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1.  A trial of early discharge with homecare compared to conventional hospital care for patients undergoing coronary artery bypass grafting 
Heart  2004;90(11):1344-1345.
PMCID: PMC1768555  PMID: 15486143
early discharge; coronary artery bypass grafting; length of stay; costs; quality of life
2.  Isolation measures in the hospital management of methicillin resistant Staphylococcus aureus (MRSA): systematic review of the literature 
BMJ : British Medical Journal  2004;329(7465):533.
Objective To evaluate the evidence for the effectiveness of isolation measures in reducing the incidence of methicillin resistant Staphylococcus aureus (MRSA) colonisation and infection in hospital inpatients.
Design Systematic review of published articles.
Data sources Medline, Embase, CINAHL, Cochrane Library, System for Information on Grey Literature in Europe (SIGLE), and citation lists (1966-2000).
Review methods Articles reporting MRSA related outcomes and describing an isolation policy were selected. No quality restrictions were imposed on studies using isolation wards or nurse cohorting. Other studies were included if they were prospective or employed planned comparisons of retrospective data.
Results 46 studies were accepted; 18 used isolation wards, nine used nurse cohorting, and 19 used other isolation policies. Most were interrupted time series, with few planned formal prospective studies. All but one reported multiple interventions. Consideration of potential confounders, measures to prevent bias, and appropriate statistical analysis were mostly lacking. No conclusions could be drawn in a third of studies. Most others provided evidence consistent with a reduction of MRSA acquisition. Six long interrupted time series provided the strongest evidence. Four of these provided evidence that intensive control measures including patient isolation were effective in controlling MRSA. In two others, isolation wards failed to prevent endemic MRSA.
Conclusion Major methodological weaknesses and inadequate reporting in published research mean that many plausible alternative explanations for reductions in MRSA acquisition associated with interventions cannot be excluded. No well designed studies exist that allow the role of isolation measures alone to be assessed. None the less, there is evidence that concerted efforts that include isolation can reduce MRSA even in endemic settings. Current isolation measures recommended in national guidelines should continue to be applied until further research establishes otherwise.
PMCID: PMC516101  PMID: 15345626
3.  Virtual outreach: economic evaluation of joint teleconsultations for patients referred by their general practitioner for a specialist opinion 
BMJ : British Medical Journal  2003;327(7406):84.
Objectives To test the hypotheses that, compared with conventional outpatient consultations, joint teleconsultation (virtual outreach) would incur no increased costs to the NHS, reduce costs to patients, and reduce absences from work by patients and their carers.
Design Cost consequences study alongside randomised controlled trial.
Setting Two hospitals in London and Shrewsbury and 29 general practices in inner London and Wales.
Participants 3170 patients identified; 2094 eligible for inclusion and willing to participate. 1051 randomised to virtual outreach and 1043 to standard outpatient appointments.
Main outcome measures NHS costs, patient costs, health status (SF-12), time spent attending index consultation, patient satisfaction.
Results Overall six months costs were greater for the virtual outreach consultations (£724 per patient) than for conventional outpatient appointments (£625): difference in means £99 ($162; €138) (95% confidence interval £10 to £187, P=0.03). If the analysis is restricted to resource items deemed “attributable” to the index consultation, six month costs were still greater for virtual outreach: difference in means £108 (£73 to £142, P < 0.0001). In both analyses the index consultation accounted for the excess cost. Savings to patients in terms of costs and time occurred in both centres: difference in mean total patient cost £8 (£5 to £10, P < 0.0001). Loss of productive time was less in the virtual outreach group: difference in mean cost £11 (£10 to £12, P < 0.0001).
Conclusion The main hypothesis that virtual outreach would be cost neutral is rejected, but the hypotheses that costs to patients and losses in productivity would be lower are supported.
PMCID: PMC164917  PMID: 12855528
4.  Training and generalization of sexual abuse prevention skills for women with mental retardation. 
Previous research has shown that behavioral skills training to teach sexual abuse prevention skills to women with mental retardation results in skill acquisition but poor generalization. In this investigation we evaluated procedures for enhancing generalization following training. Five women with mental retardation received 10 behavioral skills training sessions followed by in situ training when the skills did not fully generalize. Behavioral skills training resulted in skill acquisition and in situ training produced generalized responding during naturalistic assessments.
