Search PubMed⌕ Search

Biomedical subjects

W A Macrae

Publications and source records attributed to W A Macrae.

18 recordsLinked to original sources
PubMed2004

Rhetoric and reality on acute pain services in the UK: a national postal questionnaire survey.

BACKGROUND: The study aimed to explore the extent to which NHS acute pain services (APSs) have been established in accordance with national guidance, and to assess the degree to which clinicians in acute pain management believe that these services are fulfilling their role. METHODS: A postal questionnaire survey addressed to the head of the acute pain service was sent to 403 National Health Service hospitals each carrying out more than 1000 operative procedures a year. RESULTS: Completed questionnaires were received from 81% (325) of the hospitals, of which 83% (270) had an established acute pain service. Most of these (86%) described their service as Monday-Friday with a reduced service at other times; only 5% described their service as covering 24 hours, 7 days a week. In the majority of hospitals (68%), the on-call anaesthetist was the sole provider of out of hours services. Services were categorized by respondents as thriving (30%), struggling to manage (52%) or non-existent (17%). There was widespread agreement (> or =85%) on the principles that should underpin acute pain services, and similar agreement on the need for better organizational approaches (95%) rather than new treatments and delivery techniques (19%). CONCLUSIONS: More than a decade since the 1990 report Pain after Surgery, national coverage of comprehensive acute pain services is still far from being achieved. Despite wide consensus about the problems, concrete solutions are proving hard to implement. There is strong support for a two-fold response: securing greater political commitment to pain services and using organizational approaches to address current deficits.

Attitude of Health Personnel↗
PubMed2001

Spinal cord stimulation--a long-term evaluation in patients with chronic pain.

Spinal cord stimulation (SCS) is an established treatment modality for chronic pain, angina pectoris, and peripheral vascular disease. This study evaluates experience with SCS over a 13-year period with emphasis on surgical complications, revisions and pain relief. It took the form of a retrospective study of medical/surgical records coupled with a postal/telephone questionnaire. The subjects consisted of seventy patients, aged from 21 to 76 years (mean 47; median 46), with severe, chronic pain refractory to conventional treatment, who underwent SCS implantation between 1984 and 1997. It investigated surgical revisions, complications and pain relief. There were 72 surgical revisions comprising electrode replacement/repositioning (32), generator replacement (22), cable failure (6) and implant removal (12). Half the devices were revised within 3 years (95% confidence interval: 2-5 years) of implantation. Six (8.6%) implants became infected. Sixty per cent of patients reported substantial relief of pain. This study shows that the majority of patients undergoing SCS derive significant benefit in terms of pain relief, but commonly require surgical revisions due to both technical and biological factors. These devices require systematic evaluation to determine optimal usage, clinical effectiveness and cost-benefit analysis.

Adult↗
PubMed1998

Cut and thrust: antecedent surgery and trauma among patients attending a chronic pain clinic.

Surgery and trauma are recognised as important causes of chronic pain, although their overall contribution has not been systematically studied. This paper reports on the contribution of surgery and trauma to chronic pain among 5130 patients attending 10 outpatient clinics located throughout North Britain. Surgery contributed to pain in 22.5% of patients, and was particularly associated with the development of pain in the abdomen and with anal, perineal and genital pain. Trauma was a cause of pain in 18.7% of patients, and was most common in pain in the upper limb, the spine and the lower limb. Patients with chronic pain associated with trauma are on average younger than those with chronic post-surgical pain. Further, and unusually for pain conditions, the trauma patients show an excess of males over females. These findings indicate that it can be unhelpful for pain classification systems to combine surgery and trauma in a single category. The results also point to areas for potentially fruitful research into the aetiology of chronic pain. In particular, studies are needed to identify the operative procedures associated with the development of pain so that preventive measures can be implemented.

Adult↗
PubMed1996

Audit in pain clinics: changing the management of low-back and nerve-damage pain.

