Effect of very early intravenous streptokinase infusion in patients with evolving myocardial infarction

The effect of very early infusion of 1.5 X 10(6) U of streptokinase intravenously was studied in 29 patients with nitroglycerin-resistant chest pain and ST-segment elevation. Infarct size was estimated from maximal LD1 isoenzyme levels, and the diagnosis confirmed by CK-MB determination. Thrombolytic therapy was started within 1 hour of pain onset in 11 patients (group A), between 1 and 2 hours in 10 (group B), and later than 2 hours in eight patients (group C). Marked differences appeared between the groups. Thus, three patients in group A and one patient in group B did not develop infarction, all had critical LAD stenoses. Three patients in group C died in shock without bleeding. Further, the average maximal LD1 values in the 22 patients who survived their infarction differed significantly between the groups, and were 12.6, 19.1 and 36.2 mu kat/l in groups A, B and C, respectively. In conclusion, very early intravenous streptokinase infusion probably reduces myocardial necrosis, and possible prevents infarction in some patients.

Antihypertensive, haemodynamic and metabolic effects of nifedipine slow-release tablets in elderly patients

In a double-blind, cross-over study for 8 weeks, including 10 non-hospitalized elderly hypertensives (average age 73.2 years), WHO stage I-II, the antihypertensive effect of nifedipine slow-release tablets, 20 mg twice daily, was compared with placebo. Nifedipine reduced supine and standing blood pressure values significantly, and no signs of orthostatic hypotension were noted. An initial increment in heart rate was found after 1 week with a subsequent fall towards control values after 8 weeks of nifedipine administration. Heart rate pressure product in the supine position was reduced, and this reduction became statistically significant at the 8th week. Cardiac output measured non-invasively in 8 patients after 6-8 weeks' nifedipine therapy, using an Irex echocardiograph, was on an average 34% higher than in the placebo period (p less than 0.05). Serum electrolytes, cholesterol, HDL cholesterol, blood glucose and renal function were not affected by the drug. Side-effects were few and mild. It is concluded that nifedipine is a potent antihypertensive agent which may represent an attractive first choice alternative in the treatment of elderly hypertensive patients.

Determination of the EC50 of levobupivacaine for femoral and sciatic perineural infusion after total knee arthroplasty

BACKGROUND

Infusion of local anaesthetic through femoral and sciatic catheters is an accepted method of providing pain relief after knee arthroplasty. However, the minimum effective concentration of perineural local anaesthetics is not known.

METHODS

Twenty-four patients received femoral and sciatic perineural infusions of levobupivacaine in order to prevent pain relief after total knee arthroplasty. The primary endpoint of the study was patient request for analgesic rescue for anterior or posterior knee pain within the first 36 h of perineural infusion. Treatment was determined by the method of sequential allocation, with a dosing interval of 0.002% w/v.

RESULTS

Thirteen patients did not require rescue analgesia for anterior knee pain and 16 patients did not require rescue analgesia for posterior knee pain. Median duration of failed blocks until rescue analgesia was 25 h (24-27 h) for the femoral block and 27 h (24-29 h) for the sciatic block. The minimum concentration at which patients did not require rescue analgesia was 0.024% for the femoral nerve and 0.014% for the sciatic nerve. Comparison of EC(50) showed that local anaesthetic requirements were significantly (P=0.03) higher by a factor of 1.25 (95% CI 1.03-1.55) for the femoral compared with the sciatic nerve.

CONCLUSIONS

The EC(50) for femoral perineural infusion is greater than the EC(50) for sciatic perineural infusion.

Signaling individual identity versus quality: a model and case studies with ruffs, queleas, and house finches

We develop an evolutionary model that predicts that characters selected to signal individual identity will have properties differing from those expected for indicator signals of quality. Traits signaling identity should be highly variable, often display polymodal distributions, not be condition dependent (i.e., be cheap to produce and/or maintain), not be associated with fitness differences, exhibit independent assortment of component characters, and often occur as fixed phenotypes with a high degree of genetic determination. We illustrate the existence of traits with precisely these attributes in the ornamental, conspicuously variable, and sexually dimorphic breeding plumages of ruff sandpipers Philomachus pugnax and red-billed queleas Quelea quelea. Although ruffs lek and queleas are monogamous, both species breed in high-density aggregations with high rates of social interactions (e.g., aggression and territory defense). Under these socioecological conditions, individual recognition based on visual cues may be unusually important. In contrast to these species, we also review plumage characteristics in house finches Carpodacus mexicanus, a nonterritorial, dispersed-breeding species in which plumage ornamentation is thought to signal quality. In keeping with expectations for quality signals, house finch plumage is relatively less variable, unimodally distributed, condition dependent, correlated with fitness measures, has positively correlated component characters, and is a plastic, environmentally determined trait. We briefly discuss signals of identity in other animals.

Effects of the Diabetes Manual 1:1 structured education in primary care

AIMS

To determine the effects of the Diabetes Manual on glycaemic control, diabetes-related distress and confidence to self-care of patients with Type 2 diabetes.

METHODS

A cluster randomized, controlled trial of an intervention group vs. a 6-month delayed-intervention control group with a nested qualitative study. Participants were 48 urban general practices in the West Midlands, UK, with high population deprivation levels and 245 adults with Type 2 diabetes with a mean age of 62 years recruited pre-randomization. The Diabetes Manual is 1:1 structured education designed for delivery by practice nurses. Measured outcomes were HbA(1c), cardiovascular risk factors, diabetes-related distress measured by the Problem Areas in Diabetes Scale and confidence to self-care measured by the Diabetes Management Self-Efficacy Scale. Outcomes were assessed at baseline and 26 weeks.

RESULTS

There was no significant difference in HbA(1c) between the intervention group and the control group [difference -0.08%, 95% confidence interval (CI) -0.28, 0.11]. Diabetes-related distress scores were lower in the intervention group compared with the control group (difference -4.5, 95% CI -8.1, -1.0). Confidence to self-care Scores were 11.2 points higher (95% CI 4.4, 18.0) in the intervention group compared with the control group. The patient response rate was 18.5%.

CONCLUSIONS

In this population, the Diabetes Manual achieved a small improvement in patient diabetes-related distress and confidence to self-care over 26 weeks, without a change in glycaemic control. Further study is needed to optimize the intervention and characterize those for whom it is more clinically and psychologically effective to support its use in primary care.

Development and validation of the Diabetes Obstacles Questionnaire (DOQ) to assess obstacles in living with Type 2 diabetes

AIMS

To develop and validate an easy-to-use questionnaire to identify obstacles to self management in Type 2 diabetes.

METHODS

The Diabetes Obstacles Questionnaire (DOQ) was developed from earlier research and the literature. It was completed by 180 people with Type 2 diabetes, recruited from 22 general practices in the UK. Responders also completed a quality-of-life questionnaire (ADDQoL) and the Problem Areas in Diabetes (PAID) scale.

RESULTS

From analysis of the 176 usable questionnaires, 36 items of the original 113 items were deemed redundant. The remaining 77 items were assembled into eight sub-scales covering Medication, Self Monitoring, Knowledge and Beliefs, Diagnosis, Relationships with Health-Care Professionals, Lifestyle Changes, Coping, and Advice and Support. Each sub-scale had a factor structure of no more than three factors, had Cronbach's alpha of more than 0.75, and a Kaiser-Meyer-Olkin of more than 0.75. Each sub-scale correlated significantly with the PAID scale (P < 0.01), demonstrating criterion validity. Construct validity was shown by significant correlation between HbA(1c) and the sub-scales which relate to managing blood glucose levels: Self Monitoring, Relationship with Health-Care Professionals, Lifestyle Changes and Coping. Construct validity was further shown by significant correlation between QoL scores and Medication, Lifestyle Changes and Coping.