PMCID: PMC1284200  PMID: 10513032
5.  Evaluation of a sexual abuse prevention program for adults with mental retardation. 
Programs to teach sexual abuse prevention skills to persons with mental retardation have rarely been evaluated empirically, and typical evaluations are limited to assessment of the participants' knowledge rather than their performance of specific skills. In the present study, 6 adult women with mental retardation were trained in sexual abuse prevention, and performance was assessed using four separate measures: pretests and posttests of knowledge, verbal report, role play, and naturalistic probes. All women learned the skills but failed to exhibit them to criterion during the probes. We discuss the implications for further training and assessment of sexual abuse prevention skills.
PMCID: PMC1284101  PMID: 9532753
8.  The site of disruption of the bronchial epithelium in asthmatic and non-asthmatic subjects. 
Thorax  1992;47(7):499-503.
BACKGROUND: Attention has recently been focused on the basal cells of the tracheobronchial epithelium as the mechanism of anchorage of the tall columnar cells, which themselves do not appear to form hemidesmosomes with the basement membrane of the epithelium. Residual basal cells have been described as remaining attached to the basement membrane after epithelial denudation. This led this group to formulate the hypothesis that there may be a potential plane of cleavage between the basal cells and the overlying columnar cell layer within the bronchial epithelium, which becomes disrupted in asthma. METHODS: Bronchoalveolar lavage samples were obtained during bronchoscopy from eight patients with atopic asthma and four normal controls. Ultrathin sections of lavage cell pellets were examined by electron microscopy and the number of columnar and basal cells found in each epithelial cell cluster was counted. Cytocentrifuge preparations of the lavage samples from the same subjects were also examined for free epithelial cells and epithelial cell clusters. RESULTS: Electron microscopic examination of the cell pellets showed that basal cells were present in very small numbers in the epithelial clusters in all subjects (mean 0.03 (SE 0.02)/cluster) and the ratio of columnar cells to basal cells was far greater than was encountered in the intact bronchial epithelium (167 nu 4). The cytocentrifuge preparations showed an increased number of epithelial cell clusters and epithelial cells in the asthmatic patients. Although these clusters were similar in size in the two groups of subjects (6.3 nu 5.1 cells/cluster) the ratio of free epithelial cells to cells within the cluster was higher in the non-asthmatic subjects. CONCLUSIONS: It is proposed that shedding of epithelial cells occurs along a suprabasal plane and that there is a potential plane of cleavage between the suprabasal and the basal cell layers, which might be more vulnerable to the various insults.
PMCID: PMC463857  PMID: 1412091
9.  Prevention of renal scarring from pyelonephritis in nonhuman primates by vaccination with a synthetic Escherichia coli serotype O8 oligosaccharide-protein conjugate. 
Infection and Immunity  1993;61(12):5214-5218.
Rhesus monkeys were vaccinated with a synthetic Escherichia coli serotype O8 oligosaccharide-protein conjugate. Using our experimental pyelonephritis monkey model, we tested whether such immunization was protective against the renal damage from inflammation following experimental infection with a P-fimbriated O-antigenically homologous E. coli strain. The vaccination did not significantly alter the duration of bacteriuria or interfere with the infection. However, the vaccine was efficient in renal protection, as vaccinated animals showed significantly less intratubular infiltration of neutrophils (P < 0.02) and the degree of renal scarring was also significantly less in these animals (P > 0.005) than in the control animals. Total kidney involvement in the vaccinated animals was 16.9%, compared with 32.5% in the control animals (P = 0.07).
PMCID: PMC281303  PMID: 8225595
10.  Cost analysis of early discharge after hip fracture. 
BMJ : British Medical Journal  1993;307(6909):903-906.
OBJECTIVE--To ascertain the economic impact of an early discharge scheme for hip fracture patients. DESIGN--Population based study comparing costs of care for patients who had "hospital at home" as an option for rehabilitation and those who had no early discharge service available in their area of residence. SETTING--District hospital orthopaedic and rehabilitation wards and community hospital at home scheme. PATIENTS--1104 consecutively admitted patients with fractured neck of femur. 24 patients from outside the district were excluded. MAIN OUTCOME MEASURES--Cost per patient episode and number of bed days spent in hospital. RESULTS--Patients with the hospital at home option spent significantly less time as inpatients (mean of 32.5 v 41.7 days; p < 0.001). Those patients who were discharged early spent a mean of 11.5 days under hospital at home care. The total direct cost to the health service was significantly less for those patients with access to early discharge than those with no early discharge option (4884 pounds v 5606 pounds; p = 0.048). CONCLUSIONS--About 40% of patients with fractured neck of femur are suitable for early discharge to a scheme such as hospital at home. The availability of such a scheme leads to lower direct costs of rehabilitative care despite higher readmission costs. These savings accrue largely from shorter stays in orthopaedic and geriatric wards.
