Showing papers by "Leicester General Hospital published in 1999"

The British Diabetic Association Cohort Study, I: all-cause mortality in patients with insulin-treated diabetes mellitus.

Abstract: Summary Aims To assess mortality in patients with diabetes incident under the age of 30 years. Methods A cohort of 23 752 diabetic patients diagnosed under the age of 30 years from throughout the United Kingdom was identified during 1972–93 and followed up to February 1997. Following notification of deaths during this period, age- and sex-specific mortality rates, attributable risks and standardized mortality rates were calculated. Results The 23 752 patients contributed a total of 317 522 person-years of follow-up, an average of 13.4 years per subject. During follow-up 949 deaths occurred in patients between the ages of 1 and 84 years, 566 in males and 383 in females. All-cause mortality rates in the patients with diabetes exceeded those in the general population at all ages and within the cohort were higher for males than females at all ages except between 5 and 15 years. The relative risk of death (standardized mortality ratio, SMR), was higher for females than males at all ages, being 4.0 (95% CI 3.6–4.4) for females and 2.7 (2.5–2.9) for males overall, but reaching a peak of 5.7 (4.7–7.0) in females aged 20–29, and of 4.0 (3.1–5.0) in males aged 40–49. Attributable risks, or the excess deaths in persons with diabetes compared with the general population, increased with age in both sexes. Conclusions This is the first study from the UK of young patients diagnosed with diabetes that is large enough to calculate detailed age-specific mortality rates. This study provides a baseline for further studies of mortality and change in mortality within the United Kingdom.

In situ replacement of infected aortic grafts with rifampicin-bonded prostheses: the Leicester experience (1992 to 1998)

Abstract: Purpose : Prosthetic graft infection after aortic aneurysm surgery is a life-threatening complication. Treatment options include total graft excision and extra-anatomic bypass grafting or in situ replacement of the graft. The latter option is gaining increasing popularity, but the long-term outcome remains uncertain, particularly in light of the increasing prevalence of methicillin-resistant Staphylococcus aureus (MRSA). We performed a prospective nonrandomized study to assess the outcome after graft excision and in situ replacement with a rifampicin-bonded prosthesis for the treatment of major aortic graft infection. Methods: In a 6-year period from January 1992 to December 1997, 11 patients (eight men, three women) with major aortic graft infection underwent total graft excision and in situ replacement with a rifampicin-bonded prosthesis. The median age of the patients was 66 years (range, 49 to 78 years). Four patients had a hemorrhage from an aortoenteric fistula, three had a retroperitoneal abscess, two had graft occlusion, one had a perigraft collection shown by means of computed tomography, and one had a ruptured suprarenal false aneurysm. Organisms were cultured from 10 patients. Results: MRSA was isolated in two patients, both of whom had originally undergone repair of a ruptured abdominal aortic aneurysm. Two patients died (18.2%) within 30 days, and three patients (27.6%) had nonfatal complications (peritoneal candidiasis, transient renal impairment, and profound anorexia). Two patients died late in the follow-up period. Seven patients remain alive and clinically free of infection. Conclusion: The long-term results after total graft excision and in situ replacement with a rifampicin-bonded prosthesis appear to be favorable. However, MRSA aortic graft infection appears to be associated with a poor prognosis. (J Vasc Surg 1999;30:92-8.)

Left in limbo: patients' views on care across the primary/secondary interface.

Abstract: OBJECTIVES: To discover the views of patients about their experiences across the interface between primary and secondary health care, including referral from general practitioners, outpatient and inpatient care, discharge, and aftercare. DESIGN: A qualitative study involving individual and focus group interviews of patients and interviews of carers. SUBJECTS: 33 patients who had attended at least one outpatient appointment or had been an inpatient between two and four months previously, and eight carers of patients with chronic conditions. SETTING: Three acute hospitals and one community health service in Leicestershire. MAIN OUTCOME MEASURES: Common themes in the views of patients and carers towards their experiences of care. RESULTS: Five themes emerged. The first four were: "getting in" (access to appropriate care), "fitting in" (orientation of care to the patient's requirements), "knowing what's going on" (provision of information), and "continuity" (continuity of staff and coordination and communication among professionals). The fifth theme was "limbo" (difficulty in making progress through the system), which was influenced by failures in care in relation to the other four themes. CONCLUSIONS: The concept of progress is central to patients' views of care. It involves both progress through the healthcare system and progress towards recovery or adjustment to an altered health state. Patients' views on how well they progress through the healthcare system may be an appropriate indicator for monitoring health service performance.

