Citizens' expectations and likely use of a NHS Walk-in Centre: results of a survey and qualitative methods of research

OBJECTIVES

To find out which groups of people would use a National Health Service walk-in centre that would offer mainly health care advice, staffed by nurses. To understand the circumstances in which people would use a walk-in centre and to ascertain to what extent it would meet patients' expressed health-care needs.

DESIGN

A postal survey of 2400 people plus 27 semi-structured interviews and one focus group.

SETTING AND PARTICIPANTS

The study was conducted in Wakefield, Yorkshire UK, and included both white and ethnic minority groups.

RESULTS

Most people reported that they would use a walk-in centre. It would be more attractive to young as compared with older people, ethnic minority as compared with white people, people who are dissatisfied with access to NHS services and people with urgent health-care problems. People want a wide range of services, including diagnosis, treatment, prevention, and general information. People also want access to both doctors and nurses, to male as well as female practitioners, to counsellors and interpreters. The type of service planned for this walk-in centre will meet some of the expressed needs. However, patients' expectations of the walk-in centre exceed planned provision in a number of key respects.

CONCLUSION

Walk-in centres without GPs and with limited services will disappoint the public. It is important that walk-in centres are evaluated and attention paid to 'local voices' before additional money is allocated for such centres elsewhere.

A review of 165 cases of transvaginal sacrospinous colpopexy performed by the Endo Stitch technique

The Endo Stitch technique has been in use in Geelong since 1994 as the method of performing transvaginal sacrospinous colpopexy (TSC). This article looks at the outcome of 165 of these procedures as assessed by a questionnaire. As the operation is technically easy, has a low complication rate and a high level of patient satisfaction we suggest that the Endo Stitch technique may be the method of choice for TSC.

Immigration and the regional demographics of the elderly population in the United States

OBJECTIVES

This research examined the impacts of past international and interregional migration flows on regional elderly population growth and distribution patterns.

METHODS

The authors used 1960, 1970, 1980, and 1990 Census data and multiregional demographic models to analyze changes in the sources of regional elderly population growth rates, age compositions, and spatial distributions over time.

RESULTS

Past elderly interregional migration patterns have exhibited considerable stability and have contributed less than aging-in-place in shaping regional elderly population geographies. Also the effects of immigration on elderly dependency ratios have been very modest.

DISCUSSION

Little evidence exists of any significant breaks with past trends in internal elderly migration patterns. Reconstruction of elderly population changes between 1950 and 1990 reveals that the driving force behind the changes was net aging-in-place and not net migration. Finally, analysis of the possible population rejuvenating effects of immigration suggests that although its impact has contributed to lower elderly-to-worker dependency ratios, its level over the past decades has been insufficient to counteract the much stronger countervailing impact of population aging.

An occupation-industry matrix analysis of mesothelioma cases in Australia 1980-1985

Australia has one of the highest national incidences of mesothelioma in the world and the rate is still rising. An industry-occupation matrix analysis was conducted for the 858 mesothelioma cases that were reported to the Australian Mesothelioma Surveillance Program between 1980 and 1985. Definite, probable, or possible occupational exposure had occurred in 57 percent (492/858) of the subjects. The primary asbestos production or manufacturing industry constituted the largest number of cases (137/492, 27.8%), followed by shipbuilding, repair and demolition (114/492, 23.2%), the building industry (69/492, 14.1%), and the railway locomotive construction and maintenance industry (47/492, 9.6%). Laborers constituted 14.8 percent (n = 73) of the occupations with a history of exposure to asbestos, followed by carpenters (13.0%, n = 64), boilermakers (10.6%, n = 52), and fitters/turners (8.1%, n = 40). The distribution of occupations in specific industries is presented in this article.

Evaluating the impact of a locality based social policy intervention on mental health: conceptual and methodological issues

Urban regeneration initiatives provide an opportunity for examining the impact of changes in socio-economic circumstances on the mental health of different groups and individuals within localities. This paper sets out the conceptual and methodological bases for evaluating the impact of a population based social policy intervention on mental health. We suggest the need to integrate a range of disciplinary and methodological developments in research on health inequalities in exploring the impact of urban regeneration on mental health. A combination of multi-level modelling, subjective indicators and narrative accounts of individuals about mental health in the context of locality and personal changes are central for developing theories and methods appropriate for exploring the action and interaction of effects operating between structural and individual/agency levels.

