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Biomedical subjects

S Capewell

Publications and source records attributed to S Capewell.

At least 73 records · Page 4Linked to original sources
PubMed1997

Coping with the inexorable rise in medical admissions: evaluating a radical reorganisation of acute medical care in a Scottish district general hospital.

OBJECTIVE: To describe radical changes in acute medical care in a district general hospital and assess their impact on staff and patients. DESIGN: A before and after comparison of structure, process and outcome indicators in the year preceding and following reorganisation. SETTING: The Adult Medicine Clinical Directorate of the Royal Alexandra Hospital in Paisley, Scotland. SUBJECTS: Staff in the Medical Directorate and a random sample of 400 patients. INTERVENTIONS: The main stimulus for reorganisation was the pressure caused by a relatively steep rise in admissions. In response, the six existing general medical wards were converted into a 38-bed Medical Admissions Unit and five more specialised wards. A new acute receiving rota allowed each consultant to concentrate almost exclusively on acute receiving for one week at a time. RESULTS: The boarding of patients in non-medical wards was eliminated through improved bed management. The needs of patients became better matched to the specialism of their consultant. The cardiologist's share of in-patients with cardiological problems rose from 34% of 2,877 cases to 58% of 3,085 cases (p < 0.001) and the respiratory physicians' share of respiratory in-patients grew from 53% of 1,281 cases to 67% of 1,287 cases (p < 0.001). After the reorganisation, medical staff had significantly fewer concerns about losing track of patients (p < 0.01) or about boarding (p < 0.01), however, concern about 'blocked beds' became greater (p < 0.05). Nurses reported more time for health promotion (p < 0.01) but also a rise in stress (p < 0.05). More patients reported that staff had time to explain their treatment (85/109 (79%) before, 93/105 (89%) after, p < 0.05) and a higher proportion felt ready for discharge (91/108 (84%) before, 99/106 (93%) after, p < 0.05). CONCLUSIONS: Radical reorganisation of medical care in response to rising acute medical admissions is achievable and may lead to improvements in care.

Adult↗
PubMed1996

Adenocarcinoma of the lung--clinical features and survival.

Four thousand patients were registered by the Edinburgh Lung Cancer Group in 1981-1987; 9.5% had adenocarcinoma. Of these, 102 patients with pathological confirmation of the diagnosis, presenting to one hospital group in Edinburgh, were reviewed. Two cases were excluded after case note review. Of the remaining 100, 64 were male and 36 were female, with a mean age of 73 years. The majority (89%) were smokers or ex-smokers, and 52% had a poor performance status (Karnofsky Index 10-70). Significantly, more adenocarcinoma patients underwent surgery compared to other cell types (39 vs. 19%, P < 0.01), and less were treated with radiotherapy (19 vs. 31%). The 5-yr survival rate for the adenocarcinoma patients was 19 vs. 7% in the remainder of patients. Of 39 patients referred for surgery, 37 had lung resections and their 5-yr survival rate was 42%. Post-operative staging showed 48% in Stage I, 27% in Stage II and 24% in Stage III. The majority of the long-term survivors had Stage I disease (64%). Forty-two percent of the patients received palliative therapy alone (all died within 10 months). Ten percent of patients receiving radiotherapy survived for 5 yr. Review of these cases suggested two patterns of presentations: (1) patients with poor performance status, extensive disease and often pleural involvement (16%); and (2) patients with more localized disease (39%), many of whom were suitable for surgical resection with surprisingly good prognosis.

Adenocarcinoma↗
PubMed1996

Measuring outcomes: one month survival after acute myocardial infarction in Scotland.