PMCID: PMC1679043  PMID: 8241853
11.  Protective anti-idiotype antibodies in the primate model of pyelonephritis. 
Infection and Immunity  1993;61(6):2289-2295.
The adherence of P-fimbriated Escherichia coli to a receptor containing alpha-D-Gal-(1-4)-beta-D-Gal (Gal-Gal) on urothelial cells is an important pathogenic mechanism in the development of pyelonephritis. Antibodies (Ab1) that had been produced by immunization with Gal-Gal conjugated with bovine serum albumin were specifically purified and used to stimulate the production of anti-idiotypic antibodies (Ab2) in cynomolgus monkeys (Macaca fascicularis). While sera from all of the Ab2-producing monkeys contained antibodies reactive with Ab1 and P-fimbriae, not all of the sera inhibited P-fimbrial binding to the Gal-Gal receptor. On the basis of the inhibition of binding, Ab2-producing monkeys were divided into two groups, termed reactive and nonreactive. The reactive and nonreactive Ab2-producing monkeys, together with a group of control monkeys, were challenged with a renal inoculation with P-fimbriated Escherichia coli. Hematologic, immunologic, microbiologic, and pathologic data were compared among the three groups. The reactive monkeys, whose Ab2 in serum inhibited binding between P-fimbriae and the Gal-Gal receptor, were protected against renal damage compared with the control group. The nonreactive group shared some parameters with the reactive group but overall developed renal damage comparable to that of the controls.
PMCID: PMC280847  PMID: 8099064
12.  Effect of hyperthyroidism on bronchial reactivity in non-asthmatic patients. 
Thorax  1989;44(7):603-604.
Thyrotoxicosis may be associated with deterioration in asthma. To determine whether bronchial reactivity to histamine is increased in hyperthyroidism 10 thyrotoxic non-asthmatic patients were assessed before and after treatment of their thyrotoxicosis. No significant change in bronchial reactivity was found after treatment.
PMCID: PMC461977  PMID: 2772862
13.  Attenuation of antibody response to acute pyelonephritis by treatment with antibiotics. 
Antimicrobial Agents and Chemotherapy  1991;35(11):2340-2344.
While acute pyelonephritis is known to elicit an antibody response, it is also known that a patient who has had pyelonephritis once is susceptible to recurrent renal infection. Using our experimental model of pyelonephritis in the monkey, we tested whether antibiotic therapy of the acute disease would affect the antibody response. We found that it did, because antibiotic therapy beginning 72 h after bacterial inoculation attenuated the antibody response so that rechallenge 3 months later produced acute pyelonephritis and prolonged bacteriuria. The animals with untreated infection had an antibody response that lasted a sufficient period of time to prevent acute pyelonephritis after renal challenge. We have confirmed that antibody titers against P fimbriae are protective, and to a degree, this protective effect may be abrogated by antibiotic therapy.
PMCID: PMC245382  PMID: 1804007
15.  Virus infections and sports performance--a prospective study. 
There are numerous anecdotal reports relating infection to deterioration in sporting performance. Unexplained failures by top sportsmen are often attributed to recent or current infections. We have carried out a prospective investigation to determine the effect of viral infections on the performance of a group of 68 elite track and field athletes. Athletes were monitored for evidence of viral infection during winter training and their form was assessed subjectively and also semi-objectively by analogue scale questionnaires. Static elevated titres of neutralising antibody to Coxsackie B 1-5 were present in 54% of the athletes and 79% had serological evidence of past viral infection. The raised titres did not relate to poor performance. There was no evidence that loss of form was related to subclinical infection. Elevated antibody levels to Coxsackie B and other common viruses should be interpreted with great caution when assessing athletes complaining of poor performance.
PMCID: PMC1478736  PMID: 2852528
16.  Maternal immunization with P fimbriae for the prevention of neonatal pyelonephritis. 
Infection and Immunity  1988;56(1):1-6.
Rhesus monkeys (Macaca mulatta) were immunized with purified P fimbriae from Escherichia coli during the last trimester of pregnancy. Infants born of these mothers were compared with those from nonimmunized rhesus mothers. A delay in the onset of renal disease after bladder infection showed protection from passive immunization. This was associated with a high antibody titer in serum. In addition to delayed onset of renal infection, a decreased number of immunized monkeys developed pyelonephritis.
