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Biomedical subjects

R J Winter

Publications and source records attributed to R J Winter.

At least 19 recordsLinked to original sources
PubMed2000

A randomized controlled evaluation of specialist nurse education following accident and emergency department attendance for acute asthma.

We investigated whether hospital-based specialist asthma nurses improved recognition and self-treatment of asthma episodes by patients followed up after attending accident and emergency departments (A&E) for asthma exacerbations. We carried out a randomized prospective controlled trial of adult asthma self-management, following a hospital outpatient nurse consultation in two outer-London District General Hospitals (secondary care centres). The study included 211 adults, over 18 years old (mean age 40 years) who attended for asthma in two accident and emergency departments over 13 months. One hundred and eight evaluable patients were randomized into the control group who continued with their usual medical treatment and were not offered any intervention during the study period. One hundred and three evaluable patients were randomized into the intervention group. They were offered three 6-weekly outpatient appointments with one of two specialist asthma nurses for a structured asthma consultation, after attendance at the accident and emergency department. Following assessment of their asthma treatment and control, the nurses advised patients, through the use of self-management-plans, how to recognize and manage uncontrolled asthma and when to seek medical assistance. Medication and inhaler device type were altered if necessary The primary outcome was patient reported self-management of asthma exacerbations for 6 months. Secondary outcomes were assessed at baseline, 3 months and 6 months. These included home peak flow and symptom diaries, structured telephone questionnaires and audit of general practitioner records to determine utilization of services (6 months before and after A&E). Data were analysed on an intention to treat basis by multiple and logistic regression. The intervention group increased their use of inhaled topical steroids in 31/61 (51%) vs. 15/70 (21%) attacks in controls (OR 3.91 CI 1.8-8.4, P<0.001) and their use of rescue medication in 54/61 (89%) severe attacks vs. 53/70 (76%) controls (OR 2.88 CI 1.1-7.9, P<0.05). Intervention patients had significantly higher (mean 20.1 l min(-1); CI 0.4-39.7; P<0.05) and less variable PEF and significantly lower and less variable symptom scores 6 months after entry. Thirty-four percent of intervention patients vs. 42% controls had severe attacks (61 and 70 respectively, OR 0.96 CI 0.7-1.4) during the 6 months. Intervention patients had fewer days off work than controls in the first 3 months (NS) but similar days off during the 6-month period. Intervention patients had fewer episodes away from work in the first (0.34 vs. 0.54, P = 0.08) and the second 3 months (0.25 vs. 0.30, NS) than the controls. Over 80% of the patients records were audited by their general practitioners; the active group had less routine consultations with the doctor (P = 0.03) and practice nurse (P = 0.03), less consultations for uncontrolled episodes (P = 0.06) and less hospital visits (NS) than the controls. Hospital-based specialist nurses reduced asthma morbidity by improving patient self-management behaviour in acute attacks leading to reduced symptoms, improved lung function, less time off work and fewer consultations with health professionals.

Acute Disease↗
PubMed1997

Longitudinal follow-up comparison of educational interventions: multimedia textbook, traditional lecture, and printed textbook.

RATIONALE AND OBJECTIVES: The goal of this prospective, interinstitutional study was to compare the long-term instructional effectiveness of a pediatric multimedia textbook (MMTB) to that of a standard lecture and a printed textbook. MATERIALS AND METHODS: A randomized cohort of 89 3rd-year medical students from two institutions were initially evaluated from June 1992 to June 1993 and reevaluated in May 1994. Students were randomly assigned to one of four instructional groups: computer-aided instruction by means of MMTBs (n = 21), traditional lecture (n = 23), printed textbook (n = 19), and a control group (n = 26). After instruction, all groups were tested by means of a multiple choice test at the end of their pediatric clerkship; they were given this same test 11-22 months later. RESULTS: The long-term instructional effectiveness of the MMTB, printed textbook, and lecture were the same as that in the control group, as determined by analysis of variance of mean test scores. CONCLUSION: The educational advantage of MMTBs observed immediately after instruction was not detected 1 year later. Because attrition reduced statistical power, further research is necessary to determine how educational fading affects these instructional formats.