DISCUSSION

The DOQ, comprising eight sub-scales, is a usable, valid instrument for both clinical and research settings. It helps to identify in detail the obstacles which an individual finds in living with Type 2 diabetes.

Advances in molecular classification of renal neoplasms

Kidney neoplasms are classified by light microscopy using the World Health Organization (WHO) system. The WHO system defines histopathologic tumor subtypes with distinct clinical behavior and underlying genetic mutations. In adults, the common malignant subtypes are variants of renal cell carcinoma (RCC). Histopathologic classification is critical for clinical management of RCC, but is becoming more complex with recognition of novel tumor subtypes, development of procedures yielding small diagnostic biopsies, and emergence of molecular therapies directed at tumor gene activity. Therefore, classification systems based on gene expression are likely to become essential for diagnosis, prognosis and treatment of kidney tumors. Recent DNA microarray studies have shown that clinically relevant renal tumor subtypes are characterized by distinct gene expression profiles, which are useful for discovery of novel diagnostic and prognostic biomarkers. In this review, we summarize the WHO classification system for renal tumors, general applications of microarray technology in cancer research, and specific microarray studies that have advanced knowledge of renal tumor diagnosis, prognosis, therapy and pathobiology.

The effectiveness of treatment for depression/depressive symptoms in adults with cancer: a systematic review

Depression is common in cancer patients, and this often remains undetected and untreated. Depression has been associated with poorer quality of life, in addition to increased impairment of immune response and poorer survival in cancer patients. Previous systematic reviews and meta-analyses of the efficacy of interventions for cancer patients with depression have failed to distinguish between caseness for depression and depressive symptoms. The findings from this systematic review show that there is limited trial data on the efficacy of prescribed antidepressants in reducing the incidence of major depression and depressive symptoms in cancer patients. Contrary to previous reviews that failed to distinguish between depressive symptoms and depression, this review found very little data from clinical trials (without the possibility of confounding factors) to demonstrate that psychotherapeutic interventions are effective in reducing depression in cancer patients. A number of small-scale, single-centre trials indicated that psychotherapeutic interventions (especially cognitive behavioural therapy) can have effects on depressive symptoms in cancer patients. However, given the methodological limitations of studies to date, lack of evidence should not be interpreted as implying lack of efficacy. In conclusion, there is a need for adequately powered studies of pharmacological and psychotherapeutic studies, which are targeted at cancer patients with a diagnosis of depression and include monitoring of the use of other pharmacological/psychotherapeutic and complementary and alternative medicine interventions.

Gaps between policy, protocols and practice: a qualitative study of the views and practice of emergency ambulance staff concerning the care of patients with non-urgent needs

AIM

To describe emergency ambulance crews' views about (1) how they make decisions on whether to convey patients to hospital; (2) an intervention enabling them to triage patients to non-conveyance; and (3) their experience of using new protocols for undertaking such triage.

METHODS

Two focus groups were held at the outset of an evaluation of Treat and Refer (T&R) protocols: one with staff based at an ambulance station who were to implement the new service (intervention station), and the other with staff from a neighbouring station who would be continuing their normal practice during the study (control station). A third session was held with staff from the intervention station following training and 3 months' experience of protocol usage.

RESULTS

Before the introduction of the T&R protocols, crews reported experience, intuition, training, time of call during shift, patient preference, and home situation as influencing their decisions concerning conveyance. Crews were positive about changing practice but foresaw difficulties with advising patients who wanted to go to hospital, and with referral to other agencies. Following experience of T&R protocol use, crews felt they had needed more training than had been provided. Some felt their practice and job satisfaction had improved. Problems with referral and with persuading some patients that they did not need to go to hospital were discussed. There was consensus that the initiative should be introduced across the service.

CONCLUSIONS

With crews generally positive about this intervention, an opportunity to tackle this difficult area of emergency care now exists. This study has, however, highlighted the complexity of the change in practice and service delivery, and professional and organisational constraints that need to be considered.

Towards primary care for non-serious 999 callers: results of a controlled study of "Treat and Refer" protocols for ambulance crews

OBJECTIVE

To develop and evaluate "Treat and Refer" protocols for ambulance crews, allowing them to leave patients at the scene with onward referral or self-care advice as appropriate.

METHODS

Crew members from one ambulance station were trained to use the treatment protocols. Processes and outcomes of care for patients attended by trained crews were compared with similar patients attended by crews from a neighbouring station. Pre-hospital records were collected for all patients. Records of any emergency department and primary care contacts during the 14 days following the call were collected for non-conveyed patients who were also followed up by postal questionnaire.

RESULTS

Twenty three protocols were developed which were expected to cover over 75% of patients left at the scene by the attending crew. There were 251 patients in the intervention arm and 537 in the control arm. The two groups were similar in terms of age, sex and condition category but intervention cases were more likely to have been attended during daytime hours than at night. There was no difference in the proportion of patients left at the scene in the intervention and control arms; the median job cycle time was longer for intervention group patients. Protocols were reported as having been used in 101 patients (40.2%) in the intervention group; 17 of the protocols were recorded as having been used at least once during the study. Clinical documentation was generally higher in the intervention group, although a similar proportion of patients in both groups had no clinical assessments recorded. 288 patients were left at the scene (93 in the intervention group, 195 in the control group). After excluding those who refused to travel, there were three non-conveyed patients in each group who were admitted to hospital within 14 days of the call who were judged to have been left at home inappropriately. A higher proportion of patients in the intervention arm reported satisfaction with the service and advice provided.

CONCLUSIONS

"Treat and Refer" protocols did not increase the number of patients left at home but were used by crews and were acceptable to patients. The protocols increased job cycle time and some safety issues were identified. Their introduction is complex, and the extent to which the content of the protocols, decision support and training can be refined needs further study.

Towards primary care for non-serious 999 callers: results of a controlled study of "Treat and Refer" protocols for ambulance crews

OBJECTIVE

To develop and evaluate "Treat and Refer" protocols for ambulance crews, allowing them to leave patients at the scene with onward referral or self-care advice as appropriate.

METHODS

Crew members from one ambulance station were trained to use the treatment protocols. Processes and outcomes of care for patients attended by trained crews were compared with similar patients attended by crews from a neighbouring station. Pre-hospital records were collected for all patients. Records of any emergency department and primary care contacts during the 14 days following the call were collected for non-conveyed patients who were also followed up by postal questionnaire.

RESULTS

Twenty three protocols were developed which were expected to cover over 75% of patients left at the scene by the attending crew. There were 251 patients in the intervention arm and 537 in the control arm. The two groups were similar in terms of age, sex and condition category but intervention cases were more likely to have been attended during daytime hours than at night. There was no difference in the proportion of patients left at the scene in the intervention and control arms; the median job cycle time was longer for intervention group patients. Protocols were reported as having been used in 101 patients (40.2%) in the intervention group; 17 of the protocols were recorded as having been used at least once during the study. Clinical documentation was generally higher in the intervention group, although a similar proportion of patients in both groups had no clinical assessments recorded. 288 patients were left at the scene (93 in the intervention group, 195 in the control group). After excluding those who refused to travel, there were three non-conveyed patients in each group who were admitted to hospital within 14 days of the call who were judged to have been left at home inappropriately. A higher proportion of patients in the intervention arm reported satisfaction with the service and advice provided.