OBJECTIVE: To examine 30 day survival after acute myocardial infarction as an outcome indicator, and explore the effects of adjusting for available prognostic factors such as age, sex, co-morbidity, deprivation, and deaths outside hospital. DESIGN: Cohort study. SETTING: The Scottish Record Linkage System was analysed. This national data-base links inpatient data to death certificate information for a population of 5.1 million. SUBJECTS: All 40,371 admissions to hospital with a principal diagnosis of acute myocardial infarction, plus all 18,452 deaths outside hospital with a principal cause of death registered as acute myocardial infarction (ICD9 code 410) during 1988-1991. MAIN OUTCOME MEASURES: The outcome event was death from any cause, within hospital or elsewhere, within 30 days of admission. RESULTS: During 1988-1991, 30 day survival after acute myocardial infarction was 77% in 40,371 hospital admissions, but only 53% when 18,452 acute myocardial infarction deaths in the community were included (a population-based outcome indicator with many advantages). Using logistic regression at an individual patient level, the odds of dying within 30 days effectively doubled for each decade of age (odds ratio compared with patients aged under 55: 2.3 aged 55-64, 4.4 aged 65-74, 8.2 aged 75-84, 12.0 aged 85 plus); were marginally higher in females than in males (odds ratio 1.07); were almost doubled in patients with a history of previous infarction, coronary heart disease, or other heart disease, and were also significantly increased in patients with circulatory disease, respiratory disease, neoplasm, or diabetes. Socioeconomic deprivation had no significant effect. Marked variations in survival between different hospitals and health board areas persisted, even after adjusting for the above prognostic factors. CONCLUSION: One month survival after acute myocardial infarction could be a useful means of measuring outcome of hospital care. There was important geographical variation in one month survival. These differences could be accounted for by variations in referral, admission, diagnosis, definition, and coding. These variables merit further research and local clinical audit before one month survival after acute myocardial infarction can be reliably used for detecting differences in quality of care. In addition, it would be essential to take account of infarct severity.

Age Factors↗
PubMed1996

An audit of BCG immunisation and tuberculin skin testing in Scotland. Scottish BCG Study Group.

BACKGROUND: BCG vaccination of all tuberculin-negative schoolchildren has been undertaken in the United Kingdom since 1954. In light of the ten-fold decline in tuberculosis, mass vaccination may no longer be justified. Since most tuberculosis cases now occur among identifiable high-risk groups, restriction of vaccination to these groups may be more appropriate. Before such changes can be recommended, further information is required on current practice within Scotland. OBJECTIVE: To determine current BCG vaccination practice within Scotland, in order to inform planning of future immunisation services. DESIGN: Postal questionnaire survey. SETTING AND SUBJECTS: The questionnaires were posted to the Consultant in Public Health Medicine responsible for Communicable Disease Control in each of the fifteen Scottish Health Boards. RESULTS: Completed questionnaires were returned by all 15 Health Boards. Marked variations were reported in the vaccination of both schoolchildren and high-risk groups. Six (40%) Health Boards immunised all tuberculin-negative children, whereas the remainder excluded those with evidence of previous BCG vaccination. All Health Boards immunised contacts of tuberculosis cases, 11 offered it to healthcare workers and 11 to immigrants from countries with a high prevalence of tuberculosis. However, only 7 offered it to the offspring of high-risk ethnic groups, 5 to students and 4 to animal workers. CONCLUSION: There are marked variations in current BCG vaccination practice. Greater efforts are required to ensure that high-risk groups receive vaccination.

Adolescent↗
PubMed1994

Testosterone levels during systemic and inhaled corticosteroid therapy.

Testosterone has importance both as a sex hormone and as an anabolic steroid promoting bone formation. Osteoporosis is associated with both hypogonadism and corticosteroid therapy. Testosterone levels are reduced by long term prednisolone treatment. Although high dose inhaled corticosteroid therapy may cause a variety of systemic effects including adrenal suppression, dermal thinning and a reduction in total bone calcium, its effect on testosterone levels is not known. Testosterone, luteinizing hormone, follicle stimulating hormone and sex hormone binding globulin were therefore measured in 35 male patients with respiratory disease attending an outpatient clinic (median age 58, range 21-75 years). They were grouped according to steroid therapy and compared with 19 age matched controls. Mean (SD) testosterone levels were 33% lower in 12 men on long term oral prednisolone [14.5 (6.0) nmol 1-1] than in controls [21.7 (6.3) nmol 1-1], but were not significantly reduced in 10 patients on low dose inhaled beclomethasone [200-800 micrograms day-1: 19.7 (3.7)] nor in 13 men taking high dose inhaled beclomethasone [1500-2,250 micrograms day-1: 17.9 (5.6)]. Levels of luteinizing hormone, follicle stimulating hormone and sex hormone binding globulin were similar in all four groups. These cross sectional data confirm that long term systemic corticosteroid therapy reduces testosterone levels. However, testosterone was reduced by only 18% (NS) by long term inhaled corticosteroids. Other mechanisms to explain the disordered bone metabolism should now be explored.

Administration, Inhalation↗
PubMed1993

Asthma in Scotland: epidemiology and clinical management.