Analysis of Variance↗
PubMed1997

Bedside nuclear medicine investigations in the intensive care unit.

The functional nature of nuclear medicine procedures makes them especially valuable in the management of patients undergoing intensive care. However, the severe nature of the patient's condition invariably prevents him or her from attending the nuclear medicine department for diagnostic investigations. We have piloted a bedside nuclear medicine service using a four-probe detector system linked to an IBM computer with curve processing software. Protocols for a range of radionuclide probe investigations, including renal, hepatobiliary, gastric outflow and lung vascular permeability, using 99Tcm and 111In radiopharmaceuticals have been established. The measurement of lung vascular permeability in patients with clinical symptoms of adult respiratory distress syndrome was considered to be a valuable procedure on the intensive care unit. Due to the poor availability of 113Inm, which had previously been used for the measurement of lung permeability, we used a technique based on in vivo labelling of serum transferrin with 111In-chloride together with 99Tcm-red blood cells for the calculation of the plasma protein accumulation index. Other procedures include the measurement of gastric outflow in patients previously on parenteral feeding, and the assessment of hepatobiliary and renal function. The equipment proved to be reliable and convenient for use at the bedside, although ultrasound imaging was essential for the correct positioning of the probe detectors over smaller organs such as the kidneys and the gallbladder. The high sensitivity of the probe detectors required only low administered amounts of activity, minimizing radiation protection measures for patients and staff. The administration of radiopharmaceuticals via indwelling lines and tubes presented particular problems and we recommend that parenteral injections should not be given through manifold giving set, or via Teflon cannulae.

Adult↗
PubMed1997

Two cases of fatal air embolism in children undergoing scoliosis surgery.

Venous air embolism during surgery is a rare but important complication and can be rapidly fatal. We present two cases of fatal air embolism in the prone position occurring in small children undergoing surgery for progressive scoliosis. Venous air embolism is a rare complication in the prone position. This is thought to be because in this position there is virtually no gravitational gradient between the site of surgery and the right atrium. The possible sites of entry of air and ways that this may be minimized are discussed.

Child↗
PubMed1996

Teaching communication skills. An essential part of residency training.

OBJECTIVE: To design a structured curriculum concerning issues of communication with patients and families for use during training of pediatric residents. BACKGROUND: The stimulus for this initiative arose from residents perceived need for such a program and the realization that a structured approach to communication techniques did not currently exist in our residency and, in fact, in many undergraduate and graduate medical education curricula. METHODS: Our program was designed to address complex and difficult areas in physician-patient interaction, including how to deliver "bad news," deal with hostile parents, and speak to children about serious illness; the psychosocial aspects of death and dying were also covered in the program. Various teaching techniques were used. We attempted to assess residents' response and alteration in behavior consequent to the program. RESULTS: The program was successfully incorporated into the training of our residents and was carried out by using existent personnel; minimal expense was incurred. The residents thought the course was valuable and effective, although no statistically significant change in the communication skills of residents could be demonstrated. CONCLUSIONS: The area of physician-patient communication can be taught in a structured fashion during residency. Programs should be devised to meet the changing needs of training during residency and should incorporate the unique strengths of individual institutions.

Adult↗
PubMed1995

A comparison of educational interventions. Multimedia textbook, standard lecture, and printed textbook.

OBJECTIVE: To compare the instructional effectiveness and efficiency of a pediatric multimedia textbook (MMTB) with that of a standard lecture and of a printed textbook in a prospective, interinstitutional study. DESIGN: Randomized, prospective cohort. SETTINGS: An urban and a rural medical school affiliated with tertiary care hospitals. POPULATION: Third- and fourth-year medical students from June 1992 to June 1993. INTERVENTIONS/OUTCOME MEASURES: Students were randomized to one of four treatment groups: (1) computer-aided instruction with MMTBs (n = 39), (2) traditional lecture (n = 39), (3) printed textbook (n = 39), or (4) a control group (n = 62). Only the control group was pretested. Following their randomized instruction, all groups were tested via a 26-question multiple-choice test. Statistical analysis was accomplished by analysis of variance of mean post-test scores. The amount of time that students spent with each educational intervention was recorded. RESULTS: Three hundred two students were eligible for the study, 267 entered the study, and 179 completed the study. The instructional effectiveness of the MMTB was greater than that of the lecture (P < .05), and it was the same as that of the printed textbook. All instructional methods were more effective than the control group (P < .05). The instructional efficiency of the MMTB was equal to that of the lecture and of the printed textbook. The subjective response to the MMTB instruction was positive. CONCLUSION: The MMTBs constitute an educationally sound alternative instructional method and have a promising future in medical education.