CONCLUSIONS

"Treat and Refer" protocols did not increase the number of patients left at home but were used by crews and were acceptable to patients. The protocols increased job cycle time and some safety issues were identified. Their introduction is complex, and the extent to which the content of the protocols, decision support and training can be refined needs further study.

308. Characterization of SIV infection in the male genital tract of juvenile macaques

Reproductive organs contribute infected cells and free viral particles to semen in human immunodeficiency type-1 (HIV-1) infected individuals, increasing the risk of infection from the HIV-1 positive male to the mother and ultimately to the offspring. The majority of information gathered with respect to the HIV-1 burden in the male reproductive tract (MGT) have been conducted in tissues obtained on autopsies of testis, prostate and epididymis of individuals that die from AIDS. Therefore, little is known about the progression and pathogenesis of the infection within these organs. Investigating the mechanism of the spread of HIV-1 in the cells and tissues of the MGT, particularly during the asymptomatic stage, remains a critical task. Infection of macaques with simian immunodeficiency virus (SIV) is a useful animal model for studies of mucosal transmission and viral transmission via breastfeeding. In this study eight juvenile macaques (2.5 yo) were infected with SIVmac for a period of 3–6 months and testis and epididymis tissue were collected in two intervals, 3 and 6 months post-infection. To determine SIV progression and pathogenesis in the MGT we have used EM, immunohistochemistry, confocal microscopy and immunoblotting. Our preliminary EM obtained via analysis of testis and epididymis tissue of SIV infected macaques show the presence of elongated spermatids in the epididymis. Scattered viral like SIV particles were observed in the testis and epididymal lumen, principally associated with aberrant germ cells. Necrosis of epididymal tissue was also observed, potentially due to the SIV burden in this organ. The data indicate that SIV infected juvenile macaques are a potential model for studying HIV-1 pathogenesis and its effect in spermatogenesis as well as the immune response of testis in a species that is closely related to humans.

Safety of telephone consultation for "non-serious" emergency ambulance service patients

OBJECTIVE

To assess the safety of nurses and paramedics offering telephone assessment, triage, and advice as an alternative to immediate ambulance dispatch for emergency ambulance service callers classified by lay call takers as presenting with "non-serious" problems (category C calls).

DESIGN

Data for this study were collected as part of a pragmatic randomised controlled trial reported elsewhere. The intervention arm of the trial comprised nurse or paramedic telephone consultation using a computerised decision support system to assess, triage, and advise patients whose calls to the emergency ambulance service had been classified as "non-serious" by call takers applying standard priority dispatch criteria. A multidisciplinary expert clinical panel reviewed data from ambulance service, accident and emergency department, hospital inpatient and general practice records, and call transcripts for patients triaged by nurses and paramedics into categories that indicated that dispatch of an emergency ambulance was unnecessary. All cases for which one or more members of the panel rated that an emergency ambulance should have been dispatched were re-reviewed by the entire panel for an assessment of the "life risk" that might have resulted.

SETTING

Ambulance services in London and the West Midlands, UK.

STUDY POPULATION

Of 635 category C patients assessed by nurses and paramedics, 330 (52%) cases that had been triaged as not requiring an emergency ambulance were identified.

MAIN OUTCOME MEASURES

Assessment of safety of triage decisions.

RESULTS

Sufficient data were available from the routine clinical records of 239 (72%) subjects to allow review by the specialist panel. For 231 (96.7%) sets of case notes reviewed, the majority of the panel concurred with the nurses' or paramedics' triage decision. Following secondary review of the records of the remaining eight patients, only two were rated by the majority as having required an emergency ambulance within 14 minutes. For neither of these did a majority of the panel consider that the patient would have been at "life risk" without an emergency ambulance being immediately dispatched. However, the transcripts of these two calls indicated that the correct triage decision had been communicated to the patient, which suggests that the triage decision had been incorrectly entered into the decision support system.

CONCLUSIONS

Telephone advice may be a safe method of managing many category C callers to 999 ambulance services. A clinical trial of the full implementation of this intervention is needed, large enough to exclude the possibility of rare adverse events.

Safety of telephone consultation for "non-serious" emergency ambulance service patients

OBJECTIVE

To assess the safety of nurses and paramedics offering telephone assessment, triage, and advice as an alternative to immediate ambulance dispatch for emergency ambulance service callers classified by lay call takers as presenting with "non-serious" problems (category C calls).

DESIGN

Data for this study were collected as part of a pragmatic randomised controlled trial reported elsewhere. The intervention arm of the trial comprised nurse or paramedic telephone consultation using a computerised decision support system to assess, triage, and advise patients whose calls to the emergency ambulance service had been classified as "non-serious" by call takers applying standard priority dispatch criteria. A multidisciplinary expert clinical panel reviewed data from ambulance service, accident and emergency department, hospital inpatient and general practice records, and call transcripts for patients triaged by nurses and paramedics into categories that indicated that dispatch of an emergency ambulance was unnecessary. All cases for which one or more members of the panel rated that an emergency ambulance should have been dispatched were re-reviewed by the entire panel for an assessment of the "life risk" that might have resulted.

SETTING

Ambulance services in London and the West Midlands, UK.

STUDY POPULATION

Of 635 category C patients assessed by nurses and paramedics, 330 (52%) cases that had been triaged as not requiring an emergency ambulance were identified.

MAIN OUTCOME MEASURES

Assessment of safety of triage decisions.

RESULTS

Sufficient data were available from the routine clinical records of 239 (72%) subjects to allow review by the specialist panel. For 231 (96.7%) sets of case notes reviewed, the majority of the panel concurred with the nurses' or paramedics' triage decision. Following secondary review of the records of the remaining eight patients, only two were rated by the majority as having required an emergency ambulance within 14 minutes. For neither of these did a majority of the panel consider that the patient would have been at "life risk" without an emergency ambulance being immediately dispatched. However, the transcripts of these two calls indicated that the correct triage decision had been communicated to the patient, which suggests that the triage decision had been incorrectly entered into the decision support system.

CONCLUSIONS

Telephone advice may be a safe method of managing many category C callers to 999 ambulance services. A clinical trial of the full implementation of this intervention is needed, large enough to exclude the possibility of rare adverse events.

A survey of current consultant practice of treatment of severe ankle sprains in emergency departments in the United Kingdom

OBJECTIVE

To determine current consultant practice in larger UK emergency departments in the management of severe ankle sprains.

DESIGN

Questionnaire study to all UK emergency departments seeing more than 50 000 new patients per year.

RESULTS

70% response rate. Most popular treatment was ice, elevation, Tubigrip, and exercise, each of which was reported as used in most cases by over 70% of respondents. Crutches, early weight bearing, and non-steroidal anti-inflammatory drugs were each reported as used in most cases at over half of responding departments. Physiotherapy was usually only used in selected cases. Rest was usually advised for one to three days (35%). Follow up was only recommended for selected patients.