Bovine colostrum is a health food supplement which prevents NSAID induced gut damage

Abstract: BACKGROUND—Non-steroidal anti-inflammatory drugs (NSAIDs) are effective for arthritis but cause gastrointestinal injury. Bovine colostrum is a rich source of growth factors and is marketed as a health food supplement. AIMS—To examine whether spray dried, defatted colostrum or milk preparations could reduce gastrointestinal injury caused by indomethacin. METHODS—Effects of test solutions, administered orally, were examined using an indomethacin restraint rat model of gastric damage and an indomethacin mouse model of small intestinal injury. Effects on migration of the human colonic carcinoma cell line HT-29 and rat small intestinal cell line RIE-1 were assessed using a wounded monolayer assay system (used as an in vitro model of wound repair) and effects on proliferation determined using [3H]thymidine incorporation. RESULTS—Pretreatment with 0.5 or 1 ml colostral preparation reduced gastric injury by 30% and 60% respectively in rats. A milk preparation was much less efficacious. Recombinant transforming growth factor β added at a dose similar to that found in the colostrum preparation (12.5 ng/rat), reduced injury by about 60%. Addition of colostrum to drinking water (10% vol/vol) prevented villus shortening in the mouse model of small intestinal injury. Addition of milk preparation was ineffective. Colostrum increased proliferation and cell migration of RIE-1 and HT-29 cells. These effects were mainly due to constituents of the colostrum with molecular weights greater than 30kDa. CONCLUSIONS—Bovine colostrum could provide a novel, inexpensive approach for the prevention and treatment of the injurious effects of NSAIDs on the gut and may also be of value for the treatment of other ulcerative conditions of the bowel. Keywords: gastrointestinal tract; intestinal injury; repair; nutrition

Analysis of IgA1 O-Glycans in IgA Nephropathy by Fluorophore-Assisted Carbohydrate Electrophoresis

Abstract: Abnormal O-glycosylation of IgA1 may contribute to pathogenic mechanisms in IgA nephropathy (IgAN). Observations of altered lectin binding to IgA1 in IgAN suggest that the O-glycan chains may be undergalactosylated, but precise structural definition of the defect has proved technically difficult, and it remains unconfirmed. This is the first study using fluorophore-assisted carbohydrate electrophoresis (FACE) to analyze IgA1 O-glycans in IgAN and controls. IgA1 was purified from serum, and the intact O-glycans were released by hydrazinolysis at 60 degrees C. After re-N-acetylation, the glycans were fluorophore-labeled and separated by polyacrylamide gel electrophoresis. Sequential exoglycosidase digestions of IgA1 allowed identification of the different O-glycan bands on FACE gels, and their relative frequencies in IgA1 samples were measured by ultraviolet densitometry. Lectin binding of the IgA1 samples was also measured. In some patients with IgAN, FACE analysis demonstrated a significant increase in the percentage of IgA1 O-glycan chains consisting of single N-acetyl galactosamine (GalNAc) units rather than the more usual galactosylated and sialylated forms. This finding was confirmed using both desialylated IgA1 and enzymatically released O-glycans. Good correlation was also found between O-glycan agalactosylation on FACE analysis and IgA1 lectin binding in IgAN, supporting the value of lectins as tools for detection of this abnormality. This is the first study in which all of the predicted O-glycan forms of IgA1 have been analyzed simultaneously, and demonstrates that in IgAN, the IgA1 Oglycan chains are truncated, with increased terminal GalNAc. This abnormality has the potential to significantly affect IgA1 behavior and handling with pathogenic consequences in IgAN.

Pathogenesis of IgA nephropathy.

