Biomedical subjects
R Baker
Publications and source records attributed to R Baker.
Family satisfaction with end-of-life care in seriously ill hospitalized adults.
OBJECTIVE: To examine factors associated with family satisfaction with end-of-life care in the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). DESIGN: A prospective cohort study with patients randomized to either usual care or an intervention that included clinical nurse specialists to assist in symptom control and facilitation of communication and decision-making. SETTING: Five teaching hospitals in the United States. PARTICIPANTS: Family members and other surrogate respondents for 767 seriously ill hospitalized adults who died. MEASUREMENTS: Eight questionnaire items regarding satisfaction with the patient's medical care expressed as two scores, one measuring satisfaction with patient comfort and the other measuring satisfaction with communication and decision-making. RESULTS: Sixteen percent of respondents reported dissatisfaction with patient comfort and 30% reported dissatisfaction with communication and decision-making. Factors found to be significantly associated with satisfaction with communication and decision-making were hospital site, whether death occurred during the index hospitalization (adjusted odds ratio (AOR) 2.2, 95% CI, 1.3-3.9), and for patients who died following discharge, whether the patient received the SUPPORT intervention (AOR 2.0, 1.2-3.2). For satisfaction with comfort, male surrogates reported less satisfaction (0.6, 0.4-1.0), surrogates who reported patients' preferences were followed moderately to not at all had less satisfaction (0.2, 0.1-0.4), and surrogates who reported the patient's illness had greater effect on family finances had less satisfaction (0.4, 0.2-0.8). CONCLUSIONS: Satisfaction scores suggest the need for improvement in end-of-life care, especially in communication and decision making. Further research is needed to understand how factors affect satisfaction with end-of-life care. An intervention like that used in SUPPORT may help family members.
Local regulation of glucocorticoid activity in sites of inflammation. Insights from the study of tuberculosis.
In sites of inflammation there is a change in the equilibrium between the enzymes that inactivate cortisol by conversion to cortisone and those that reactivate cortisone by conversion to cortisol. Current evidence suggests that during an immune response with a Type 1 cytokine profile such as tuberculosis, there is locally enhanced reductase activity with locally increased cortisol concentrations due to recruitment of cortisone. This results in enhanced cortisol mediated feedback on the inflammatory process, and deviation of the response towards Type 2. Preliminary data suggest that eventually, in the presence of Type 2 cytokine polarization, the enzyme equilibrium may reverse again and cortisol is then locally inactivated to cortisone. Together with changes in glucocorticoid receptor expression and function this may result in local cortisol resistance and susceptibility to tissue damage mediated by proinflammatory cytokines. These observations help to explain the sequence of events in several infectious, inflammatory and autoimmune diseases.
Incorporation of zidovudine into cord blood DNA of infants and peripheral blood DNA of their HIV-1-positive mothers.
The nucleoside analogue 3'-azido-3'-deoxythymidine (AZT) is a weak carcinogen in adult female mice and a moderately strong carcinogen in the offspring of female mice given the drug during gestation. In addition, incorporation of AZT into DNA was observed in multiple organs of transplacentally exposed newborn mice. Here we investigate the incorporation of AZT into peripheral leukocyte DNA of HIV-1-positive adult pregnant women given AZT for variable times during gestation and cord blood of infants exposed to AZT in utero. The length of treatment varied between 10 days and 9 months. High molecular weight DNA was extracted from maternal peripheral blood mononuclear cells (PBMC) and infant cord blood. A specific AZT-DNA radioimmunoassay was used to determine the amount of AZT incorporated into leukocyte DNA. Incorporation of AZT into DNA ranged up to 183.3 and 344.5 molecules of AZT/10(6) nucleotides in the mothers and infants, respectively, and was detected in about 70% of samples. Therefore, AZT-induced mutagenic events are possible in the majority of adults and infants. No correlation was found between level of incorporation and length of AZT treatment, suggesting that the differences observed among the individuals arise from variability in AZT metabolism. These data support previous observations that a high degree of inter-individual variability in AZT phosphorylation occurs in primates.
Managing quality in primary health care: the need for valid information about performance.
Explore the source record for details and available documents.
The Evidence-Based Primary Care Handbook.: Mark Gabbay, editor. (Pp 314; pound19.50). London: Royal Society of Medicine, 1999. 1 85315 415 6Quality in Health Care 2000;9:264-265.
Explore the source record for details and available documents.
Anatomy and discharge properties of pre-motor neurons in the goldfish medulla that have eye-position signals during fixations.