CONCLUSIONS

The results of this survey suggest that there is considerable variation in some aspects of the clinical approach (including drug treatment, walking aids, periods of rest) taken to the management of severe ankle sprains in the UK, although in some areas (for example, not routinely immobilising, early weight bearing as pain permits, use of physiotherapy, use of rest, ice, and elevation) there was concordance.

Attitudes of GPs towards the provision of acupuncture on the NHS

OBJECTIVE

To investigate the attitudes of General Practitioners (GPs) to acupuncture, whether they think it should be available on the NHS and, if so, how it should be provided.

DESIGN

Attitudinal postal survey.

SETTING

All 65 practising GPs in the 12 GP practices of the Melton Rutland & Harborough Primary Care Group, UK.

RESULTS

A response rate of 83% was achieved. The main findings show that 59% of GPs agreed that acupuncture should be available on the NHS, 83% agreed that it can be clinically useful and 72% that it can be cost effective. Among GPs who acknowledged the potential for an increased role for acupuncture on the NHS there was support for the provision of treatment from either medical or non-medical practitioners, delivered at either NHS or non-NHS premises, and with the NHS providing some, or all, of the required funding.

CONCLUSION

The findings suggest that a majority of GPs are in favour of acupuncture being more widely available on the NHS.

Computer assisted assessment and advice for "non-serious" 999 ambulance service callers: the potential impact on ambulance despatch

OBJECTIVE

To investigate the potential impact for ambulance services of telephone assessment and triage for callers who present with non-serious problems (Category C calls) as classified by ambulance service call takers.

DESIGN

Pragmatic controlled trial. Calls identified using priority dispatch protocols as non-serious were allocated to intervention and control groups according to time of call. Ambulance dispatch occurred according to existing procedures. During intervention sessions, nurses or paramedics within the control room used a computerised decision support system to provide telephone assessment, triage and, if appropriate, offer advice to permit estimation of the potential impact on ambulance dispatch.

SETTING

Ambulance services in London and the West Midlands.

SUBJECTS

Patients for whom emergency calls were made to the ambulance services between April 1998 and May 1999 during four hour sessions sampled across all days of the week between 0700 and 2300.

MAIN OUTCOME MEASURES

Triage decision, ambulance cancellation, attendance at an emergency department.

RESULTS

In total, there were 635 intervention calls and 611 controls. Of those in the intervention group, 330 (52.0%) were triaged as not requiring an emergency ambulance, and 119 (36.6%) of these did not attend an emergency department. This compares with 55 (18.1%) of those triaged by a nurse or paramedic as requiring an ambulance (odds ratio 2.62; 95% CI 1.78 to 3.85). Patients triaged as not requiring an emergency ambulance were less likely to be admitted to an inpatient bed (odds ratio 0.55; 95% CI 0.33 to 0.93), but even so 30 (9.2%) were admitted. Nurses were more likely than paramedics to triage calls into the groups classified as not requiring an ambulance. After controlling for age, case mix, time of day, day of week, season, and ambulance service, the results of a logistic regression analysis revealed that this difference was significant with an odds ratio for nurses:paramedics of 1.28 (95% CI 1.12 to 1.47).

CONCLUSIONS

The findings indicate that telephone assessment of Category C calls identifies patients who are less likely to require emergency department care and that this could have a significant impact on emergency ambulance dispatch rates. Nurses were more likely than paramedics to assess calls as requiring an alternative response to emergency ambulance despatch, but the extent to which this relates to aspects of training and professional perspective is unclear. However, consideration should be given to the acceptability, reliability, and cost consequences of this intervention before it can be recommended for full evaluation.

Tissue-culture enhanced transposition of the maize transposable element Dissociation in Brassica oleracea var. ' Italica'

To investigate the potential of heterologous transposons as a gene tagging system in broccoli ( Brassica oleracea var. Italica), we have introduced a Ds-based two-element transposon system. Ds has been cloned into a 35S-SPT excision-marker system, with transposition being driven by an independent 35S-transposase gene construct ( Tpase). In three successive selfed generations of plants there was no evidence of germinal-excision events. To overcome this apparent inability to produce B. oleracea plants with germinal excisions, we performed a novel tissue-culture technique to select for fully green shoots from seed with somatic-excision events. The results showed a very high efficiency of regeneration of fully green plants (up to 65%) and molecular analysis indicated that the plants genetically were like plants that contain a germinal-excision event. Further molecular analysis of these plants showed that 69% exhibited reinsertion of Ds back into the plant genome. Sequencing of donor-site footprints after Ds excision, revealed that there is an indication of more-severe deletions and rearrangements when higher concentrations of streptomycin are used in the tissue-culture selection process. Adapted versions of this regeneration technique have a high potential for providing germinal excision-like events in heterologous plants species which show low transposon activity. Alternatively, there is the potential to increase the proportion of 'germinal' plants in earlier generations of more-active plant species.

A qualitative study of older people's views of out-of-hours services

BACKGROUND

Out-of-hours primary care services continues to change with the growth of general practitioner (GP) co-operatives and the more recent development of NHS Direct. While older people are more likely to have increased needs for such services, evidence suggests that they are reluctant users of GP out-of-hours services.

AIM

To explore older people's experiences and perceptions of different models of general practice out-of-hours services.

DESIGN OF STUDY

Focus group methodology, with qualitative data analysis undertaken using a grounded theory (Framework) approach.

SETTING

Thirty people aged between 65 and 81 years old from community groups based in south east London.

METHOD

Four focus groups were held, each with between five and 12 participants. Each focus group session lasted 90 minutes and was audiotape-recorded with the permission of the participants. The tapes were transcribed verbatim.

RESULTS

Two related themes were identified. First, attitudes to health and healthcare professionals with reference to the use of health services prior to the establishment of the NHS, a stoical attitude towards health, and not wanting to make excessive demands on health services. Second, the experience of out-of-hours care and the perceived barriers to its use, including the use of the telephone and travelling at night. Participants preferred contact with a familiar doctor and were distrustful of telephone advice, particularly from nurses.

CONCLUSIONS

Older people appear reluctant to make use of out-of-hours services and are critical of the trend away from out-of-hours care being delivered by a familiar GP. With increasing numbers of older people in the population it is important to consider steps to address their reluctance to use out-of-hours and telephone advice services, particularly those based around less personal models of care.

Weight gain following treatment of hyperthyroidism

OBJECTIVE

Patients frequently express concern that treating hyperthyroidism will lead to excessive weight gain. This study aimed to determine the extent of, and risk factors for, weight gain in an unselected group of hyperthyroid patients.

DESIGN AND SUBJECTS

We investigated 162 consecutive hyperthyroid patients followed for at least 6 months. Height, weight, clinical features, biochemistry and management were recorded at each clinic visit.

RESULTS

Documented weight gain was 5.42 +/- 0.46 kg (mean +/- SE) and increase in BMI was 8.49 +/- 0.71%, over a mean 24.2 +/- 1.6 months. Pre-existing obesity, Graves' disease causing hyperthyroidism, weight loss before presentation and length of follow-up each independently predicted weight gain. Patients treated with thionamides or radioiodine gained a similar amount of weight (thionamides, n = 87, 5.16 +/- 0.63 kg vs. radioiodine, n = 62, 4.75 +/- 0.57 kg, P = 0.645), but patients who underwent thyroidectomy (n = 13) gained more weight (10.27 +/- 2.56 kg vs. others, P = 0.007). Development of hypothyroidism (even transiently) was associated with weight gain (never hypothyroid, n = 102, 4.57 +/- 0.52 kg, transiently hypothyroid, n = 29, 5.37 +/- 0.85 kg, on T4, n = 31, 8.06 +/- 1.42 kg, P = 0.014). This difference remained after correcting for length of follow-up. In the whole cohort, weight increased by 3.95 +/- 0.40 kg at 1 year (n = 144) to 9.91 +/- 1.62 kg after 4 years (n = 27) (P = 0.008), representing a mean weight gain of 3.66 +/- 0.44 kg/year.