Systemic mastocytosis

Mastocytosis is a disease characterized by an abnormal increase in mast cells. Rare in occurrence, protean in its manifestations, it is a disease which is very seldom thought of and hence, possibly even overlooked. The last few decades have witnessed an upsurge in the understanding of the physiology and pathobiology of mast cells. Better means for diagnosis and follow-up have become available. Once a diagnosis is established histamine antagonists remain the mainstay of treatment. Most patients live and die with the disease rather than of it. The objective of this review is to discuss this entity with a special focus on diagnosis and treatment.

Intracerebral aneurysms in human immunodeficiency virus infection: case report and literature review

We describe a child with human immunodeficiency virus infection who presented with a large subarachnoid hemorrhage. She had multiple saccular and fusiform aneurysms in the proximal cerebral arterial circulation and no evidence of bacterial or fungal infection. The arteriopathy coincided with a high human immunodeficiency virus RNA load. Human immunodeficiency virus may cause cerebral arteriopathy with potentially life-threatening complications.

Biochemical markers as predictors of rates of bone loss after menopause

Biochemical markers of bone turnover may correlate with rates of bone loss in a group of postmenopausal women, but it is uncertain how useful they are in predicting rates of bone loss in the individual. The aim of this study was to determine the value of measurements of biochemical markers for the prediction of rates of bone loss in the individual. We studied 60 postmenopausal women (ages, 49-62 years), 43 of whom had gone through a natural menopause 1-20 years previously and 17 of whom had undergone hysterectomy 3-22 years ago. Lumbar spine bone mineral density (BMD) was measured using dual-energy X-ray absorptiometry (DXA) over 2-4 years. Bone formation markers (bone-specific alkaline phosphatase [ibAP] and amino terminal of type I collagen [PINP] and osteocalcin [OC]) were measured in serum. Bone resorption markers (N-telopeptide of type 1 collagen [NTx] and immunoreactive free deoxypyridinoline [iFDpd]) were measured in urine and corrected for creatinine (Cr). Rates of bone loss were calculated as percent change per year. We found significant negative correlations (Spearman rank) between all measured biochemical markers and rate of change in bone density with r values ranging from -0.35 to -0.52. When markers and rates of bone loss were divided into tertiles, prediction of bone loss in an individual was poor (kappa < 0.2). There was an exponential relationship between rate of bone loss and years since menopause (YSM) in the 43 women having a natural menopause (r2 = 0.44; p = 0.008) indicating higher rates of loss in the early postmenopausal period. Levels of NTx, iFDpd, and PINP also showed a significant negative correlation with YSM. We conclude that there is a strong relationship between rates of spinal bone loss and levels of bone turnover markers. Although this is a small study, the results also suggest that using DXA measurements of the lumbar spine as the "gold standard," it is not possible to use biochemical markers to predict rate of bone loss in the individual.

Immediate changes in biochemical markers of bone turnover and circulating interleukin-6 after parathyroidectomy for primary hyperparathyroidism

OBJECTIVE

The time course of the immediate change in bone turnover after parathyroidectomy (PTX) for primary hyperparathyroidism (PHPT) is not clear. It is uncertain whether circulating interleukin-6 (IL-6) plays a role in mediating the acute withdrawal of the effects of parathyroid hormone (PTH) on bone turnover after PTX. The aims of this study were to determine the time course of immediate changes in biochemical markers of bone turnover after PTX and whether circulating IL-6 is involved in the immediate changes of bone turnover after PTX.

DESIGN AND METHODS

IL-6 and bone turnover markers were measured in eight women (aged 55+/-11 years, mean+/-s.d. ) with PHTP at baseline and at 1-2h, and 1, 2, 5, 7 and 12 days after PTX. We compared the results with those from eight individually matched women (healthy controls) and five subjects undergoing major surgery (surgical controls).