Previous work in goldfish has suggested that the oculomotor velocity-to-position neural integrator for horizontal eye movements may be confined bilaterally to a distinct group of medullary neurons that show an eye-position signal. To establish this localization, the anatomy and discharge properties of these position neurons were characterized with single-cell Neurobiotin labeling and extracellular recording in awake goldfish while monitoring eye movements with the scleral search-coil method. All labeled somata (n = 9) were identified within a region of a medially located column of the inferior reticular formation that was approximately 350 microm in length, approximately 250 microm in depth, and approximately 125 microm in width. The dendrites of position neurons arborized over a wide extent of the ventral half of the medulla with especially heavy ramification in the initial 500 microm rostral of cell somata (n = 9). The axons either followed a well-defined ventral pathway toward the ipsilateral abducens (n = 4) or crossed the midline (n = 2) and projected toward the contralateral group of position neurons and the contralateral abducens. A mapping of the somatic region using extracellular single unit recording revealed that position neurons (n > 120) were the dominant eye-movement-related cell type in this area. Position neurons did not discharge below a threshold value of horizontal fixation position of the ipsilateral eye. Above this threshold, firing rates increased linearly with increasing temporal position [mean position sensitivity = 2.8 (spikes/s)/ degrees, n = 44]. For a given fixation position, average rates of firing were higher after a temporal saccade than a nasal one (n = 19/19); the magnitude of this hysteresis increased with increasing position sensitivity. Transitions in firing rate accompanying temporal saccades were overshooting (n = 43/44), beginning, on average, 17.2 ms before saccade onset (n = 17). Peak firing rate change accompanying temporal saccades was correlated with eye velocity (n = 36/41). The anatomical findings demonstrate that goldfish medullary position neurons have somata that are isolated from other parts of the oculomotor system, have dendritic fields overlapping with axonal terminations of neurons with velocity signals, and have axons that are capable of relaying commands to the abducens. The physiological findings demonstrate that the signals carried by position neurons could be used by motoneurons to set the fixation position of the eye. These results are consistent with a role for position neurons as elements of the velocity-to-position neural integrator for horizontal eye movements.
Finding the neutral position: patient and analyst perspectives.
In light of current debates between classical and intersubjective schools of psychoanalysis, the challenge posed by the latter to such basic concepts as the analyst's neutrality, anonymity, and abstinence is taken up. It is maintained that the term neutral position is today more germane and meaningful than the term neutrality, which frequently has been taken to prescribe the analyst's posture. It is proposed that for each patient the neutral position is uniquely sited and that it is incumbent on the analyst to find its location. The neutral position is defined within the context of the interaction between analyst and patient. The concept is therefore compatible with--indeed it is essential to--an intersubjective or relational orientation. The manifold reasons, conscious and unconscious, why the analyst is vulnerable to leaving the neutral position are considered. The patient's reaction to the analyst who has left the neutral position and the analyst's clinical use of this reaction are discussed.
Hospitalists for the NHS?
Explore the source record for details and available documents.
Best place of care for older people after acute and during subacute illness: a systematic review.
OBJECTIVES: To assess the evaluative research literature on the costs, quality and effectiveness of different locations of care for older patients. METHODS: A systematic review of evaluative research from 1988 using CRD4 guidelines. Twenty-five databases were searched, using processes developed specially for this review. Library OPACS, the Internet and research registers were also searched for relevant material. The final stage of the review was confined to randomised and pseudorandomised trials. Studies were selected for review by pairs of researchers working independently who then met to reach a decision. Analysis was predominantly descriptive; simple pooled odds ratios were used to explore some outcomes. RESULTS: Eighty-four papers from 45 trials were included. Firm conclusions were difficult to draw, except in relation to some outcomes for stroke units, early discharge schemes and geriatric assessment units. Few trials in this area have adequately addressed issues of patients' quality of life and costs to health services, social care providers, patients and their families. CONCLUSIONS: Despite considerable recent development of different forms of care for older patients, evidence about effectiveness and costs is weak. However, evidence is also weak for longer-standing care models. A substantial service evaluation agenda emerges from this review. This study also raises questions about the usefulness of systematic review techniques in the area of service delivery and organisation.
Assessment of incomplete effort with the California Verbal Learning Test.
The false-positive rates of 2 formulas for the detection of incomplete effort on the California Verbal Learning Test (CVLT; Delis, Kramer, Kaplan, & Ober, 1987) were evaluated in a sample of 134 patients with traumatic head injury (THI) who had been carefully screened to eliminate any individuals who might be expected to have financial incentives for poor performance. One formula incorrectly identified only 7.46% of the sample as providing incomplete effort, confirming its potential usefulness in clinical settings. The other formula fared much worse, misidentifying an unacceptably high 18.66% of the sample. Lower levels of education were found to increase the likelihood of false-positive results with that formula. It is concluded that the CVLT holds promise for the evaluation of incomplete effort after THI but only within the context of a more comprehensive neuropsychological evaluation.
Diagnosis of patients with chronic heart failure in primary care: usefulness of history, examination, and investigations.