CONCLUSION

We have demonstrated marked weight gain after treatment of hyperthyroidism. Pre-existing obesity, a diagnosis of Graves' disease and prior weight loss independently predicted weight gain and weight continued to rise with time. Patients who became hypothyroid, despite T4 replacement, gained most weight.

What is chronic fatigue syndrome? Heterogeneity within an international multicentre study

OBJECTIVE

We sought to compare the characteristics of patients presenting with chronic fatigue (CF) and related syndromes in eight international centres and to subclassify these subjects based on symptom profiles. The validity of the subclasses was then tested against clinical data.

METHOD

Subjects with a clinical diagnosis of CF completed a 119-item self-report questionnaire to provide clinical symptom data and other information such as illness course and functional impairment. Subclasses were generated using a principal components-like analysis followed by latent profile analysis (LPA).

RESULTS

744 subjects returned complete data sets (mean age 40.8 years, mean length of illness 7.9 years, female to male ratio 3:1). Overall, the subjects had a high rate of reporting typical CF symptoms (fatigue, neuropsychological dysfunction, sleep disturbance). Using LPA, two subclasses were generated. Class one (68% sample) was characterized by: younger age, lower female to male ratio; shorter episode duration; less premorbid, current and familial psychiatric morbidity; and, less functional disability. Class two subjects (32%) had features more consistent with a somatoform illness. There was substantial variation in subclass prevalences between the study centres (Class two range 6-48%).

CONCLUSIONS

Criteria-based approaches to the diagnosis of CF and related syndromes do not select a homogeneous patient group. While substratification of patients is essential for further aetiological and treatment research, the basis for allocating such subcategories remains controversial.

Patient-perceived benefits of and barriers to using out-of-hours primary care centres

BACKGROUND

The rapid growth of GP co-operatives has encouraged the development of primary care centres, but little is known about patients' views and experiences of these new forms of out-of-hours service delivery.

OBJECTIVES

This study was designed to understand patients' views, expectations and experiences of attending an out-of-hours primary care centre which was part of an inner London GP co-operative.

METHODS

Systematic samples of patients using the out-of-hours service received semi-structured interviews covering the decision to contact the service, expectations and experience of the service and, if relevant, the experience of travelling to the primary care centre. Interviews were conducted by telephone between 7 and 10 days after patient contact.

RESULTS

Interviews were completed with 55.4% (72/130) of sampled patients who were primary care centre attenders, 50.0% (47/94) of those receiving telephone advice and 45.3% (53/117) of those receiving a home visit. Most attenders of the primary care centre said that they were satisfied with the consultation (90.0%, 65) and were able to get all the help they needed (83%, 60). The speed of being seen and the opportunity of having a face-to-face consultation were key benefits identified. For some, this outweighed difficulties experienced in attending the centre, including arranging transport, caring for other children, managing several children on the journey and travelling while ill. The main barriers patients identified for not wanting to attend the primary care centre included feeling too ill to travel, having other dependants to care for or lacking transportation.

CONCLUSIONS

While primary care centres offer patients speedy access to face-to-face consultations, there are a range of obstacles which are encountered. Those who are socially disadvantaged appear likely to experience greatest difficulty, raising concerns about equity in access to services. Out-of-hours services may need to give consideration to patient transport and a more flexible approach to visiting at home if such inequities are to be avoided.

Patients' experiences of receiving telephone advice from a GP co-operative

BACKGROUND

The use of the telephone to deliver health care advice has increased considerably in recent years. Little research has been carried out to explore the experience of patients who receive such advice and its acceptability.

OBJECTIVES

The aim of this study is to describe the expectations of patients, or third party callers, who had contacted a GP out-of-hours co-operative and their satisfaction with telephone advice received.

METHODS

Semi-structured interviews were conducted by telephone 7-10 days after contact with one inner city GP co-operative.

RESULTS

A total of 47 telephone consultations were followed up with an interview. Of these, 23 (48.9%) callers had expected to be offered a home visit when they called. Reasons for wanting a home visit were either to do with the nature of the condition and its perceived severity, problems in being able to attend the primary care centre and the risks of travel, or because of problems in communicating over the telephone. Satisfaction with telephone consultations centred mostly on the doctor being able to provide reassurance and give adequate time to allay concerns. The most common reasons given for dissatisfaction were the caller feeling that the doctor could not make a correct diagnosis without having seen the patient, or the caller being made to feel that they were wasting the doctor's time. Many patients were anxious about their ability to describe symptoms over the telephone, or understand and follow the advice that they received.

CONCLUSIONS

There appears to be a need for patients to be better informed about the service they can expect to receive from GP co-operatives. Recent developments such as NHS Direct may have an influence on the telephone consultation rate to GP co-operatives.

Lesbian plays and their players

SUMMARY This discussion focuses on various texts for the theatre by women dramatists in Aotearoa/New Zealand. It raises a number of questions initially about lesbian plays and playwrights, and then about the per-formability of gender. Finally, I consider briefly some theoretical issues to do with textual reading,Including post-structural readings of "the lesbian." Much usage of the term "lesbian identity" presupposes that there is such a thing, and that it is fixed, univocal and stable. As my readings of these texts show, however, "the lesbian" constitutes a set of fluid identifications, expressed in heterogeneity and change. In these critical readings I examine dramatic texts generating lesbian identities, in the specific social context of Aotearoa/New Zealand.

Ornamental plumage does not signal male quality in red-billed queleas

Sexually selected ornaments often function as condition-dependent signals of quality (or 'indicators'). When ornamentation is costly, only high-quality individuals can afford to produce the most elaborate signals. The plumage ornamentation of male red-billed queleas, Quelea quelea, is an ideal candidate for an indicator because it is continuously variable, conspicuous, sexually dimorphic, is displayed only during breeding and is partially based on carotenoid pigmentation. However, I show here that quelea plumage is not an indicator because first, plumage colour is not correlated with physical condition or age; second, plumage colour is a genetically determined phenotype that is unresponsive to environmental variation; third, different plumage characters have bimodal distributions; fourth, plumage characters vary independently of one another; and finally, plumage colour is not correlated with reproductive success. To my knowledge, this is the first demonstration of non-condition dependence in colourful and sexually dimorphic breeding ornamentation. Instead, plumage variation may function as a sexually selected signal of individual identity among territorial males that nest in huge, densely packed and highly synchronized colonies.

Decreased bone mineral density during low dose glucocorticoid administration in a randomized, placebo controlled trial

OBJECTIVE

While osteoporosis and bone fractures are clearly recognized side effects of high dose glucocorticoids, the effect of low dose glucocorticoids remains controversial. We investigated the effect of 3 months of low dose hydrocortisone on bone mineral density (BMD).