Abstract: IgA nephropathy (IgAN) is initiated by glomerular deposition of polymeric IgA1(pIgA1). In IgAN pIgA production is reduced in the mucosal immune system, perhaps mediated by a mucosal gamma delta T cell defect, and mucosal IgA responses to immunisation are impaired. But pIgA1 production by the marrow is increased. Human pIgA1 has an O-glycosylated hinge region unique to circulating immunoglobulins and there is reduction of galactosyl residues in the hinge of serum IgA1 in IgAN and Henoch-Schonlein nephritis. This reduced galactosylation may be due to a functional defect in plasma cell beta 1,3-galactosyltransferase. Altered hinge region glycosylation may alter IgA1 structure, modifying interactions with matrix proteins, IgA receptors and complement, and therefore influence mesangial deposition and subsequent injury through mechanisms other than classical antigen-antibody reactions. IgA clearance through the hepatic asialoglycoprotein receptor or Fc alpha receptors on circulating white cells may also be impaired. The unique features of human IgA1 have prevented development of satisfactory animal models for the early stages of IgAN. It is likely that events after pIgA1 deposition which result in glomerular inflammation and scarring are not specific to IgAN but generic to many forms of glomerulonephritis.

Randomised controlled trial of effectiveness of Leicester hospital at home scheme compared with hospital care

Abstract: Objective: To compare effectiveness of patient care in hospital at home scheme with hospital care. Design: Pragmatic randomised controlled trial. Setting: Leicester hospital at home scheme and the city9s three acute hospitals. Participants: 199 consecutive patients referred to hospital at home by their general practitioner and assessed as being suitable for admission. Six of 102 patients randomised to hospital at home refused admission, as did 23 of 97 allocated to hospital. Intervention: Hospital at home or hospital inpatient care. Main outcome measures: Mortality and change in health status (Barthel index, sickness impact profile 68, EuroQol, Philadelphia geriatric morale scale) assessed at 2 weeks and 3 months after randomisation. The main process measures were service inputs, discharge destination, readmission rates, length of initial stay, and total days of care. Results: Hospital at home group and hospital group showed no significant differences in health status (median scores on sickness impact profile 68 were 29 and 30 respectively at 2 weeks, and 24 and 26 at 3 months) or in dependency (Barthel scores 15 and 14 at 2 weeks and 16 for both groups at 3 months). At 3 months9 follow up, 26 (25%) of hospital at home group had died compared with 30 (31%) of hospital group (relative risk 0.82 (95% confidence interval 0.52 to 1.28)). Hospital at home group required fewer days of treatment than hospital group, both in terms of initial stay (median 8 days v 14.5 days, P=0.026) and total days of care at 3 months (median 9 days v 16 days, P=0.031). Conclusions: Hospital at home scheme delivered care as effectively as hospital, with no clinically important differences in health status. Hospital at home resulted in significantly shorter lengths of stay, which did not lead to a higher rate of subsequent admission. Key messages The effectiveness of hospital at home schemes for avoiding hospital admission has not been tested in a trial In this study patients suitable for hospital at home care were randomised to hospital at home or hospital care and followed up for three months There were no clinically or statistically significant differences in outcome as measured by the sickness impact profile 68, Barthel index, Philadelphia geriatric morale scale, and EuroQol Length of stay in care and total days of care were about 45% less for patients randomised to hospital at home For patients who meet the admission criteria, hospital at home schemes can provide an effective and acceptable alternative to hospital admission

A survey of antidepressant prescribing in the terminally ill

Abstract: Depression is a symptom in a quarter of patients admitted to a palliative care unit, but little is known of how depression in terminally ill patients is treated. We reviewed 1046 consecutive patien...

Computerized histomorphometric assessment of protocol renal transplant biopsy specimens for surrogate markers of chronic rejection.

Abstract: Background. Chronic transplant rejection has emerged as the commonest cause of long-term renal allograft failure, and early identification of those grafts at risk could allow the targeting of specific therapies aimed at delaying this process. This study explores the usefulness of quantitative immunohistochemistry in defining biopsy-based surrogate markers of allograft damage. Methods. A consecutive series of 52 renal transplant recipients immunosuppressed with cyclosporine were studied. Needle core transplant biopsies were performed at 1, 3, and 6 months postoperatively. Immunostaining for collagen III, and smooth muscle actin, tenascin, and infiltrating leukocytes was performed using an indirect immunoperoxidase technique. The interstitial area stained (%) was measured using a semiautomatic image analysis system. The results were related to glomerular filtration rates (GFR) measured at 6, 12, and 24 months after transplantation using rank correlation coefficients. Results. The area fraction of immunostained collagen III correlated with 6-month GFR (r=-0.42, P=0.005) and was predictive of 12-month GFR (r=-0.32, P=0.03). An area fraction of immunostained collagen III of >40% at 6 months was associated with a significantly lower GFR at 24 months, compared with a percentage area of ≤40% (31±4 versus 45±4 ml/min/ 1.73 m 2 , P=0.01). Furthermore, a collagen III of >40% at 6 months identified patients who were at risk of progressive deterioration in graft function. Conclusions. Grafts with poorer long-term function can be predicted using 6-month protocol biopsy specimens immunostained for collagen III. This should prove to be a useful ad interim surrogate marker of allograft damage in studies addressing the effects of new immunosuppressive agents on the development of chronic rejection.

