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.