PMCID: PMC259223  PMID: 2891616
17.  Converting a teaching hospital medical clinic to a group practice: patients vote with their feet. 
Public Health Reports  1986;101(1):76-82.
Traditional general medical clinics (GMCs) have been criticized as providing less than optimal primary care while losing money for the sponsoring teaching hospital. In addition, the GMC has become less attractive as a site for training house staff. In response, a number of teaching hospitals have sponsored the development of a primary care group practice as a more efficient alternative to the GMC. Under the new model, certain measures of patient care frequently improve, house staff receive better training, and the hospital may be able to trim financial losses. While the literature contains numerous descriptions of such conversions, very little information is available about the compliance of patients who are transferred to the new model with relatively little preparation or choice. Institutions that convert their GMCs may do so to attract new clientele. But they have a responsibility to their long-time patients and certainly should address the question of whom they expect to transfer successfully and what the dropout rate will be. New York City's Mount Sinai Hospital completed conversion of its GMC to a primary care group practice in 1983. A sampling of patients taken before the conversion, then followed up 6 months latter, revealed that 82 percent of the former GMC patients were successfully referred to the new model. Patients given specific appointments rather than instructions to call for their own appointment had a better "show" rate. Noncompliers were more likely to be female, Medicaid-covered, 46-65 years old, and living outside the hospital's immediate service area.(ABSTRACT TRUNCATED AT 250 WORDS)
PMCID: PMC1477654  PMID: 3080795
18.  Effect of verapamil and sodium cromoglycate on leukotriene D4 induced bronchoconstriction in patients with asthma. 
Thorax  1986;41(10):753-758.
Leukotriene D4 (LTD4) may be an important mediator in asthma. The effect of verapamil and sodium cromoglycate on LTD4 induced bronchoconstriction has been examined in seven patients with asthma. The bronchoconstrictor response to increasing concentrations of inhaled LTD4 (0.0032-50 micrograms/ml) was assessed by measuring changes in FEV1, specific airways conductance, and flow rate at 30% of vital capacity (V30(p)). Results were expressed as the provocation concentration (PC) producing a 10% fall in FEV1 (PC10FEV1), a 35% fall in specific airways conductance (PC35SGaw), and a 30% fall in flow at 30% of vital capacity (PC30 V30(p)). Neither verapamil nor cromoglycate inhibited LTD4 induced bronchoconstriction in asthmatic subjects. These results suggest that in asthmatic patients LTD4 induced bronchoconstriction is not mediated via verapamil or cromoglycate sensitive mechanisms.
PMCID: PMC460470  PMID: 3097863
19.  In vitro and in vivo effect of verapamil on human airway responsiveness to leukotriene D4. 
Thorax  1986;41(1):12-16.
The mechanism by which leukotriene D4 (LTD4) induces airway narrowing in man is unclear. We have investigated this by examining the effect of the calcium channel blocker verapamil on the sensitivity of in vitro preparations of human bronchi to LTD4 and methacholine, and on the bronchoconstriction induced in normal subjects by these agonists in vivo. In vitro smooth muscle sensitivity was assessed by the concentration of LTD4 and methacholine causing a 50% of maximum contraction (EC50) and as the maximum tension generated. Verapamil did not alter baseline tension or the response to LTD4 but did inhibit contractile responses to methacholine. In vivo studies were performed in six normal subjects; they inhaled increasing concentrations of LTD4 (0.4-50 micrograms/ml) or methacholine (2-64 mg/ml). Airway responsiveness in vivo was expressed as the provocation concentration (PC) of agonist producing a 35% fall in specific airways conductance (PC35sGaw) and a 30% fall in flow at 30% of vital capacity (PC30 V30(p)). Verapamil did not alter baseline sGaw or V30(p). One subject did not respond to LTD4 on either day. In contrast to the in vitro results, verapamil produced a greater than 10 fold reduction in LTD4 induced bronchoconstriction, but had no effect on methacholine induced bronchoconstriction. These results suggest that in normal subjects bronchoconstriction induced by inhaled LTD4 is due to a combination of direct and indirect mechanisms.
PMCID: PMC460245  PMID: 3518128
20.  Airway responsiveness to histamine in man: effect of atropine on in vivo and in vitro comparison. 
Thorax  1985;40(4):261-267.