Vascular endothelial growth factor mRNA expression in minimal change, membranous, and diabetic nephropathy demonstrated by non-isotopic in situ hybridisation.

Abstract: AIM: To investigate vascular endothelial growth factor (VEGF) mRNA expression in glomerular disease in the context of heavy proteinuria. METHODS: Non-radioisotopic in situ hybridisation was performed using a cocktail of 12 deoxyoligonucleotides complementary to VEGF mRNA labelled during solid phase synthesis with 2,4-dinitrophenyl. Archival renal biopsies were studied from cases of minimal change nephropathy, membranous nephropathy, diabetic nephropathy, and controls, matched for age, sex, race, and storage time. Hybrid detection used NBT/BCIP colorimetric development. RESULTS: More VEGF mRNA positive glomerular cells per unit cross sectional diameter were seen in minimal change nephropathy (mean (SEM), 19.35 (1.5)) compared with controls (12.6 (1.73)), p < 0.01. In contrast, fewer were seen in diabetic nephropathy (5.93 (0.97)) compared with controls (9.97 (1.25)), p < 0.03. Analysis of membranous nephropathy (10 (1.62)) showed no difference from controls (10.98 (1.51)), NS. In addition, in minimal change nephropathy there was a significant correlation between 24 hour protein excretion at the time of biopsy and the number of VEGF mRNA cells per glomerulus (r = 0.08, p = 0.01). CONCLUSIONS: Using non-radioisotopic in situ hybridisation, VEGF mRNA is almost exclusively expressed by visceral glomerular epithelial cells. Abnormal numbers of cells are seen in both minimal change and diabetic nephropathy. As VEGF exists in a number of functionally distinct isoforms, further study of qualitative VEGF isoform expression in diagnostic groups is indicated.

Malignant Transformation of Human Prostatic Epithelium Is Associated with the Loss of Androgen Receptor Immunoreactivity in the Surrounding Stroma

Abstract: The cellular pathways involved in the pathogenesis of hormone resistance remain unclear. Studies evaluating the role of changes in human androgen receptor (hAR) expression in the progression of prostatic tumors have been inconclusive. Androgenic influence over prostatic growth is mediated via the regulation of interactions between stromal and epithelial cells. We hypothesized that neoplastic transformation of the prostate would be associated with alterations in hAR expression in the adjacent stroma. Using immunohistochemical techniques, we determined hAR positivity in the epithelium and adjacent stroma of sections from 17 benign and 39 malignant prostatic glands. We found that whereas the expression of the receptor decreased in both cellular compartments as the tissues dedifferentiated, the depletion was more pronounced in the stromal nuclei (P<0.0001). However, in sections from both untreated and hormone-resistant prostate cancer tissues, although heterogeneity of hAR expression in malignant epithelia was increased, there appeared to be a unique field effect around the cancerous prostate glands that resulted in a decreased expression of the receptor in the adjacent benign glands and its total loss in the surrounding stroma. The loss of hAR in the stroma adjacent to malignant prostatic epithelium may play an important role in prostate cancer progression. Furthermore, the similarity of the lack of stromal hAR expression in newly diagnosed and hormone-resistant prostate cancer (P = 0.85) may be an indication that the mechanisms responsible for the acquisition of hormone independence are established early in the malignant transformation process.

A model for clinical governance in primary care groups

Abstract: Clinical governance is the core component of the new quality programme for the NHS (see box on next page) announced in the consultation document A First Class Service .1 It is described as “a framework through which NHS organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.” It will be the central focus for assuring the quality of care and addressing the issue of providing accountability through the Commission for Health Improvement.2 The activities of the commission will reflect national and local priorities as identified by the National Institute of Clinical Excellence and health improvement programmes respectively. Although A First Class Service included details about the structure and functioning of clinical governance in health service trusts, arrangements for primary care groups were not specified. In this paper, we suggest a possible model for clinical governance in primary care groups. Clinical governance is central to the NHS quality programme, but how it will operate in primary care groups remains unclear Although many activities included in the new concept of clinical governance are already being undertaken, these need to be coordinated A model of governance that addresses the core tasks of defining, accounting for, and improving quality and incorporates evidence on effective methods of changing performance is suggested This model can improve professional, practice, and primary care group performance It shows how groups can introduce and develop clinical governance and how health authorities and the Commission for Health Improvement can monitor progress The model is based on three underlying precepts:

Secretion of chemokines and cytokines by human tubular epithelial cells in response to proteins.