METHODS

Subjects, 18 to 55 years old with chronic fatigue syndrome and no medical or psychiatric illness requiring medication, were randomized in a double blind, placebo controlled trial to receive oral hydrocortisone, 13 mg/m2 body surface area every morning and 3 mg/m2 every afternoon (25 to 35 mg/day, equivalent to about 7.5 mg prednisone/day) or placebo for 12 weeks. Before and after treatment BMD of the lumbar spine was measured by dual energy x-ray absorptiometry.

RESULTS

We studied 23 subjects (19 women, 4 men). For the 11 hydrocortisone recipients there was a mean decrease in BMD: mean change from baseline of the lateral spine was -2.0% (95% CI -3.5 to -0.6. p = 0.03) and mean change of the anteroposterior spine was -0.8% (95% CI -1.5 to -0.1, p = 0.06). Corresponding changes for the 12 placebo recipients were +1.0% (95% CI -1.0 to 3.0, p = 0.34) and +0.2% (95% CI -1.4 to 1.5, p = 0.76).

CONCLUSION

A 12 week course of low dose glucocorticoids given to ambulatory subjects with chronic fatigue syndrome was associated with a decrease in BMD of the lumbar spine. This decrease was statistically significant in lateral spine measurements and nearly so in anteroposterior spine measurements.

Randomised training after myocardial infarction: short and long-term effects of exercise training after myocardial infarction in patients on beta-blocker treatment. A randomized, controlled study

In this study we assessed the short- and long-term effects of 4-weeks of exercise training (MI) soon after myocardial infarction in patients on beta-blocker treatment. Thirty-seven male patients < or = 65 years of age were included in the study, 19 of them randomized to exercise training (ET) and 18 to a control group (Ctr). Cumulated work (CW), calculated in kiloJoules (kJ), was recorded before immediately after the intervention period and again six months after the MI. In the short term the mean (SD) CW increased by 22% (from 65(20) to 79(25) kJ) in the ET group, compared with no change in the Ctr patients (65(24) vs 65(21) kJ) (p = 0.009). At late follow-up CW was 14% above baseline in the ET patients (65(20) vs 74(20) kJ) p = 0.036, compared with only 6% in the 15 Ctr patients who were still available for follow-up (68(24) vs 72(29) kJ), but without a significant between-group difference. In post-MI patients on beta-blocker treatment, and with a high baseline exercise capacity, physical training improved exercise capacity in the short term, but there was no significant between-group difference at long-term follow-up.

Patient satisfaction with out-of-hours services; how do GP co-operatives compare with deputizing and practice-based arrangements?

BACKGROUND

Although the rapid growth in general practitioner (GP) co-operatives has met with GP satisfaction, little is known about patient satisfaction. This study compares patient satisfaction with co-operative, GP practice-based and deputizing arrangements within one geographical area 15 months after a co-operative had become established; and with telephone, primary care centre and home consultations within the co-operative.

METHODS

A validated postal questionnaire survey of weighted samples of patients making contact with the co-operative, practice-based and deputizing arrangements was undertaken.

RESULTS

A total of 1,823 (53.2 per cent) patients responded. There were no significant differences between organizations in terms of overall satisfaction, but patients using practice-based arrangements were significantly more satisfied with the waiting time for telephone consultations (p<0.001) and more satisfied with waiting times for home visits than deputizing patients (p=0.020). Within the co-operative, overall satisfaction, satisfaction with the doctor's manner and with the process of making contact was greater among those attending the primary care centre, and satisfaction with explanation and advice received greater than for patients receiving telephone consultations alone (p<0.01). Those receiving telephone advice reported increased information needs and help seeking during the following week (p< 0.05).

CONCLUSIONS

Overall, patients were as satisfied with the co-operative as with practice-based or deputizing service arrangements, although many concerns were expressed about the quality of service provision. Differences in satisfaction were greater between forms of service delivery within the co-operative. Dissatisfaction with telephone consultations needs to be considered, together with issues relating to equity in access to out-of-hours' primary care centre consultations and the potential impact of NHS Direct.

Short-term physical training reduces left ventricular dilatation during exercise soon after myocardial infarction

Coronary heart disease and beta-blocker treatment can increase the use of the Frank-Starling mechanism during exercise. The aim of the study was to assess whether this could be influenced by physical training. Male patients on beta-blocker treatment after myocardial infarction were randomised to four weeks of training (ET, n = 19) or to a control group (Ctr, n = 18). Cardiac output (CO) at rest and at identical submaximal exercise levels in each patient were determined by radionuclide ventriculography at baseline and after the intervention period. CO was calculated as end diastolic volume (EDV) x ejection fraction x heart rate, and deltaCO and deltaEDV as change in parameter from rest to exercise. The mean (SD) deltaCO decreased from 6.5 (2.1) L/min(-1) to 5.1 (2.4) in ET patients and increased from 5.0 (1.7) to 5.8 (2.7) in Ctr, p = 0.004. deltaEDV decreased from 30 (30) mL to 12 (35) in ET and increased from 11 (20) to 36 (33) in Ctr, p = 0.005. When adjusting for baseline dissimilarities between the groups in a multivariate linear regression analysis, these differences were still statistically significant, p = 0.018 and p = 0.044, respectively. Physical training reduces the CO increase needed to perform identical submaximal exercise, and this is accompanied by less left ventricular dilatation, with a potential for reducing exercise-induced ischaemia.

Sexual harassment in the veterinary academic environment

OBJECTIVE

To survey faculty and house officers of clinical departments of colleges of veterinary medicine (CVM) to identify characteristics of sexual harassment (SH) in the veterinary academic environment, to report the opinions of survey respondents on how SH is being handled, and to determine how the process can be improved at veterinary academic institutions.

PROCEDURE

On the basis of lists obtained from 25 CVM, a survey was mailed to 1,294 academic veterinarians. Four hundred seventy-eight completed surveys were returned.

RESULTS

The prevalence of SH in the population of respondents was 31%. Nonphysical forms of SH were reported 6 times as often as physical forms of harassment, with the most common type reported being offensive sexual comments and unwanted attention. Fear of reprisal was the most prevalent reason cited by respondents for not confronting the harasser. Survey respondents rated the following as very important to improve the system of dealing with SH at their academic institution: guarantee of protection from retaliation, assurance of confidentiality, clear explanation of what will happen to you, and a clearer definition of SH.

CONCLUSION

A clear definition of SH is the first step in preventing SH. Other cited steps include professional development programs to educate the academic population as to what constitutes SH, inform the entire academic population what the institution's SH policy is, and enforce this policy with sensitivity, fairness, confidentiality, and quick resolve to protect the victim.

Lipoprotein(a), other lipoproteins and hemostatic profiles in patients with ischemic stroke: the relation to cardiogenic embolism

Lipoprotein and hemostatic profiles including coagulation inhibitors were determined in 136 patients with acute ischemic stroke. Based on clinical examination, cerebral computed tomography, Doppler ultrasonography of precerebral arteries and transthoracic echocardiography, the strokes were classified as cardioembolic (n = 38), non-cardioembolic (n = 92), and mixed cardioembolic/hypertensive (n = 6). Patients with cardioembolic stroke were older than patients with non-cardioembolic stroke. Lipoprotein(a) was higher in the cardioembolic than in the non-cardioembolic group. Lipoprotein(a) was not significantly correlated to the other lipid levels and may represent an independent lipid risk factor. The non-cardioembolic group had higher levels of total cholesterol, triglycerides, total cholesterol/high-density lipoprotein cholesterol ratio, low-density lipoprotein cholesterol, apolipoprotein A1, and apolipoprotein B. The cardioembolic group had higher concentrations of fibrinogen and D-dimer, and lower levels of antithrombin, protein C, protein S and heparin cofactor 2 than the non-cardioembolic group. The differences in the hemostatic profile are consistent with thrombosis due to activated coagulation being more involved in the pathogenesis of cardioembolic than of non-cardioembolic stroke. Lipoprotein(a) seems to be more associated with coagulation markers of thrombosis than with atherosclerosis, whereas the other lipids mainly seem to be risk factors for atherosclerosis.