Airway responsiveness to histamine in man may be determined by the smooth muscle sensitivity to histamine or to the interaction between vagal nerve input and smooth muscle sensitivity. We have compared in vivo responsiveness to histamine with in vitro smooth muscle sensitivity to histamine in 20 non-asthmatic patients and one asthmatic patient undergoing thoracic surgery. Histamine responsiveness was assessed in the first 10 non-asthmatics without atropine pretreatment, in the second 10 after atropine pretreatment, and in the asthmatic patient both with and without atropine. In vivo responsiveness was also measured in 10 normal subjects and 10 asthmatic patients not undergoing surgery. Results were expressed as the provocation concentration (PC) causing a decrease in FEV1 of 20% (PC20FEV1) and in specific airways conductance of 35% (PC35SGaw), and in terms of maximal expiratory flow at 35% vital capacity, measured from the partial (V35(P] and complete (V35(C] flow volume curves of 35% (PC35V35(P); PC35V35(C]. In vitro smooth muscle sensitivity to histamine of bronchial tissue obtained at thoracotomy was expressed as the concentration causing a 50% maximum contraction (EC50) and as the maximum tension generated. There was considerable variation between patients in the in vivo responsiveness but a relatively narrow range for in vitro responses. There was no significant correlation between in vivo responsiveness, either with or without atropine pretreatment, and in vitro results. The asthmatic patient showed hyperresponsiveness in vivo but but not in vitro. These results suggest that in vitro airway smooth muscle sensitivity to histamine is not the sole determinant of in vivo airway responsiveness and that this lack of relationship is not explained by the influence of vagal nerve input on in vivo measurements. The results in the asthmatic patient suggest that airway hyperresponsiveness may be an in vivo phenomenon which is not related to a primary abnormality of airway smooth muscle.
PMCID: PMC460043  PMID: 4023976
23.  Comparison of in vivo airway responsiveness and in vitro smooth muscle sensitivity to methacholine in man. 
Thorax  1984;39(11):837-843.
Airway responsiveness to methacholine varies between normal people and is increased in patients with asthma. The importance of airway smooth muscle sensitivity in determining in vivo responsiveness is unknown. We have examined this question by comparing in vivo airway responsiveness with in vitro airway smooth muscle sensitivity to methacholine in 10 patients undergoing thoracic surgery. In vivo responsiveness was determined by administration of inhalations of doubling concentrations of methacholine. Results were expressed as the provocation concentration (PC) causing a decrease in forced expiratory volume in one second of 20% (PC20FEV1), specific airway conductance of 35% (PC35SGaw), and maximal expiratory flow at 35% vital capacity, measured for the partial (V35(p)) and complete (V35(c)) flow volume curves, of 35% (PC35V35(p); PC35V35(c)). In vitro airway smooth muscle sensitivity was determined from specimens obtained at thoracotomy. Log dose-response curves to methacholine were constructed and the concentration causing a 50% maximum contraction (EC50) was derived. There were differences between patients for both in vivo airway responsiveness and in vitro smooth muscle sensitivity to methacholine. There were no significant relationships between the in vivo and in vitro measurements. The results suggest that factors other than solely the sensitivity of smooth muscle must determine in vivo airway responsiveness to methacholine.
PMCID: PMC459934  PMID: 6390773
25.  A family study of isolated cleft palate. 
Journal of Medical Genetics  1982;19(5):329-331.
A family study was based on 245 boy and 329 girl patients treated surgically for non-syndromic cleft palate between 1920 and 1929; 86 and 81 respectively were traced and had had children. These 167 were the probands for the family study and were interviewed in their homes. None was born to a consanguineous marriage. Altogether they had had 384 children of whom 11 had cleft palate (2.9 +/- 0.9%). They had 398 sibs of whom five had cleft palate, 117 grandchildren of whom one was affected, and 517 nephews and nieces of whom one was affected. This is the largest series yet available on which to base an estimate of the risks to children of patients with non-syndromic cleft palate. The risk is probably increased where a parent or sib of the proband is affected and increased to a lesser degree where a second or third degree relative is affected. The family patterns in these and other studies suggest that the aetiology of cleft palate is heterogeneous, with some families showing modified dominant inheritance. This is in contrast to cleft lip (+/- cleft palate) where the data are consistent with a multifactorial threshold model.
PMCID: PMC1048915  PMID: 7143384

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