Barriers to uptake of services for coronary heart disease: qualitative study

OBJECTIVES

To identify factors within the South Yorkshire coalfields that influence use of health services by people with angina.

DESIGN

Qualitative study using semistructured individual and group interviews.

SETTING

General practice and community settings in Barnsley and Rotherham health authorities.

PARTICIPANTS

14 patients with stable angina and nine primary care staff had individual interviews plus five community groups and one group of general practitioners.

MAIN OUTCOME MEASURES

Barriers to accessing health services.

RESULTS

A complex web of factors was identified that prevented, delayed, or facilitated referral to secondary care. Delay, denial, and self management by patients meant that the full extent of symptoms often remained hidden from general practitioners, resulting in a delayed or missed referral. Barriers identified fell into six categories: structural, personal, social and cultural, past experience and expectations, diagnostic confusion, and knowledge and awareness.

CONCLUSIONS

Many of the factors influencing referral operate before general practitioners become involved. Community development could be one way of tackling inequalities and promoting sustainable change. Structural changes are needed to improve access and increase the acceptability of general practice services. Primary care staff should be educated to detect underreporting of symptoms and promote appropriate referral.

An unusual case of subdural haematoma presenting to the accident and emergency department

A case of subdural haematoma associated with an intracranial arachnoid cyst is reported. The pathogenesis, clinical presentation and treatment options of intracranial arachnoid cysts is discussed.

Transfer of radioactivity to fruit: significant radionuclides and speciation

One of the roles of the BIOMASS Theme 3 Fruit Working Group was to identify significant radionuclides to support its work programme. This paper provides a short review of radionuclide emissions to atmosphere together with comments on their relative dosimetric impacts to identify those radionuclides most relevant to the Fruit Working Group. Speciation of the identified radionuclides is also discussed to identify the most likely chemical forms to which fruits might be exposed. It is noted that no information currently exists on radionuclide speciation in regard to the uptake and retention of radionuclides in fruit crops.

Outbreak of meningococcal disease in Rotherham illustrates the value of coordination, communication, and collaboration in management

On New Year's Eve 1998, two teenagers from the same school in Rotherham died of serogroup C meningococcal septicaemia. A third linked case occurred three days later. Over eight days starting on New Year's Eve, a further five cases of meningococcal disease arose across Rotherham district, four of whom were severely ill with serogroup C meningococcal septicaemia. Intense media interest, high levels of public concern, and anxieties caused by several 'false alarm' cases added to the challenge faced by a small health district. This article describes the epidemiology of the incident and policy decisions made, but focuses on the operational aspects of outbreak management (coordination, communication, and collaboration), an area often neglected in outbreak reports.

Patients' information needs in intensive care and surgical wards

Meeting the information and psychosocial support needs of surgical patients who have been in intensive care can contribute significantly to their recovery. In this article, the author examines the nursing opportunities for meeting these needs and suggests how they can be addressed.

A Study of the Housing Needs of Disabled Applicants to the Nottingham City Council Housing Department and the Problems Faced by Local Housing Providers in Meeting These Needs

This study of the housing needs of disabled people and the problems faced by housing providers in Nottingham was carried out with a view to establishing a data base of adapted properties and disabled people. A small survey of 47 disabled people, with 22 respondents, reported problems when trying to find a new home. Less than a quarter of those who replied had been assessed prior to looking for a new home by an occupational therapist, while over half said that they would like help from an occupational therapist when choosing a new home. A survey of 42 housing providers found that, of the 26 respondents, over half had disabled people waiting for a property and a third had adapted properties that they were unable to let.

These findings supported local concern about housing problems for disabled people and led to the development of the Disabled People and Adapted Properties Register (DPAPR). This register holds a computerised list of disabled people looking for a new home and of the adapted properties in Nottingham, for sale or for rent.

Early discharge schemes for hysterectomy patients

This review looks at the needs of hysterectomy patients discharged early from hospital. The author explores the concept of early discharge schemes and evaluates whether they can be safe, cost effective and provide quality care. Reflection on these factors suggests that an early discharge scheme could be a way to provide choice, and fulfill expectations of quality, holistic care and cost effectiveness, while allowing the nurse to work as an expert practitioner.

Recognition of the Xenopus ribosomal core promoter by the transcription factor xUBF involves multiple HMG box domains and leads to an xUBF interdomain interaction

The interaction of the ribosomal transcription factor xUBF with the RNA polymerase I core promoter of Xenopus laevis has been studied both at the DNA and protein levels. It is shown that a single xUBF-DNA complex forms over the 40S initiation site (+1) and involves at least the DNA sequences between -20 and +60 bp. DNA sequences upstream of +10 and downstream of +18 are each sufficient to direct complex formation independently. HMG box 1 of xUBF independently recognizes the sequences -20 to -1 and +1 to +22 and the addition of the N-terminal dimerization domain to HMG box 1 stabilizes its interaction with these sequences approximately 10-fold. HMG boxes 2/3 interact with the DNA downstream of +22 and can independently position xUBF across the initiation site. The C-terminal segment of xUBF, HMG boxes 4, 5 or the acidic domain, directly or indirectly interact with HMG box 1, making the core promoter sequences between -11 and -15 hypersensitive to DNase. This interaction also requires the DNA sequences between +17 and +32, i.e. the HMG box 2/3 binding site. The data suggest extensive folding of the core promoter within the xUBF complex.