Asthma in Scotland is briefly reviewed including epidemiology, management and the potential for research, education and audit. Asthma is characterised by variable wheeze and shortness of breath caused by variable narrowing of the bronchial airways secondary to inflammation. Confusion with chronic obstructive airways disease is increasingly common in the elderly and epidemiological studies tend to focus on the age range 5-44 years. Asthma prevalence is critically dependent on the definitions used and exceeds 20% based on questionnaire alone, less if objective measurements of airways obstruction is also used: perhaps 15% in children, 5% in adults in Scotland. Comparisons between studies and countries are therefore potentially hazardous. Routine information sources confirm the high levels of morbidity and use of health services by asthmatic patients. A true increase in the prevalence of asthma in children over the last two decades appears likely. This has been compounded by increased willingness to use the diagnostic label of asthma. Asthma, hayfever and eczema have increased significantly in Aberdeen school children over the last 25 years and asthma symptoms and airways obstruction have increased significantly in South Wales. Similar increases are reported in New Zealand children between 1975 and 1985, the prevalence being significantly higher than in Welsh children using standardised methodology. In Zimbabwe an intriguing strong association has been demonstrated between asthma, urban life style and higher socio economic groups. Most asthma deaths are caused by bronchial narrowing and subsequent asphyxia. Asthma mortality has apparently increased in most industrialised countries but problems of definition remain even when attention is confined to the age span 5-44 years. The epidemic of asthma deaths in mid-60s was undeniable and may have reflected good symptomatic control by bronchodilators, which made doctors and patients neglect the underlying risk of asthma death. A gradual increase in asthma mortality in western countries over the 1970s and 1980s is apparent, including almost 5% annual increase in England and Wales between 1974 and 1984 which then levelled off. This may again reflect excess dependence on bronchodilator treatment and under-usage of steroid treatment. A more dramatic increase in mortality in New Zealand in the early 1980s is likely to have a number of contributory factors. In contrast, the mortality rate in Scotland had been relatively static over the last two decades, although hospital discharge rates have doubled. Emergency asthma self admission schemes developed in Edinburgh are increasing popular and these, along with nebulised bronchodilators in ambulances, may be beneficial.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗
PubMed1992

Pulmonary eosinophilia with systemic features: therapy and prognosis.

Of 65 patients presenting with pulmonary eosinophilia to one Respiratory Unit during a 20-year period, 12 (18%) had systemic features associated with their pulmonary disease. Eleven had fever, three night sweats, three arthralgia, three vasculitic rashes and two weight loss. Anaemia, myalgia, peripheral neuropathy, mononeuritis, pericardial effusion and photosensitivity rash were each recorded in single patients. None had evidence of hypersensitivity to drugs, helminthes or other allergens. Ten of the 12 patients could be classified as cryptogenic pulmonary eosinophilia and two as Churg Strauss syndrome. Ten were female. The maximum recorded eosinophil counts were higher in the 12 patients with systemic features compared with the remaining 53 patients [mean (SD) 5613 (3883) vs. 2359 (3046) x 10(6) 1(-1), P < 0.02], whereas both asthma and recurrent episodes of eosinophilia were significantly less common. Steroid therapy achieved a good clinical response and radiological clearing in the majority of patients. All 12 patients were treated with prolonged duration oral prednisolone [mean (SEM) dose 8.5 (3.8) mg day-1 duration 5.5 (1.3) years]. The two patients with Churg Strauss syndrome required azathioprine in addition to long-term prednisolone. There were no deaths and currently four patients are off all steroids and six receive less than 5 mg day-1. During a median follow-up period of 11 years, there was no significant decline in FEV1 or VC, measured as percent predicted values. Persistent radiographic abnormalities consistent with fibrosis or bronchiectasis were not seen.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1992

Lung cancer in young patients.

During 1981-1986 the Edinburgh Lung Cancer Group prespectively registered 3560 new patients with lung cancer of whom only 48 (1.3%) were aged less than 45 years. When compared with 3512 older patients aged more than 45 years, a similar proportion of young patients were female (17/48; 35% vs. 28% of the older patients) and had equally advanced disease (30/48; 62% vs. 58% in stage III). Slightly more young patients were in better Karnofsky performance status groups (28/48; 59% vs. 45%, score > 80) and duration of symptoms was considerably shorter (median 45 vs. 93 days); only three of the younger patients were non-smokers. A pathological diagnosis was obtained more often in young patients (47/48; 98% vs. 81%). The commonest cell type was small cell (16/48; 34% vs. 24%) with 10/48 adenocarcinoma (20% vs. 13%) and less squamous carcinoma (11/48; 23% vs. 48%). Although only 12/48 young patients (25% vs. 19%) underwent surgical resection, six of these were still alive after 5 years (50% vs. 30% in older patients). More young patients received chemotherapy either alone (14) or combined with radiotherapy (6)--42% vs. 16% in older patients. There were no long-term survivors and the median survival was 8 months in 13 patients with small cell and only 4 months in seven with non-small cell carcinoma.