This audit study took place in ten outpatient pain clinics and focused on the management of low back pain and nerve-damage pain. The objective was to identify and promote appropriate changes in management. An analysis of the treatment of 1236 patients with low back pain and/or nerve-damage pain highlighted wide variations in practice. Presentation of these data to the clinics was used as a means of promoting change. Data on a further 1791 patients were used to assess the extent of any changes in practice. Prior to the audit feedback, treatments were used often in some clinics, but only rarely in other clinics, for seemingly similar patients. During the feedback sessions three treatments were identified for more frequent use by several of the clinics: antidepressant and anticonvulsant drugs, and transcutaneous electrical nerve stimulation. Many changes in practice occurred after the audit intervention, with large increases in the utilisation of these three treatments. Since there is reasonable evidence to support the use of these treatments for chronic pain this represents an improvement in the process of care. The audit demonstrated that patient management can be improved by a combination of active feedback and discussions based around comparisons between centres.

Anticonvulsants↗
PubMed1994

Care of dying patients in hospital.

OBJECTIVE: To study the process of care of dying patients in general hospitals. DESIGN: Non-participant observer (MM) carried out regular periods of continuous comprehensive observation in wards where there were dying patients, recording the quantity and quality of care given. Observations were made in 1983. SETTING: 13 wards (six surgical, six medical, and one specialist unit) in four large teaching hospitals (bed capacity 504-796) in west of Scotland. SUBJECTS: 50 dying patients (29 female, 21 male) with mean age of 66 (range 40-89); 29 were dying from cancer and 21 from non-malignant disease. RESULTS: Final period of hospitalisation ranged from 6 hours to 24 weeks. More than half of all patients retained consciousness until shortly before death. Basic interventions to maintain patients' comfort were often not provided: oral hygiene was often poor, thirst remained unquenched, and little assistance was given to encourage eating. Contact between nurses and the dying patients was minimal; distancing and isolation of patients by most medical and nursing staff were evident; this isolation increased as death approached. CONCLUSIONS: Care of many of the dying patients observed in these hospitals was poor. We need to identify and implement practical steps to facilitate high quality care of the dying. Much can be learned from the hospice movement, but such knowledge and skills must be replicated in all settings.

Adult↗
PubMed1994

Entering the loop: assessing the contribution of pain clinics in northern Britain.

A survey of patients attending ten outpatient pain clinics throughout northern Britain was undertaken to identify opportunities for improving the treatment of pain patients. A short data collection form was designed to obtain information at every patient consultation. The patients were found to be a diverse group, many with complex pain problems. For many patients meaningful diagnoses could not be obtained. The focus of the study was altered to address a selected group of patients: those with neurogenic pain. This group was selected because it was comparatively easy to define, and previous studies suggested that nerve damage pain might not always be well managed. Many patients were found not to have had adequate trials of potentially effective therapies prior to attendance at the pain clinics. Some of these therapies, such as antidepressants and anticonvulsants, could have been prescribed by general practitioners. However, there were also substantial differences between the clinics in the proportion of patients receiving particular therapies. Finally, although many patients had psychological morbidity few were offered psychological assessment and management. These studies have shown that the pain clinics provide a range of therapies which patients are unlikely to receive elsewhere. But there is scope for improvement in the management of patients in pain clinics and efforts are currently being directed towards this.

Humans↗
PubMed1994

Waiting in pain. Delays between referral and consultation in outpatient pain clinics.

Patients with chronic pain may benefit from referral to a pain specialist. This study describes the delay between referral and first appointment of 3386 new referrals seen in ten outpatient pain clinics between 1990 and 1992. We then assess the follow-up patterns of the pain clinics and how these relate to waiting times. Patients wait in pain for long periods before being seen in a pain clinic. In 1992 about half of patients waited more than 3 months for an appointment at a teaching hospital pain clinic; and half waited 9 weeks or longer to be seen at a district general hospital pain clinic. In many clinics the situation is worsening. Pain clinics differ widely in their patient follow-up, with patients averaging more than twice as many visits in some clinics than others. Clinic practice on reappointing patients largely determines the number of new referrals who can be accepted for management, and hence affects waiting lists. Thus our data suggest that pain clinics themselves can help reduce waiting times, by changing the extent and nature of patient follow-up. Ultimately, however, additional consultant sessions may be needed to enable pain clinics to meet the increasing demands placed on them.

Chronic Disease↗
PubMed1994

Why use a pain clinic? Management of neurogenic pain before and after referral.