High resolution studies of the Xenopus laevis ribosomal gene promoter in vivo and in vitro

The first high resolution maps of the Xenopus laevis ribosomal promoter and its flanking regions (-179 to +14) have been created by assaying point mutants both in oocyte and in vitro. Within the promoter boundaries (-141(-145) to +3(+4)), domains analogous to the Core Promoter and "Upstream Control Element" (UCE) were clearly detected. The base pairs at -133, within the UCE, and -20, -10, -7, and +3, within the Core, were all shown to be especially important for promotion. Between the Core and UCE, two central promoter elements (CPEs) were also resolved. Surprisingly, these CPEs did not correspond to the highly conserved enhancer homology (approximately -70 to -110), but to CCCGGCC motifs immediately flanking it. Although xUBF was shown to be a limiting component for in vitro transcription, none of the point mutations was found to affect the interaction of this factor with the promoter.

The hospital trauma team: a model for trauma management

A triage system was established as the initiating mechanism for a trauma team response to assist the assessment and early management of patients presenting to an accident and emergency department. A checklist of triage criteria was used. During a 6-month period, 342 patients (29.7% of trauma admissions) satisfied the triage criteria, which should have resulted in an average of 1.9 trauma team calls per day. Staff compliance with the triage tool was 75.4%. The overtriage rate for the checklist criteria was 52.7%. The triage tool identified patients with severe injuries who were not initially considered sufficiently injured to justify initiation of the trauma team response. The sensitivity of the triage tool in identifying patients with serious injury was 95.0%. Comparison of the review with a similar review performed 12 months earlier demonstrated that staff compliance with initiating the trauma team response had improved. Using data from 564 patients from both series, logistic regression analysis of the power of the triage criteria to predict serious injury contributed to a revision of the triage criteria. This trauma triage tool and trauma team response constitute a valid approach to the early hospital management of trauma patients. This system may be more appropriate or achievable in many hospitals than the construction of dedicated trauma reception units or permanent surgical staffing of general Accident and Emergency departments.

Point mutation analysis of the Xenopus laevis RNA polymerase I core promoter

The core region of the Xenopus laevis pre-ribosomal RNA promoter was subjected to point mutation analysis. A total of 27 point mutants within a 78 base pair region from -64 to +14, (relative to the start of transcription at +1), were assayed by oocyte microinjection. The results locate the 3' boundary of the core promoter at +4 and the 5' boundary at between -33 and -39 and suggest that this region of the Xenopus promoter is generally similar in organisation to mammalian core promoters. In particular, the conserved guanidine nucleotides at -7 and -16 are clearly essential for promoter function. The data suggest that interactions between the transcription machinery and the promoter occur in four distinct regions around +2 to +4, -7, -17 to -20 and -28 to -33. This particular periodicity of functionally important nucleotides is consistent with a model in which all protein-DNA interactions take place from predominantly one side of the DNA helix.

The Xenopus laevis ribosomal gene terminator contains sequences that both enhance and repress ribosomal transcription

A DNA segment approximately 200 base pairs upstream of the Xenopus laevis ribosomal promoter acts both as an upstream promoter element that augments transcription and as a transcription terminator. It is, however, unclear to what extent these two activities are related. A segment of the X. laevis ribosomal DNA, containing the terminator and the upstream promoter element, was subjected to point mutation, and the effects of the resulting mutations were investigated by oocyte microinjection. Analysis of 26 point mutants revealed not only sequences that augment 40S transcription but also those that repress it. The sequences that augmented transcription lay within the T3 homology box and also near the site of 3'-end formation. These sequences also played a role in termination. The sequences that repressed transcription lay within the G+C-rich DNA flanking the T3 box. It can be concluded that termination is probably essential but may not be sufficient for the activity of the upstream promoter element.

Implementation of a trauma team

A team approach to the initial assessment, investigation and management of potentially seriously injured patients has been instituted. Team members are alerted through an emergency paging system which is activated when a patient fulfills one of a predetermined list of criteria relating to the injury incident, physiological status of the patients and anatomic injuries. Medical members of the team include surgical, intensive care, anaesthetic, and accident and emergency staff. The surgical representative acts as team co-ordinator. Aspects of the function of the trauma team system were assessed over 4 months during which time 721 injured patients were admitted, 240 patients satisfied the trauma team criteria, and the team was called 152 times. The observed 'false alarm' rate was 38% but the true false alarm rate would have been 46%. Injuries sustained by some patients, who satisfied the criteria but who were not evaluated by the team, were of sufficient severity to justify a greater compliance with the system than was observed at this early stage after its implementation. Although a false alarm rate of 46% is higher than desirable, the number of calls per day would still only average 2 in a hospital with a high trauma patient load. The checklist criteria were highly sensitive (97%) in identifying those patients who should have been evaluated by the trauma team. Although hospitals differ in workload and staffing, this trauma team model is recommended for more widespread use and for further evaluation and modification.

The management of injuries--a review of deaths in hospital

A prospective review was undertaken of the management of 111 consecutive patients who died in hospital after admission for treatment of injuries. A standard set of data relating to each patient was reviewed by each member of a trauma death audit committee and then by the whole committee. Autopsy reports were available on all patients. Conclusions were drawn concerning defective aspects of patient management and possible avoidance of each death. Injury severity was assessed using the Trauma Score (TS) and Injury Severity Score (ISS). The possibly avoidable death (PAD) rate was 17%. The most common defects in management were related to inadequate fluid resuscitation and delays in definitive management. The greatest contributions to the PAD rate were from inadequate fluid resuscitation, delays and inadequate perception of the severity of injuries or significance of clinical deterioration. Increasing age was related to a higher frequency of PAD. PAD rate in the presence of severe head injury was 8%, but was 63% in the absence of a severe head injury. It is concluded that review of all trauma deaths is an achievable, beneficial and essential part of a hospital-based integrated trauma service. TS and ISS are not sufficiently sensitive to justify their use in selecting deaths for review. Improved blood volume replacement, earlier and more direct management and supervision by senior specialist staff, and elimination of causes of delay in patient management should all decrease the death rate from injuries particularly in patients without severe head injury.