Biomedical subjects
R Robinson
Publications and source records attributed to R Robinson.
Day shift.
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Kt/V, nutritional parameters, serum cortisol, and insulin growth factor-1 levels and patient outcome in hemodialysis.
Despite many technical advances in dialysis care, morbidity and mortality in chronic hemodialysis patients in the United States remains high. In this study, we analyzed the effects of Kt/V, nutritional parameters (serum albumin level, triceps skin-fold thickness, mid-arm muscle circumference, and normalized protein catabolic rate), and predialysis serum cortisol and insulin growth factor-1 levels on predicting morbidity and mortality. The cohort studied consisted of 52 patients recruited from a single outpatient dialysis facility. Cox proportional hazards modeling indicated that only Kt/V predicted subsequent mortality (P = 0.02), while both predialysis cortisol levels (P = 0.03) and Kt/V (P = 0.03) predicted hospitalization. Kaplan-Meier analysis demonstrated that the ability of cortisol levels to predict hospitalization was largely confined to the group with values greater than 22 micrograms/dL predialysis. High serum cortisol levels were correlated with low serum albumin levels and a trend toward low triceps skin-fold thickness and higher normalized protein catabolic rate, suggesting a catabolic state. Both predialysis serum cortisol and insulin growth factor-1 levels were higher than those in age- and sex-matched normal human controls. These results demonstrate the importance role of Kt/V in predicting subsequent hospitalization rates and mortality, and that high predialysis serum cortisol levels correlate with a high hospitalization rate.
Strengthening mental health services in Head Start. A challenge for the 1990s.
Steps must be taken to strengthen mental health services by building on Head Start's philosophy and by translating innovations in mental health services for older children and adolescents into improved services for young children and their families. Recommendations for strengthening Head Start's mental health program include creating a unified vision that reaffirms a holistic, family-focused, and comprehensive services approach; ensuring that mental health services are responsive to the diversity in families served; increasing coordination of mental health services and linkages with new initiatives; increasing resources and providing assistance in gaining access to new sources of funding; supporting innovation; and integrating the new paradigm for children's mental health services into more traditional approaches to intervention within Head Start.
Quencher-enhanced specificity of psoralen-photosensitized virus inactivation in platelet concentrates.
BACKGROUND: Treatment with psoralens and UVA (PUVA) has been shown to be efficacious in eliminating the risk of virus transmission by platelet concentrates (PCs). It has previously been demonstrated that, during the inactivation of cell-free vesicular stomatitis virus (VSV) by aminomethyltrimethylpsoralen (AMT) and UVA in PCs, platelet function could be protected either by oxygen removal before irradiation or by inclusion of a type I free radical quencher, such as mannitol. STUDY DESIGN AND METHODS: Under previous PUVA treatment conditions for PCs (25 micrograms/mL AMT; 30 min UVA at 7 mW/cm2; 2 mM [2 mmol/L] mannitol), more than 6 log10 of added cell-free VSV was completely inactivated. In the current study, various PUVA conditions are evaluated for efficacy in inactivating other viral forms that could be present in PCs. Maintenance of platelet integrity (i.e., platelet number, solution pH, and aggregation response during initial storage after treatment) and kill of cell-associated VSV are examined. RESULTS: While cell-free viruses were inactivated efficiently under previous PUVA conditions, cell-associated VSV and the non-lipid-enveloped bacteriophage M13 were not. Effective inactivation of these viruses was achieved by raising the concentration of AMT to 50 micrograms per mL and extending the period of irradiation to 90 minutes (39 J/cm2). However, for maintenance of platelet integrity under these conditions, the prior removal of oxygen or the inclusion of compounds known to quench both type I and type II photoreactants (e.g., flavonoids such as rutin) was required. CONCLUSION: These findings suggest that the viral safety of PCs may be enhanced through treatment with AMT and UVA in the presence of flavonoids, and that flavonoid use may prove beneficial in other systems where oxygen-mediated damage occurs.
Unrecognised and unregistered visual impairment.