Abstract: Background. Chronic interstitial scarring contributes to the progression of renal failure in glomerular disease but its cause is unknown. The development of proteinuria could stimulate tubular cells to release cytokines, chemoattractants and matrix proteins into the interstitium, thus contributing to interstitial disease. Methods. Polarized human tubular epithelial cells were grown on permeable supports and exposed to serum proteins on their apical surface. The release of tumour necrosis factor α(TNFα), platelet derived growth factor (PDGF) and monocyte chemoattractant protein-1 (MCP-1) by the cells was measured using immunoassays. Results. Under control conditions there was polarized release of PDGF-AB with predominant basolateral secretion (basolateral to apical ratio 4.7±1.6). MCP-1 release was less polarized (ratio 1.7±0.5). TNFα was not detected. Exposure of the cells to normal human serum proteins on their apical side increased basolateral release of PDGF-AB (1.7±0.4 fold) and MCP-1 (2.4±0.2 fold). Fractionation of the serum showed that this effect on human tubular epithelial cells was reproduced by a fraction of molecular weight 40-100 kDa. The predominant proteins in this fraction were albumin and transferrin but these purified proteins alone did not alter secretion of PDGF-AB or MCP-1. Conclusion. This data demonstrates that human tubular cells exposed to proteins, which would be filtered in glomerular disease, produce inflammatory mediators with the potential to stimulate inflammation and scarring in the interstitium of the kidney.

The trefoil peptide TFF1 inhibits the growth of the human gastric adenocarcinoma cell line AGS.

Abstract: TFF1 is a 60-amino acid peptide produced in normal gastric mucosa which forms dimers spontaneously. Tumours of patients with gastric cancer usually have reduced TFF1 levels and disruption of the TFF1 gene causes animals to develop gastric adenomas and carcinomas. The effect of normal sequence human recombinant TFF1 and an analogue (Cys(58)-->Ser(58)), which is unable to dimerize, on the proliferation and morphology of the human gastric adenocarcinoma cell line AGS was therefore investigated. Proliferation, assessed by total cell number and [methyl-(3)H]thymidine incorporation, was reduced by dimeric TFF1 in a dose-dependent manner. Monomeric TFF1 also reduced proliferation but was less potent than the dimeric form. It is concluded that TFF1 may be an important controller of gastric cell proliferation, that dimerization of TFF1 is important in this effect, and that the reduced levels of TFF1 seen in gastric cancer may be of clinical relevance.

Social implications of childhood Crohn's disease.

Abstract: Background:Children with Crohn's disease may have an impaired quality of life.Methods:A validated questionnaire was mailed to the parents of all child members of Crohn's in Childhood Research Association (CICRA) (age range, 5-17 years). It investigated aspects of the quality of life of child

What do patients want from doctors? Content analysis of written patient agendas for the consultation.

Abstract: BACKGROUND: Although much has been written about what patients want when they contact their general practitioner (GP), there are no published data from large cohort studies of what patients expect. AIM: To describe the expectations of a large group of patients who consulted with their GPs. METHOD: A GP and a social sciences graduate carried out a content analysis of written agenda forms completed by 819 patients who consulted 46 randomly selected GPs. Inter- and intra-rater reliabilities were confirmed. RESULTS: A total of 756 (92%) agenda forms were returned. Inter-rater reliability was satisfactory (kappa > 0.6 for all but two main themes). Almost all patients had requests they wished to make of their doctor, 60% had their own ideas about what was wrong, and 38% had considered explanations about why they were unwell. Forty-two per cent and 24% of patients had consulted because they had reached the limit of their anxiety or tolerance respectively. Seven per cent, 4%, and 2% had comments, which were usually negative, to make about previous management, communication with doctors, or time in the consultation. CONCLUSION: These data demonstrate that most patients come to the consultation with a particular agenda. Failure to address this agenda is likely to adversely affect the outcome of many consultations.