Out-of-hours care. Co-operative society

The last decade has seen a burgeoning of out-of-hours services in a movement characterized by experimentation and innovation that may have implications for all health services. The system needs to be more integrated to remove duplication and fill existing gaps in the service. But resistance from healthcare professionals is a major barrier. A shift from an out-of-hours emergency service towards 24-hour access for routine healthcare would be unsustainable and have limited health gain. NHS Direct should be the single point of access, with open access to A&E services restricted to people unable to telephone and who require urgent specialist care.

A multi-differential neuromorphic approach to motion detection

This paper presents a multi-differential neuromorphic approach to motion detection. The model is based evidence for a differential operators interpretation of the properties of the cortical motion pathway. We discuss how this strategy, which provides a robust measure of speed for a range of types of image motion using a single computational mechanism, forms a useful framework in which to develop future neuromorphic motion systems. We also discuss both our approaches to developing computational motion models, and constraints in the design strategy for transferring motion models to other domains of early visual processing.

Access to and use of out-of-hours services by members of Vietnamese community groups in South London: a focus group study

BACKGROUND

Communication difficulties, lack of knowledge of services and the appropriateness of services influence access to health care services by black and ethnic minority groups. These problems may be accentuated outside normal working hours. This may be so particularly for those who do not speak English as a first language, as interpreting services across the UK are extremely limited in the out-of-hours period.

OBJECTIVE

We aimed to describe the experiences and perceptions of members of the Vietnamese community groups in seeking out-of-hours health services and to identify potential solutions from participants' perspectives.

METHOD

This qualitative study used a focus group methodology. Participants were members of three established community groups in the South London boroughs of Southwark and Lewisham. Participants attended six focus groups which were conducted in Cantonese and Vietnamese.

RESULTS

Participants did not know about GPs' out-of-hours arrangements. And their access to the range of services normally available was limited. They were unable to communicate with health care professionals or answering services and were unaware of out-of-hours interpreting arrangements. Generally, participants were dependent on other people in gaining access to services. Some participants had used 999 services despite communication problems. Participants' experienced delays in seeking health care services and confusion regarding the medicines and advice given.

CONCLUSIONS

Communication difficulties limited knowledge of and access to out-of-hours services for the Vietnamese participants. Direct contact with interpreters in the out-of-hours period was suggested as a means of increasing participants' ability to gain access to services. Health service planners need to be aware of the difficulties experienced by such groups if issues of equity in gaining access to health care services are to be addressed.

Inherited human Caspase 10 mutations underlie defective lymphocyte and dendritic cell apoptosis in autoimmune lymphoproliferative syndrome type II

Caspases are cysteine proteases that mediate programmed cell death in phylogenetically diverse multicellular organisms. We report here two kindreds with autoimmune lymphoproliferative syndrome (ALPS) type II, characterized by abnormal lymphocyte and dendritic cell homeostasis and immune regulatory defects, that harbor independent missense mutations in Caspase 10. These encode amino acid substitutions that decrease caspase activity and interfere with death receptor-induced apoptosis, particularly that stimulated by Fas ligand and TRAIL. These results provide evidence that inherited nonlethal caspase abnormalities cause pleiotropic apoptosis defects underlying autoimmunity in ALPS type II.

Defective CD95/APO-1/Fas signal complex formation in the human autoimmune lymphoproliferative syndrome, type Ia

Heterozygous mutations in the CD95 (APO-1/Fas) receptor occur in most individuals with autoimmune lymphoproliferative syndrome (ALPS) and dominantly interfere with apoptosis by an unknown mechanism. We show that local or global alterations in the structure of the cytoplasmic death domain from nine independent ALPS CD95 death-domain mutations result in a failure to bind the FADD/MORT1 signaling protein. Despite heterozygosity for the abnormal allele, lymphocytes from ALPS patients showed markedly decreased FADD association and a loss of caspase recruitment and activation after CD95 crosslinking. These data suggest that intracytoplasmic CD95 mutations in ALPS impair apoptosis chiefly by disrupting death-domain interactions with the signaling protein FADD/MORT1.

Provision of telephone advice from accident and emergency departments: a national survey

This study sought to gain a national picture of the provision of telephone advice using a postal survey of senior nurses from accident and emergency (A&E) and minor injury units (MIUs). In all, 268/313 (85%) of hospitals/units responded. The average number of calls reported as received per day was 15.5 (median 12; quartiles 6, 20) for weekdays and 21.0 (median 17; quartiles 10, 29) for weekends. Most (89%) viewed the provision of telephone advice as an important component of their work, but few units offered staff training for this role or had implemented protocols or guidelines. Only 5.4% units included the number of calls received in their department in their workload figures, but 91.9% felt that they should be. Extrapolation of the data from this study to all 313 A&E and MIUs in the UK suggests that just under two million calls for telephone advice are currently made to units each year. Recognition and formalization of this aspect of work is likely to be of increasing importance given the constraints on services and the need to manage demand effectively. Future integration of A&E telephone advice calls with NHS Direct should be considered as a means of managing demand and avoiding duplication of service provision.

Concerns and confidence of general practitioners in providing telephone consultations

BACKGROUND

In recent years the number of telephone consultations provided out of hours has increased. However, most general practitioners (GPs) have received little training in this area despite the specific skills needed to compensate for lack of visual information. Moreover, there has been no research exploring GPs' concerns and training needs in telephone consulting.

AIM

To assess GPs' concerns and levels of confidence in providing telephone consultations in order to inform the development of a new training course.

METHOD

Prior to attending the course, GPs were surveyed by interview or self-completion questionnaire to explore their confidence in providing telephone consultations.

RESULTS

Thirty-eight GPs participated, and the sample was highly skewed towards females. The average age of participants was 42 years, 5 years less than the mean for GPs in the area. Low levels of confidence were reported by GPs in providing telephone consultations out of hours. A number of characteristics were common to telephone consultations described as difficult. The most important were lack of visual clues and lack of information about the patient, both of these were heightened in the out-of-hours period. Organizational factors leading to reduced confidence levels were also identified.

CONCLUSIONS

This study demonstrates low levels of confidence among GPs conducting telephone consultations, and highlights contributing factors. Although it is not clear how far these results can be generalized, they demonstrate the need to consider telephone consulting skills training in the context of new out-of-hours arrangements. The results have been used to develop a two-day course.

Responding to out-of-hours demand: the extent and nature of urgent need

BACKGROUND

Little research has been undertaken concerning GPs' perceptions about urgent or 'appropriate' out-of-hours demand.

OBJECTIVE

We aimed to measure GPs' perceptions about patients' need for urgent out-of-hours general medical help according to indicators of physical, psychological/emotional and social need, and the medical necessity of a home visit.