Recent community based studies have shown that only a minority of visually impaired people who are eligible to be registered as partially sighted or blind are actually registered as such. To determine how many unregistered but eligible people are attending ophthalmic clinics a prospective study was undertaken of all patients (n = 1543) attending ophthalmic outpatient departments, at a single specialty eye hospital and two district general hospitals over a 1 week period. All patients with visual acuity < or = 6/18 or restricted visual field were interviewed. Registration status and factors affecting this were then determined. Although 95/174 patients interviewed were eligible for registration, 68 as partially sighted and 27 as blind, only 46 (48.4%) of these were registered. Asians and Afro-Caribbeans were under-represented in the group eligible for registration. Active treatment impeded registration. Patients having four or more hospital visits were on average 16 times more likely to be registered as those who had fewer attendances. Disabilities, in addition to visual impairment, were present in 40% (n = 38). This study shows that there is unregistered visual impairment in patients attending ophthalmic departments. As registration triggers multidisciplinary support, ophthalmologists need to be more alert to the benefits and criteria for partial sight and blind registration.
Clinical and psychosocial origins of chronic depressive episodes. II. A patient enquiry.
BACKGROUND: We consider how well the psychosocial and clinical factors found to predict a chronic course for depressive episodes in the community, held for female psychiatric patients. METHOD: A consecutive series of depressed patients, aged 18 to 60, treated as in-patients, out-patients or day-patients at psychiatric departments of two London hospitals, were interviewed initially and at follow-up two years later. RESULTS: Indices of childhood adversity and current interpersonal difficulties predicted episodes taking a chronic course (of more than 12 months' duration). Half of the episodes associated with one or the other factor were chronic, compared with 22% of those with neither. The patients were at higher risk than the community series (75% v. 34%) and this explains their much greater rate of chronicity. There was also some evidence that social support reduced risk. Clinical features and the presence of a personality disorder were unrelated to chronicity. CONCLUSIONS: Similar psychosocial factors are important for predicting chronicity in both community and patient series.
The role of the nurse executive.
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Quantitative applications: forecasting and costing nursing service at an Army community hospital.
The utilization of a quantitative method of forecasting, coupled with an existing patient classification system (the Army's Workload Management System for Nursing), provides a creative costing tool for managing nursing resources at military medical facilities. Although the nursing management options discussed in this article are focused on a downsizing situation at an Army Community Hospital, they are applicable throughout military medical facilities.
Stereotactic core breast biopsy. An alternative.
Stereotactic core breast biopsy provides diagnostic accuracy equal to open surgical biopsy and is more comfortable and more cost effective than open surgical biopsy. A series of 75 patients is presented, of which 15 (20%) had positive findings, including 11 cancers and 4 atypical hyperplasias. The authors discuss indications, methods, patient preparation and results relating to this series of patients, including initial use of lateral compression for stereotactic core biopsies. This procedure promises to become the procedure of choice for nonpalpable, mammographically detected, indeterminate lesions of the breast and is likely to alter the conventional roles for the surgeon and radiologist regarding breast biopsy.
The policy context.
The final article in the series considers the ways in which the methods described previously are used in the formation of policy. When health authorities are making decisions about how to spend their money they have to draw on several sources of information about priorities: diktats from policy makers, opinions of consumers and of the professional bodies involved, and evidence gained from research. They must also consider the various methods of costing and select the right one for their circumstances. Some of these methods are still in the early stages of development, but more are being developed all the time and they have a valuable role in helping decision making throughout the NHS.
Glucose transport in L6 myoblasts overexpressing GLUT1 and GLUT4.
The roles of the glucose transporter isoforms, GLUT1 and GLUT4, in mediating insulin-stimulated glucose transport were investigated by stably overexpressing the transporters in L6 myoblasts. Levels of GLUT1 and GLUT4 in myoblasts from the cell lines having the highest content of these transporters were approximately 16- and 30-fold higher, respectively, than levels in nontransfected cells. The basal rate of 2-deoxy[3H]glucose uptake was severalfold higher in cells overexpressing GLUT1 than in the parent L6 myoblasts or in control cell lines that were generated by transfecting cells with expression vectors lacking transporter insert. The basal rate was not elevated in any of the lines expressing GLUT4. The net increase in 2-deoxy[3H]glucose uptake produced by insulin was larger in both the GLUT1 and GLUT4 cells than in the control cells. Insulin increased uptake in GLUT4 cells by as much as 6-fold; whereas, the fold increase over basal uptake produced by insulin in GLUT1 cells was comparable to that (2-fold) observed in the control myocytes. Thus, both GLUT1 and GLUT4 can mediate insulin-stimulated glucose transport in L6 myoblasts, although GLUT4 is needed to observe large percentage increases comparable to those observed in skeletal muscle fibers in vivo. In contrast to insulin, the protein phosphatase inhibitors, okadaic acid and calyculin A, inhibited glucose transport in cells expressing either GLUT1 or GLUT4. Calyculin A, which produced a half-maximum effect at 10 nM, was approximately 100 times more potent than okadaic acid in decreasing both basal and insulin-stimulated 2-deoxyglucose uptake. Inhibition of uptake by calyculin A was associated with a decrease in the cell surface concentration of both GLUT1 and GLUT4. These results indicate that increased protein phosphorylation can lead to inhibition of transport mediated by both GLUT1 and GLUT4.