Quality of care of patients with diabetes: collation of data from multi-practice audits of diabetes in primary care.

Abstract: BACKGROUND GPs are now playing a greater role in the care of patients with diabetes. The challenges described in the Saint Vincent Joint Task Force Report include achievement of a reduction in long-term complications by collecting key clinical information and systematically organizing care of patients with diabetes. The number of practices conducting audit and the number of primary care audit groups conducting multi-practice audits of diabetes have increased since the introduction of audit in 1991. OBJECTIVES We aimed to determine the feasibility of collating data from multi-practice audits of diabetes in primary care and to describe the pattern of care for diabetes patients in primary care. METHODS A confidential postal questionnaire was sent to all medical audit advisory groups that had completed a multi-practice audit of diabetic care. The main outcome measures studied were prevalence and treatment of known diabetes and annual compliance with key process measures. RESULTS Data could be collated for 17 of the 25 audit groups that supplied data representing information from 495 practices with 38 288 diabetic patients. Seven audit groups supplied data from a population denominator comprising 1475512 patients giving a prevalence of 1.46% (range 1.1-1.7%), 50.7% (range 32.5-69.0%) were managed by general practice only, 19.1% (7.6-39.7%) by hospital care only and 30.2% (11.0-49.5%) by shared care. Annual mean compliance for process measures showed wide variations: glycated haemoglobin or fructosamine checked for 72.5% (range 25.3-89.3%), fundi checked for 67.5% (57.8-86.6%), urine checked for 65.8% (27.5-80.0%), blood pressure checked for 87.6% (76.9-96.5%), smoking checked for 71.45 (21.9-86.0%), feet checked for 67.7% (40.0-90.8%) and BMI checked for 52.5% (26.4-68.2%). CONCLUSION This study shows the feasibility of collating audit data and the potential of this approach for describing patterns of care and highlighting general and local deficiencies. Information about levels of performance in large numbers of patients can be used to set standards or norms against which individual practitioners can compare their own activity. Comparison of the health needs of local populations with national data could be used to inform commissioning services. However, audits should employ uniform evidence-based criteria so as to facilitate collation and allow comparison.

The mucous neck cell in the human gastric corpus: a distinctive, functional cell lineage.

Abstract: There is considerable debate about whether the mucous neck cell (MNC) in the mucosa of the gastric corpus is merely a transit cell population, intermediate between gastric stem cells and the differentiated zymogenic (chief or peptic) cell lineages, or has distinct functions of its own. To cast light on these possibilities, the secretory phenotype of the MNC has been examined. Archival gastric body samples from non-ulcer dyspepsia biopsies and gastrectomies performed for peptic ulcer disease were stained with antibodies to the trefoil peptides TFF1/pS2 and TFF2/SP, pancreatic secretory trypsin inhibitor (PSTI), epidermal growth factor (EGF) and its receptor (EGFR), and to the MUC1 gene product--HMFG2. Human MNCs express PSTI, TFF1/pS2, TFF2/SP, and EGF proteins, while rat MNCs express TFF2/SP; the mucin contained in the MNCs is diastase/periodic acid Schiff (D/PAS)-positive and stains with human milk fat globulin (HMFG2). The canaliculi but not the cytoplasm of adjacent parietal cells were also decorated focally by D/PAS, by HMFG2, and by antibodies to TFF2/SP and TFF1/pS2. These findings favour the hypothesis that MNCs have a defined phenotype and are thus a separate and distinct cell lineage, secreting a number of luminally-active peptides which protect the gastric mucosa, and in particular the adjacent parietal cells, from the effects of secreted gastric acid. Moreover, a considerable degree of similarity in secretory profile is noted between MNCs and the so-called 'reparative lineages' in the gut--the ulcer-associated cell lineage (UACL) and hyperplastic polyp epithelium. If, on the other hand, the MNCs are indeed a transit population differentiating into zymogenic or peptic cells, then it is clear that having differentiated into one secretory phenotype producing a range of peptides, the MNC then proceeds to differentiate into a cell with a totally different secretory phenotype, a phenomenon unique in gastrointestinal cell lineage relationships.

The immediate impact of opening an adult high dependency unit on intensive care unit occupancy.