Adult↗
PubMed1995

Rhabdomyolysis following acute alcohol intoxication.

The case of a fit young man who developed rhabdomyolysis after a short period of immobilization following acute alcohol intoxication is described. Rhabdomyolysis should be considered in an intoxicated patient presenting with muscle tenderness, particularly after immobilization.

Adult↗
PubMed1994

Reversal of pulmonary vascular remodelling following hypoxic exposure: no effect of infusion of atrial natriuretic factor and neutral endopeptidase inhibitor.

OBJECTIVE: The aim was to investigate whether infusion of either atrial natriuretic factor (ANF, 800 ng.h-1.rat-1) or a specific inhibitory of neutral endopeptidase 24.11 (NEI, UK 73,967, 5.4 mg.kg-1.d-1) can influence the reversal of the pulmonary vascular remodelling produced by exposure to hypoxia. METHODS: Male Wistar rats were kept in a normobaric hypoxic chamber (FiO2 = 10%) for 7 d. Chronically hypoxic rats were then treated with intravenous infusion of vehicle, ANF, or NEI by osmotic minipumps. Measurements of pulmonary artery pressure, systemic blood pressure, heart rate, right ventricular hypertrophy, micro-haematocrit, and pulmonary vascular remodelling (percentage of thick walled peripheral vessels) were made in all the rats at different time points. RESULTS: The changes in packed cell volume, right ventricular hypertrophy, and pulmonary hypertension induced by a 7 d hypoxic exposure diminished gradually and returned to normal at different time points during the 24 d recovery period. In contrast, vascular hypertrophy in peripheral pulmonary arteries was present after 24 d. There were no significant differences in pulmonary arterial pressure, packed cell volume, right ventricular hypertrophy and vascular remodelling between ANF, NEI, and vehicle treatment groups at either day 8 or day 15. CONCLUSIONS: ANF and NEI treatment had no effect on the reversal of pulmonary hypertension, right ventricular hypertrophy, and vascular remodelling, in contrast to the beneficial actions of ANF and NEI during the development of pulmonary vascular remodelling.

Animals↗
PubMed1994

Pediatric resident attitudes about technologic support of vegetative patients and the effects of parental input--a longitudinal study.

OBJECTIVE: To evaluate the change over time of attitudes about withdrawal of care from hopelessly ill children among a cohort of pediatric residents. DESIGN: Prospective data collection via surveys. SETTING: A pediatric residency program in a children's hospital. SUBJECTS: Pediatric residents beginning training in 1987 and 1988; 29 residents completed the study. INTERVENTIONS: Study participants completed a structured case-oriented questionnaire yearly from June 1988 through the completion of their residency training. The withholding of vasoactive agents or cardiopulmonary resuscitation, and the withdrawal of intravenous fluids, nutrition, or mechanical ventilation were the specific therapeutic options presented for a patient in a persistent vegetative state. The effects of time (further training) and parental wishes on resident decisions were assessed. MEASUREMENTS AND MAIN RESULTS: No resident wanted to provide intensive care to a child in a persistent vegetative state who was in respiratory failure; all residents would withhold vasoactive agents and CPR from such a child. At the conclusion of training, most (97%) would withdraw mechanical ventilation. A minority would withdraw intravenous (IV) fluids (41%) or nutrition (35%). Residents became more willing to withdraw IV fluids from these patients (0/16 vs 6/16; P = .03) and to withhold or withdraw therapies in general (P = .03) over the course of their training. All of this change occurred over the first year of training. Parental wishes altered treatment plans for these patients significantly, both when parents desired additional treatment (P < .0001), and when parents wanted treatment stopped (P = .04). The residents' level of training had no effect on responses to parents' therapeutic requests. CONCLUSION: Although exposure to level of care issues occurs throughout pediatric residency training, almost all changes in trainees' attitudes occur during the first year. Efforts to promote effective learning and coping should be concentrated in this period.

