for defining good-quality care for audit purposes; audit can provide high-quality data for nonexperimental evaluative research; research into the effectiveness and cost-effectiveness of audit is needed to establish the value of different interventions; and, in common with other research areas, evaluative research needs to be audited to ensure high-quality work is performed. Recognition of the unique and interrelated roles of research and audit will be of benefit to both endeavours.
Evaluation Studies as Topic↗
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↗
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↗
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↗
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↗
Appropriateness of cholecystectomy: the public and private sectors compared.
OBJECTIVE: To investigate the appropriateness of cholecystectomies undertaken in the public and private health sectors. DESIGN: Retrospective case note review using the findings of two consensus panels. SETTING: 35 consultant surgeons working for North West Thames Regional Health Authority and in the private sector. PATIENTS: 269 patients undergoing cholecystectomy during the study period, of whom 17 were excluded because there was insufficient information available. MAIN OUTCOME MEASURES: Appropriateness ratings as assessed by two consensus panels, one composed of surgeons and one mixed, containing doctors from different specialties. RESULTS: The mixed panel would have rated 41 per cent of cases appropriate, less than 1 per cent equivocal and 30 per cent inappropriate. The remaining 29 per cent had indications about which the panel did not reach agreement. The surgical panel would have rated 52 per cent appropriate, 3 per cent equivocal and 2 per cent inappropriate. The remaining 44 per cent had indications about which the panel did not reach agreement. Most of the patients who would have been rated inappropriate had vague symptoms only. There were no significant differences between the NHS and private patients as regards their appropriateness. NHS patients were more likely to have more than one ultrasound and to be operated on as an emergency. CONCLUSIONS: An appreciable proportion of patients undergo cholecystectomy for indications which were deemed inappropriate by a mixed panel, but not a surgical panel. Variation in clinical judgement is an important factor in the decision to operate--44 per cent of cases had indications, the appropriateness of which the surgical panel were undecided about. There were no significant differences between NHS and private patients as regards the appropriateness of their indications. These findings need to be confirmed by further studies comparing the public and private sectors.
Adult↗
What will happen to the quality of care with fewer junior doctors? A Delphi study of consultant physicians' views.
Hospital medical staffing: achieving a balance proposed a reduction in the number of junior doctors and an expansion in the number of consultant posts. This change was to be subject to the 'safety net'--that the number of staff should not fall below a minimum safe level for 24-hour emergency cover. However, no operational definition of 'safe' was offered. Consultant physicians in one NHS region were interviewed to find out how they thought safety would be affected by a reduction in junior doctor numbers. It emerged that consultants' concerns over reductions in staff covered a wider range of issues than just the clinical effectiveness of care. The interpretation of safety extended to cover general adverse effects on care. A survey, using the Delphi method, revealed that consultant physicians were most concerned over reductions in the humanity of care if numbers of junior staff were reduced. This included such factors as the time spent by patients waiting in outpatient and A&E departments, and the time doctors spend talking to patients. Consultants were less concerned over the effect of reduced staff numbers on the technical efficiency of provision, and least of all on the effectiveness of care. This last point was seen to be a reflection of consultant physicians' confidence in the basic medical knowledge and skill of their junior staff.
Attitude of Health Personnel↗
Reliability of questionnaire responses as compared with interview in the elderly: views of the outcome of transurethral resection of the prostate.
Three hundred and eighty-eight men undergoing transurethral resection of the prostate for benign prostatic hypertrophy completed a presurgical questionnaire and three follow-up questionnaires 3, 6 and 12 months after surgery. The questionnaires covered details of prostatic symptoms, general health, and expectations and results of surgery. At each follow-up point 40 randomly selected patients were interviewed by two female research assistants. The response rate to the questionnaires was over 90% at each follow-up point while that for the interviews was lower at around 80%. We examine the reliability of the postal questionnaires in assessing health status by comparing questionnaire and interview responses, with a view to the wider employment of such a method in the follow-up of surgical patients. In general, and as reported elsewhere, responses to questions on easily defined topics are highly comparable between questionnaire and interview. Responses to more subjective questions are moderately reliable, but with a tendency for postal questionnaires to underestimate a patient's health problems. It is difficult to assess the reliability of the questionnaires with regard to questions of an intimate nature since such questions caused embarrassment during interview with consequent incomplete responses.
Adult↗
Do doctors and patients agree? Views of the outcome of transurethral resection of the prostate.
In an attempt to establish the extent to which patients and doctors agree on the outcome of health care, the pre- and postoperative states of health of 388 men undergoing transurethral resection of the prostate for benign disease were studied. Generally, high levels of concordance (greater than 70%) were obtained. The strongest agreement was for clearly defined events, such as episodes of acute retention (95%); the weakest agreement occurred over the most subjective symptoms, prognostic expectations, and ambiguous terms (around 60%). The level of agreement was not associated with any characteristics of the patient, surgeon, or treatment.
Cystoscopy↗
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↗
When does consensus exist in expert panels?
Increasingly, expert panels are being used to determine whether or not a consensus exists about criteria of good practice. It is, however, unclear how sensitive the panels' conclusions are to changes in the definitions of agreement and disagreement used. To explore this, two expert panels were established to assess the appropriate indications for cholecystectomy. Analyses of the results showed that the level of agreement depended on whether or not the views of outliers were included or eliminated. Exclusion of outliers increased the proportion of appropriate indications from about 40 per cent to 60 per cent. In contrast, the proportion of indications felt to be inappropriate was dependent on how strict the definitions employed were. Given that the principal purpose of expert panels is to inform quality assurance activities, the higher levels of agreement and disagreement achieved by eliminating outliers and employing more relaxed definitions are to be favoured.
Cholecystectomy↗
Appropriateness of cholecystectomy in the United Kingdom--a consensus panel approach.
A consensus development approach was used to assess the extent to which doctors in the UK agreed about the appropriate indications for cholecystectomy. Two panels, one composed entirely of surgeons and one containing a mix of relevant specialists, were asked to rate a series of possible indications. A consensus was achieved for 61% (surgical panel) and 67% (mixed panel) of indications considered. The surgical panel considered more indications as being appropriate for cholecystectomy (29% v 13%) and fewer indications as being inappropriate (27% v 50%) than the mixed panel. For between one third and a half of all indications, the panels were unable to reach agreement, partly as a result of differences in views as to the role of endoscopic sphincterotomy.
Aged↗
Which general surgical operations must be done at night?
During the 1980s there has been increasing concern about hospital medical staffing. Achieving a Balance will lead to a reduction in the number of registrars and a possible increase in the work done out-of-hours by consultants. The deleterious effects of long hours of work have also attracted attention and, in particular, there is concern about the safety of operations performed at night by unsupervised junior doctors. There is an urgent need to examine how out-of-hours work can be reduced. This study was conducted in two phases. The out-of-hours surgical workload in four hospitals was examined. Appropriateness of the procedures and activities being carried out was then considered by a consensus panel, aided by a literature review. Most out-of-hours operations were performed by junior staff. The principal reasons suggested for operating at night are lack of day-time theatre space and the need to gain experience. There was considerable variation in the frequency with which different types of operation were performed among hospitals. The views of the panel suggest that up to one-third of operations currently performed at night could be postponed. It may be possible to postpone a higher proportion of operations performed after midnight. The appropriateness of the remaining operations has major implications for the work of consultants following the implementation of Achieving a Balance.
Emergencies↗