Adenocarcinoma↗
PubMed1992

Decreased cardiac parasympathetic activity in chronic heart failure and its relation to left ventricular function.

BACKGROUND: Activation of the sympathetic nervous system has been extensively studied in patients with chronic heart failure, but the parasympathetic nervous system has received relatively little attention. The objective in this study was to investigate cardiac parasympathetic activity in chronic heart failure and to explore its relation to left ventricular function. METHODS: Heart rate variability was measured from 24 hour ambulatory electrocardiograms by counting the number of times each RR interval exceeded the preceding RR interval by more than 50 ms (counts). This method provided a sensitive index of cardiac parasympathetic activity. RESULTS: Mean (range) of counts were: waking 48 (1-275)/h, sleeping 62 (0-360)/h, and total 1310 (31-7278)/24 h. These were lower than expected, and in 26 (60%) of the 43 patients counts fell below the lower 95% confidence intervals (95% CI) for RR counts in normal subjects. A significant correlation between total 24 hour RR counts and left ventricular ejection fraction was present (r = 0.49, p less than 0.05). CONCLUSIONS: These results indicate that most patients with chronic heart failure have reduced heart rate variability and therefore reduced cardiac parasympathetic activity. The degree of parasympathetic dysfunction is related to the severity of left ventricular dysfunction. This may be relevant to the high incidence of ventricular arrhythmias and poor prognosis of patients with chronic heart failure.

Adult↗
PubMed1992

Bone turnover during short course prednisolone treatment in patients with chronic obstructive airways disease.

BACKGROUND: Although osteoporosis is a well known side effect of long term prednisolone, the effects of a short course are less clear. Biochemical markers of bone turnover were therefore studied in 10 men with chronic obstructive airways disease who required assessment of "steroid reversibility" (mean age 65 years, mean FEV1 1.2 1). METHOD: Patients received, single blind, two weeks of placebo, four weeks of prednisolone 20 mg/day, and then two further weeks of placebo. RESULTS: The mean (SD) fasting urinary hydroxyproline:creatinine ratio, a marker of bone resorption, increased by 65% with prednisolone (from 8.9 (5.7) to 14.7 (8.5) mumol/mmol) and returned to baseline after placebo. Serum alkaline phosphatase, a marker of net bone formation, fell after prednisolone by 28% (from 113 (41) to 81 (30) IU/1). Substantial changes occurred after only two weeks of prednisolone. Serum osteocalcin, calcium, and phosphate concentrations did not change significantly. CONCLUSIONS: Short courses of prednisolone increased bone resorption and inhibited bone formation after two and four weeks.

Aged↗
PubMed1992

Clinical Directorates: a panacea for clinicians involved in management?

A clinical Directorate is a managerial subunit led by a Clinical Director who is accountable for the Directorate's functioning and who exerts budgetary control over staff, equipment and supplies. The composition of Directorates and their possible structures are discussed, and requirements, conflicts of interest, and potential benefits are reviewed in the light of current experience.

Hospital Administration↗
PubMed1991

Central and peripheral haemodynamic responses to felodipine in congestive heart failure.

Using non-invasive radionuclide techniques, we studied the arterial and venous effects of 0.1 mg/kg oral felodipine in 12 men with heart failure due to ischaemic heart disease aged 37-72 y. All were in New York Heart Association Class II or III, required frusemide 40-120 mg daily and were clinically stable. Felodipine produced significant falls in blood pressure (-19%) and systemic vascular resistance (-39%) with increases in cardiac index (+34%), heart rate (+12%) and left ventricular ejection fraction (from 0.25 to 0.32). Peripheral venous volume fell by 10.6% after felodipine indicating venoconstriction rather than venodilatation and may be caused by an acute sympathetic reflex associated with the increase in heart rate. Our results confirm that felodipine is an arterial vasodilator. The previously observed changes in cardiac filling pressures may simply represent improved ventricular function as a consequence of reduced afterload, not venodilatation.

Adult↗