Pain arising from damage or malfunction of the nervous system (for example postherpetic neuralgia, peripheral nerve injuries and the neuropathies) is often severe and resistant to standard analgesics. These patients are commonly seen in pain clinics where they receive a variety of treatments including psychotropic drugs (such as antidepressants and anticonvulsants), nerve blocks and stimulation. There is concern that the management of these difficult patients may be less than optimal where they are not seen by pain specialists. We examined a cohort of 703 patients with long-established nerve-damage pain seen in ten outpatient pain clinics. We compared their use of treatments prior to referral with the management given in the pain clinic. The majority of patients (79%) had had their pain for over 1 year before being seen in the pain clinic, yet many had not tried simple and effective treatments prior to referral. Less than a quarter had received an adequate trial of antidepressants; only one in seven had been appropriately treated with anticonvulsants; and only one in 10 had tried a nerve stimulator. All these treatments were frequently provided in the pain clinic. Referral of patients with nerve-damage pain to a pain clinic may greatly increase their access to therapies of proven value.

Anticonvulsants↗
PubMed1989

Low-dose intrathecal diamorphine analgesia following major orthopaedic surgery.

In a randomized double-blind study we examined the effect of adding diamorphine 0.25 mg and 0.5 mg to intrathecal bupivacaine anaesthesia for major orthopaedic surgery. Duration of postoperative analgesia was considerably greater in patients given either doses of intrathecal diamorphine than in a control group of patients given bupivacaine alone (P less than 0.001). However, there was no significant difference between the two diamorphine doses (0.25 mg and 0.5 mg), each providing prolonged analgesia (10.8 and 9.9 h, respectively). Although there was no evidence of late respiratory depression, the frequency of adverse effects, in particular urinary retention, nausea and vomiting, was high in both groups receiving intrathecal diamorphine.

Aged↗
PubMed1985

Continuous subcutaneous infusion of morphine for postoperative pain relief.

A double-blind randomised study of 48 patients in whom continuous subcutaneous infusion and regular intramuscular injection of morphine were compared as analgesic regimens after upper abdominal surgery, is described. Over a 48-hour period, no difference in pain intensity between the two groups was found by comparing linear analogue scores, assessments on a four-point rank scale, peak expiratory flow rates or requirement for additional analgesia. Nausea and sedation were assessed using a four-point rank scale. These side effects were less frequent with subcutaneous infusion (p less than 0.05). Two patients from each group were judged to have received an overdose. The infusion apparatus was simple and convenient to use. Continuous subcutaneous infusion of morphine is a practical and effective means of achieving post-operative analgesia but, as with other mandatory dosing regimens, relative overdosage may occur.

Adolescent↗
PubMed1982

A simple suction device.

A simple suction device is described, suitable for portable resuscitation kits. It can be made cheaply, from parts already available in most hospitals and is reliable and effective.

Equipment Design↗
PubMed1980

Angiotensin II in human cerebrospinal fluid may be an immunoassay artifact.

1. Concentrations of angiotensin II (ANG II) were measured by radioimmunoassay in cerebrospinal fluid and plasma from neurosurgical patients and patients having spinal anaesthesia. Cerebrospinal fluid concentrations of renin, renin substrate and ANG I were also measured. 2. Cerebrospinal fluid concentrations of ANG II measured with antiserum 30/VI were low in neurosurgical patients (mean 6 pmol/l, range < 2 - 12 pmol/l, n = 7) and lower in spinal anaesthesia patients (mean 1 pmol/l, range < 2 - 4 pmol/l, n = 14) and unrelated to concurrent plasma concentrations of ANG II. 3. A second more sensitive immunoassay with ANG II antiserum 9/P gave higher cerebrospinal fluid concentrations of ANG II in spinal anaesthesia patients (mean 15 +/- 1 pmol/l, n = 7, P < 0.01). 4. Paper chromatography showed that the ANG II immunoreactive material measured with antiserum 9/P was not ANG I, ANG II, ANG II-(2-8), ANG II-(3-8) or ANG II-(4-8). 5. The concentration of ANG I in cerebrospinal fluid was low (4 +/- 0.04 pmol/l, n = 7). No renin was detected (n = 32) and the concentration of renin substrate was 45 +/- 2.6 nmol/l (n = 24). 6. Much of the immunoreactive ANG II in human cerebrospinal fluid is an immunoassay artifact.

Aged↗