Chronic heart failure is a common clinical syndrome that may have different causes. Its incidence and prevalence are predicted to rise substantially over the next 10 years. There are therefore major consequences for resource provision, especially in primary care, where most patients are managed. Chronic heart failure is a serious condition with high morbidity and mortality. There is good evidence to show that treatment with angiotensin-converting enzyme (ACE) inhibitors in patients with left ventricular systolic dysfunction improves symptoms and signs, slows progression of heart failure, reduces hospitalisation rates, and improves survival. Despite this evidence, primary care studies show that patients with heart failure are incorrectly diagnosed and inadequately treated. Most patients present in general practice, and because effective treatment relies on a correct diagnosis, this is a key step in the appropriate management of heart failure. The aim of this paper is to review the evidence about the usefulness of signs, symptoms, and investigations in diagnosing heart failure in primary care. To identify relevant studies for this review, four strategies were used: a MEDLINE search from 1993 to January 1998 using the diagnosis search filter; a MEDLINE search from 1993 to January 1998 using the guideline search filter to locate published heart failure guidelines; a search for review articles in the Cochrane Library; and a check of references in the studies identified. The search terms included MeSH terms and the keywords 'heart failure' and 'diagnosis'. All searches were limited to humans and English language articles. Studies were included in this review on the basis of quality and relevance to primary care. The review shows that symptoms and signs are important because they alert clinicians to the possibility of heart failure as a diagnosis. However, they are not sufficiently specific for confirming left ventricular systolic dysfunction. From the evidence available, a patient with suspected heart failure must have objective tests to confirm the diagnosis. These should include an electrocardiogram and, ideally, an echocardiogram. Further research is also needed on the usefulness of signs and symptoms in primary care, as most studies of heart failure have been conducted in secondary care.
Levels of hydrogen peroxide in tissues adjacent to failing implantable devices may play an active role in cytokine production.
Late aseptic loosening of total joint implants continues to be a common cause of implant failure. However, the pathophysiology of implant loosening remains controversial as to which factors at the implant tissue interface plays a crucial role in implant failure. The most prominent features of the foreign body membrane obtained from patients undergoing revision hip surgery were the presence of lymphocytes, histiocytes, giant cells, and immature collagen formation. Biochemical and immunochemical analysis of the tissues revealed increased levels of pro-inflammatory cytokines as well as increased levels of hydrogen peroxide and decreased activity of catalase Increasing concentrations of hydrogen peroxide also caused increases in macrophage release of pro-inflammatory cytokine (IL-1). Macrophage activation by cytokine (TNF alpha) or lipopolysaccharide (LPS) is mediated via translocation of NF kappa B from the cytosol to the nucleus and appears to be dependent upon phospholipase D (PLD). In tissues of patients with aseptic loosening of implants, over production of hydrogen peroxide in response to wear debris stimuli, may activate NF kappa B and initiate cytokine production.
What proportion of patients refuse consent to data collection from their records for research purposes?
In a randomised trial of the implementation of guidelines for asthma and angina, we sent questionnaires that included a request for consent to collect data from the patient's clinical records to 5069 patients in 81 general practices. Of these 3429 (67.6%) responded, of whom 335 (9.8% [95%, CI = 8.8%-10.8%]) refused consent. We conclude that consent should always be sought unless a research ethics committee has waived this requirement for pressing reasons.
Clinical governance for diabetes in primary care: use of practice guidelines and participation in multi-practice audit.
Explore the source record for details and available documents.
Effect of denture adhesive on retention of the mandibular and maxillary dentures during function.
The purpose of this study was to determine the effect of denture adhesive on retention of mandibular and maxillary dentures over a four-hour period. Denture movements were measured using an alternating magnetic field tracking device that determines the position of magnetic receiver coils relative to a transmitter coil positioned over the head. Ten adults with complete maxillary dentures and complete mandibular implant overdentures were enrolled in the study. Specially fabricated mandibular dentures contained a relief area that exposed the implant post which no longer anchored the denture, but now served as an attachment point for a receiver coil that measured mandibular movement. The denture coil was attached lateral to the post coil on a shelf cut into the denture. Mandibular denture movements were recorded as the difference between the mandible movement signal and the mandible + mandibular denture signals. Measurements of denture movements were made at baseline (no adhesive) and at 0, 2, 4 hours post-adhesive application with Fixodent cream for standardized chewing and biting. The MoveTrack signals were recorded on a digital data cassette recorder for subsequent computer analysis. The results of the measurements were analyzed using paired sample t-tests. Specifically, the following comparisons of movement means were made: mandibular vs. maxillary, baseline vs. post-baseline and successive changes (e.g., baseline vs. hour 0, hour 0 vs. hour 2, etc.). Results of these analyses showed that: 1) mandibular denture movements under both adhesive and non-adhesive conditions were significantly greater than maxillary denture movements; 2) the adhesive significantly reduced movement of the maxillary and mandibular dentures during both chewing and biting; and 3) the improvement occurred immediately post-application of the adhesive and was maintained for the four hours of follow-up.
Working with labor unions. What occupational health nurses need to know.
1. The work of many occupational health nurses involves interaction with labor unions in a range of settings, yet little training is provided to understand unions and their role. 2. Understanding the structure and function of unions can help nurses work more effectively in collaboration with labor toward the common goal of reducing workplace injury and illness. 3. Nurses need to educate union members and leadership to better understand the full range of skills and responsibilities of occupational health nurses.
Differentiating between audit and research: postal survey of health authorities' views.
Explore the source record for details and available documents.