Cost-benefit analysis.
Cost-benefit analysis is probably the most comprehensive method of economic evaluation available and it can be applied in two ways. The human capital approach means that the value of people's contributions is linked to what they are paid. The approach based on individuals' observed or stated preference means that their personal valuations are placed on an activity by assessing how much money they are prepared to accept for an increased risk or to pay for a particular service. Each method has its disadvantages and the most successful that has been devised so far is the "willingness to pay" (stated preference) approach, though the response to this is to a large extent dependent on the income of the person being questioned. There are still problems with its application, however, so its usefulness is limited.
Cost-utility analysis.
Decisions have to be made about allocating health resources. Currently the best economic evaluation method for doing this is cost-utility analysis. This compares the costs of different procedures with their outcomes measured in "utility based" units--that is, units that relate to a person's level of wellbeing. The most commonly used unit is the quality adjusted life year (QALY). QALYs are calculated by estimating the total life years gained from a procedure and weighting each year to reflect the quality of life in that year. To compare outcomes of different programmes the Rosser index is one measure that is widely used to assign quality of life scores to patients. Combined with a measure of life years gained from a procedure, this enables QALYs to be calculated and procedures ranked according to cost per QALY gained. In this article Ray Robinson explains the measures used and discusses how QALY league tables can be used to guide decisions on resource allocation.
Cost-effectiveness analysis.
When different health care interventions are not expected to produce the same outcomes both the costs and the consequences of the options need to be assessed. This can be done by cost-effectiveness analysis, whereby the costs are compared with outcomes measured in natural units--for example, per life saved, per life year gained, and per pain or symptom free day. Many cost-effective analyses rely on existing published studies for effectiveness data as it is often too costly or time consuming to collect data on cost and effectiveness during a clinical trial. Where there is uncertainty about the costs and effectiveness of procedures sensitivity analysis can be used, which examines the sensitivity of the results to alternative assumptions about key variables. In this article Ray Robinson describes these methods of analysis and discusses possibilities for how the benefits of alternative interventions should be valued.
Costs and cost-minimisation analysis.
Whatever kind of economic evaluation you plan to undertake, the costs must be assessed. In health care these are first of all divided into costs borne by the NHS (like drugs), by patients and their families (like travel), and by the rest of society (like health education). Next the costs have to be valued in monetary terms; direct costs, like wages, pose little problem, but indirect costs (like time spent in hospital) have to have values imputed to them. And that is not all: costs must be further subdivided into average, marginal, and joint costs, which help decisions on how much of a service should be provided. Capital costs (investments in plant, buildings, and machinery) are also important, as are discounting and inflation. In this second article in the series Ray Robinson defines the types of costs, their measurement, and how they should be valued in monetary terms.
Economic evaluation and health care. What does it mean?
Ever since the concept of value for money in health care was introduced into the NHS, economic terms and jargon have become part of our everyday lives--but do we understand what the different types of economic evaluation all mean, particularly those that sound similar to the uninitiated? This article introduces readers to the purpose of economic evaluation, and briefly explains the differences between cost-minimisation analysis (used when the outcomes of the procedures being compared are the same); cost-effectiveness analysis (used when the outcomes may vary, but can be expressed in common natural units, such as mm Hg for treatments of hypertension); cost-utility analysis (used when outcomes do vary--for example, quality of life scales); and cost-benefit analysis (used when a monetary value is being placed on services received). Further articles will deal with each one in more detail.
Checks and balances.
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