Adult↗
PubMed1993

Endothelium-derived relaxing factor activity in rat lung during hypoxic pulmonary vascular remodeling.

We have investigated the role of endothelium-derived relaxing factor in modulating hypoxic pulmonary vasoconstriction by inhibiting its synthesis with the false substrate NG-monomethyl-L-arginine (L-NMMA) in the isolated blood-perfused lungs of Wistar rats after chronic hypoxia (CH, fractional inspiratory O2 concentration 10%) for 15 h, 2 days, and 7 days. Lungs were perfused with blood of normal hematocrit at constant flow (18 ml/min) ventilated with 1) 95% air-5% CO2 (normoxia) and 2) 2% O2-5% CO2-93% N2 (hypoxia) and were studied in the absence and presence of L-NMMA (30 and 300 microM) or L-arginine (L-Arg, 1 and 6 mM) in separate groups. Pulmonary arterial pressure (Ppa) rose incrementally with hypoxic exposure (all P < 0.05 vs. normoxic control group). Hypoxic pulmonary vasoconstriction (HPV) was markedly reduced after 15 h and 2 days of CH: the mean increases in Ppa (delta Ppa) in hypoxia were 15.3, 3.5, 3.8, and 13.6 mmHg in control rats and rats exposed to 15 h (P < 0.05 vs. control and 7 days of CH), 2 days (P < 0.001 vs. control and 7 days of CH), and 7 days of CH, respectively. Ppa in control rats and rats exposed to 15 h, 2 days, and 7 days of CH were 137, 179, 184, and 166% of control, respectively, after 30 microM L-NMMA (all P < 0.05 when expressed as percent change vs. no L-NMMA). Similar augmentation in HPV was seen after 30 microM L-NMMA, with all hypoxic groups having a greater response than control groups.(ABSTRACT TRUNCATED AT 250 WORDS)

Angiotensin II↗
PubMed1993

Early changes in the calcitonin gene-related peptide (CGRP) content of pulmonary endocrine cells concomitant with vascular remodeling in the hypoxic rat.

Morphologic changes are reported to occur in rat lung vasculature after 3 days of hypoxia. We have previously shown that immunoreactivity for the vasodilator calcitonin gene-related peptide (CGRP) is increased in pulmonary endocrine cells by 7 days of hypoxia. Because these cells may be among the earliest mediators of the hypoxic response, we examined endocrine cell CGRP content in rat lung after 0, 2, 4, and 8 h and 1, 5, 10, 15, 20, 28, and 35 days of normobaric hypoxia, using optimal and supraoptimal dilutions of CGRP antibodies to demonstrate changes in CGRP immunoreactivity. This was compared with temporal changes in pulmonary vascular smooth muscle after 1, 5, and 20 days of hypoxia exposure by evaluating vascular immunoreactivity for alpha-smooth muscle actin (alpha-SM actin), platelet-derived growth factor (PDGF) beta-receptor, and proliferating cell nuclear antigen (PCNA). Significant increases in endocrine cell CGRP immunoreactivity were found after 4 h of hypoxia, and levels increased up to 1 day, followed by a decrease (at 5 days) and then a progressive increase up to 35 days. After 1 day of hypoxia, the number of vessels displaying immunoreactivity for alpha-SM actin, PDGF beta-receptor, and PCNA were also significantly increased. Whereas PDGF beta-receptor and PCNA returned to control values by day 20, alpha-SM actin reached a plateau that persisted until 20 days. The results indicate that modulation of endocrine cell CGRP content in response to hypoxia is rapid and characterized by a significant and persistent increase, paralleled by a proliferation of vascular cells leading to vascular muscularization.(ABSTRACT TRUNCATED AT 250 WORDS)

Actins↗