Abstract: We assessed the hourly occupancy of our intensive care and high dependency units over an 8-week period commencing on the day our high dependency unit opened. Using criteria established by the working group on ‘Guidelines on Admission to and Discharge from Intensive Care and High Dependency Units’ published by the National Health Service Executive, we defined each patient daily as intensive care or high dependency status. Compared with hourly occupancy figures obtained before the high dependency unit opened, occupancy of the intensive care unit by high dependency patients has been shown to decrease significantly from 21.6% to 11.2%. Use of intensive care beds became more appropriate, their occupancy increasing significantly from 63.7% to 73.4%. A significant decrease in readmissions occurred, supporting the hypothesis that having high dependency beds reduces the number of patients discharged prematurely to the wards.

Propofol or sevoflurane for laryngeal mask airway insertion.

Abstract: Purpose Sevoflurane is a volatile anesthetic agent, which combines rapid, smooth inhalational induction of anesthesia with rapid recovery, making it particularly suitable for day case anesthesia. The laryngeal mask airway is often also used in ambulatory anesthesia, with intravenous propofol being the agent of choice for its insertion. Our objective was to compare the conditions for laryngeal mask airway (LMA) insertion obtained by modified vital capacity breath sevoflurane inhalational induction of anesthesia with propofol intravenous induction.

Prevalence and management of urinary incontinence in stroke survivors.

Abstract: Urinary incontinence after stroke is common and is closely associated with a poor outcome and depression in both stroke survivor and carer. Despite the personal, economic and psycho-social costs, research into the management of urinary incontinence in stroke survivors is sparse. The purpose of this review is, therefore, to present current knowledge of the association between urinary incontinence and stroke and its management in order to promote research in this field. We have used the term ‘stroke survivor’ throughout to include any person who has had a stroke in the past and has come into contact with hospitals and specialist treatment, as well as those living in the community. The term ‘stroke patient’ is referred to only if that term was used in the original paper.

Questionnaires: the use and abuse of social survey methods in medical research

Abstract: We present a working review of survey methods based on market research technology. The structure of questionnaires, their distribution and analysis, are considered, together with techniques for increasing response rates.

A quantitative study comparing adjustment and acceptance of illness in adults on renal replacement therapy.

Abstract: Adjustment and acceptance of illness are major factors influencing quality of life in different modes of renal replacement therapy. A quantitative tool was used to compare adjustment and acceptance of illness in adult patients on maintenance dialysis to those with a functioning renal transplant. A questionnaire incorporating Felton's Acceptance of Illness Scale was sent to 273 patients receiving replacement therapy for end stage renal disease (ESRD) in Leicester, UK. The instrument examined the effects of a variety of clinical and social parameters on the Acceptance of Illness Scale Score (AISS). Patients with a functioning renal transplant had a significantly higher AISS than patients on hemodialysis (HD) or peritoneal dialysis (PD) (P < 0.0001). Patients in employment or full-time education had a higher AISS than other patients (P < 0.01). White/Caucasian ethnic origin had a higher AISS than Asian (P = 0.011). There were weak inverse correlations between age and AISS, and between AISS and perception of 'choice' in treatment modality. Health care professionals need to be aware of all variables that affect patient acceptance of illness in order to administer optimum clinical care.

A double blind, placebo controlled study of intracavernosal vasoactive intestinal polypeptide and phenotolamine mesylate in a novel auto-injector for the treatment of non-psychogenic erectile dysfunction

Abstract: Three hundred and four patients with non-psychogenic erectile dysfunction (ED) completed a dose assessment phase with intracavernosal injection utilizing 25 micrograms vasoactive intestinal polypeptide (VIP) combined with phentolamine mesylate 1.0 mg (VIP/P-1) or 2.0 mg (VIP/P-2) in an auto-injector for a response rate of 83.9%. In a sub-group of 183 patients who withdrew from one or more previous ED therapies, 82% responded with an erection suitable for intercourse. One hundred and ninety-five patients were subsequently treated in a placebo controlled phase. 75.1% responded to VIP/P-1, 12% to placebo (P < 0.001); 66.5% responded to VIP/P-2, 10.3% to placebo (P < 0.001), with the median duration of erection of 54 min. The principal adverse event was transient facial flushing in 2770 injections (33.9%). There was no pain post injection and two episodes of priapism (0.05%). Only nine patients withdrew because of adverse events. Over 85% and 95% of patients were satisfied with the drug and auto-injector, respectively. Over 81% of patients and 76% of partners reported an improved quality of life.