METHODS

Twenty-five practices participated in an audit and research study whereby GPs completed an audit form for all contacts during November/December 1995 and February/March 1996. Each contact was assessed according to the indicators of urgent need and GPs commented on reasons for making such assessments.

RESULTS

Audit forms were completed on 1862 patients, and GPs considered that 66.6% (1027) of contacts had either a physically, psychologically/emotionally or socially urgent need for help and were uncertain about a further 10.7% (165). Over half (53.0%) were considered to have an urgent physical need, almost one-third (31.0%) to have an urgent psychological/emotional need and 10.1% (119) to have an urgent social need for help. Over half (55.2%) of visits were considered to be medically necessary, the majority of which (89.9%) were assessed as having an urgent physical need for help.

CONCLUSIONS

The findings raise questions about the strategic direction of newer forms of service delivery (GP Co-operatives) and suggest the need for further research to inform the strategic reduction in home visiting, particularly in inner-city areas where many residents have little access to transport out-of-hours to enable them to attend a primary care centre. GP co-operatives are, however, well placed to improve interagency working and cross-referral to other health and social service personnel, and respond more 'appropriately' to some psychological/emotional and social problems.

Training and supervision needs and experience: a longitudinal, cross-sectional survey of accident and emergency department senior house officers

The aim of this study was to investigate senior house officers' (SHOs) perceptions about their training needs, satisfaction with teaching and supervision, and the relationship this has with psychological distress levels. All 171 SHOs employed within 27 accident and emergency (A&E) departments in the South Thames region were sent questionnaires at the start of their attachments in A&E, at the end of months four and six. The questionnaires asked SHOs to rate on visual analogue scales their perceived need for further training for 23 clinical and practical activities relevant to A&E practice. At the end of the fourth month SHOs were asked to indicate who had provided them with the most valuable teaching and supervision, indicate their satisfaction levels with training received, and suggest ways to improve teaching and supervision. SHOs' psychological distress levels were measured in all three questionnaires. Overall, satisfaction with supervision and training was mixed. SHOs perceived greatest need for further training in areas encountered less frequently in A&E. Registrars were the most valued providers of supervision and teaching. Increased numbers of middle grade staff and protected study time were suggested as ways to improve supervision and teaching. SHOs with higher scores for training need at the end of their attachment in A&E expressed significantly less satisfaction with training and higher psychological distress levels. The variation between SHOs' perceptions of training needs indicates the importance of tailoring training and supervision to individual requirements.

Attitudes towards general practice and primary care: a survey of senior house officers in accident and emergency

OBJECTIVES

The attitudes and knowledge of hospital based staff about the capabilities of general practice may be important obstacles to continuity of care and the quality of communication at the primary-secondary care interface. However, little research has sought to investigate such factors or how they change over time. The study aims to assess how senior house officers (SHOs) in accident and emergency (A&E) departments perceive general practice, and to test how attitudes change during their six months' tenure.

METHODS

Questionnaires were sent to all A&E SHOs working in the 27 A&E departments in South Thames region. At the end of the first month and at the end of the sixth months SHOs were asked to respond using 100 mm visual analogue scales to statements about the quality of general practitioner (GP) services in their area and their attitudes towards treating primary care patients in A&E.

RESULTS

After sending reminders, 135 (79%) SHOs responded to the questionnaire at the end of the first month, and 115 (67%) responded to the questionnaire at the end of the sixth month; 104 (61%) responded to both. Statements relating to GP accessibility within and outside normal working hours, perceptions of patients' satisfaction with GP services, GPs' effectiveness in educating patients about use of services, and the frustrations and lack of reward of treating primary care patients scored most negatively. The overall trend was for attitudes to become more negative during SHOs' period of employment in A&E, particularly for those intent on hospital specialist careers or those working within London hospitals.

CONCLUSIONS

The findings indicate the extent to which attitudes become more entrenched over time. This may lead to care that is more hospital focused. These issues need to be addressed if quality improvement is to occur across the A&E-primary care interface.

Left ventricular thrombus formation and resolution in acute myocardial infarction

Left ventricular thrombus formation and resolution were studied by serial echocardiography in 38 patients with acute anterior myocardial infarction. Twenty (52.6%) patients developed thrombus. Cumulative rates were: 12/20 (60%) at 24 h (+/-24 h), 17/20 (85%) at 72 h (+/-24 h), and 19/20 (95%) at 120 h (+/-24 h). Early thrombus formation was associated with worse left ventricular wall motion relative to those with delayed thrombus development (P=0.00016). In patients with initially normal echocardiograms, subsequent thrombus formation was associated with wall motion deterioration (P=0.016). A thrombus occurred in 16/28 (57.1%) patients given streptokinase. Heparin and warfarin were given in case of thrombus formation. Among survivors with thrombus, resolution occurred with a cumulative rate of 1/18 (5.6%) at 72 h (+/-24 h), 2/18 (11.1%) at 120 h (+/-24 h), 10/18 (55.6%) at 3 months (+/-1 week) and 16/18 (88.9%) at 6 months (+/-1 week). No embolic events occurred. Left ventricular thrombus formation occurs often and early after acute anterior myocardial infarction, even when streptokinase is given. Delayed thrombus formation is associated with wall motion deterioration. Thrombus resolution occurs frequently during anticoagulation and seems not associated with increased embolic risk.

Low-dose hydrocortisone for treatment of chronic fatigue syndrome: a randomized controlled trial

CONTEXT

Chronic fatigue syndrome (CFS) is associated with a dysregulated hypothalamic-pituitary adrenal axis and hypocortisolemia.

OBJECTIVE

To evaluate the efficacy and safety of low-dose oral hydrocortisone as a treatment for CFS.

DESIGN

A randomized, placebo-controlled, double-blind therapeutic trial, conducted between 1992 and 1996.

SETTING

A single-center study in a tertiary care research institution.

PATIENTS

A total of 56 women and 14 men aged 18 to 55 years who met the 1988 Centers for Disease Control and Prevention case criteria for CFS and who withheld concomitant treatment with other medications.

INTERVENTION

Oral hydrocortisone, 13 mg/m2 of body surface area every morning and 3 mg/m2 every afternoon, or placebo, for approximately 12 weeks.

MAIN OUTCOME MEASURES

A global Wellness scale and other self-rating instruments were completed repeatedly before and during treatment. Resting and cosyntropin-stimulated cortisol levels were obtained before and at the end of treatment. Patients recorded adverse effects on a checklist.

RESULTS

The number of patients showing improvement on the Wellness scale was 19 (54.3%) of 35 placebo recipients vs 20 (66.7%) of 30 hydrocortisone recipients (P =.31). Hydrocortisone recipients had a greater improvement in mean Wellness score (6.3 vs 1.7 points; P=.06), a greater percentage (53% vs 29%; P=.04) recording an improvement of 5 or more points in Wellness score, and a higher average improvement in Wellness score on more days than did placebo recipients (P<.001). Statistical evidence of improvement was not seen with other self-rating scales. Although adverse symptoms reported by patients taking hydrocortisone were mild, suppression of adrenal glucocorticoid responsiveness was documented in 12 patients who received it vs none in the placebo group (P<.001).

CONCLUSIONS

Although hydrocortisone treatment was associated with some improvement in symptoms of CFS, the degree of adrenal suppression precludes its practical use for CFS.