RESULTS

At baseline, serum levels of IL-6 and bone turnover markers were higher in PHPT than those in healthy controls (P<0.05). Serum levels of procollagen propeptides increased by 22 and 27% at days 2 and 5, respectively, compared with baseline (P<0.05). Serum tartrate-resistant acid phosphatase decreased by 2 days after PTX, and urinary collagen crosslinks decreased significantly by 21-41% within 24h (P<0.05). Serum IL-6 levels increased immediately in both PHPT and surgical controls at postoperative follow-up (repeated measures ANOVA).

CONCLUSIONS

(1) PTX decreases bone resorption immediately and (2) circulating IL-6 is not involved in the changes in bone turnover immediately after PTX.

'All the services were excellent. It is when the human element comes in that things go wrong': dissatisfaction with hospital care in the last year of life

Patient satisfaction surveys are seen as an important way of obtaining 'user views' of health service provision. However, there is a growing body of research and theoretical literature that questions the validity of the concept of 'patient satisfaction' and hence the use of this type of survey. A postbereavement survey of people who registered a random sample of cancer deaths in an inner London health authority was undertaken in 1996/7. The survey questionnaire (VOICES) included 14 open-ended questions which asked respondents to add any comments they felt were relevant about the care of the deceased. This paper uses these data to examine the causes of dissatisfaction with hospital-based care. Of the 229 informants responding to the questionnaire, 138 included some written comment about care in hospital. At least one negative comment was made by 59% (82) of those making any comment. Of these, 55% (44) rated the care given by doctors as 'excellent' or 'good' and 63% (50) rated that given by nurses as 'excellent' or 'good'. Qualitative analysis of responses to open questions suggest that expressions of dissatisfaction arise from a sense of being 'devalued', 'dehumanized' or 'disempowered' and from situations in which the 'rules' governing the expected health professional-patient relationships were broken. As such, the causes of dissatisfaction for this particular group of patients are similar to the causes of dissatisfaction with health care in general reported elsewhere. The palliative care approach emphasizes patient- and family-centred care and aims to promote physical and psychosocial well-being. The study findings suggest that adoption of the palliative care approach could reduce the experience of dissatisfaction for many service users, not only those whose deaths are anticipated.

"If a patient is too costly they tend to get rid of you:" the impact of people's perceptions of rationing on the use of primary care

Despite the increasing focus on rationing, and rationing decisions in the NHS, little attention has been given to patient's perceptions of rationing and the potential impact this might have on people's use of services. Drawing on the qualitative findings of a study conducted in the North West of England which was concerned with the pattern and processes of primary care help seeking, this paper sets out to examine perceptions and experiences of rationing in primary care and the potential impact this has on people's use of services. In relation to primary care services people had experienced rationing by deterrence, dilution and delay. There was some evidence that perceptions of rationing impacted on help seeking and the use of primary care services. The implications for understanding the way in which perceptions of rationing might influence the formulation of demand and help seeking by people using primary care services are discussed.

Evolving populations with overlapping generations

In this paper, we extend a previously published model of an evolving finite population of multi-locus organisms, where the dynamics of the evolving system are described by the cumulants of the population efficacy distribution. We consider the case of overlapping generations and compare it to the previously studied case where generations are discrete. In the weak selection limit, we can solve the dynamics analytically and show that the changes in population genetic variance due to stochastic effects-genetic drift-is twice as great when generations overlap. The comparison of the dynamics of the two models shows many of the features seen in the comparison, performed by Moran, of simple one-locus genetic models with overlapping and non-overlapping generations. Studying the dynamics of the two models gives some insights into these comparisons.

Depressive symptoms in the frail elderly: physical and psycho-social correlates

The elderly who suffer from chronic illness are at unusually high risk of depression and depressive symptoms. This study was conducted to describe the prevalence of depressive symptoms in a sample of chronically-ill elders and to examine the relationship between physical illness and depression, both as it is illuminated in a regression model and as it is understood by the respondents themselves. Interviews were conducted with a random sample of 100 clients in a community-based care program for low-income elderly at risk of nursing home placement. Over one-third of the sample (36%) reported significant depressive symptoms, as measured by the CES-D. Multiple regression analysis identified functional limitations, cognitive impairment and self-perception as significant correlates of depression in a model that explained 30 percent of the variance in CES-D scores.

Distribution of mesothelioma cases in different occupational groups and industries in Australia, 1979-1995

Australia was a producer and user of asbestos and has one of the highest national incidences of mesothelioma in the world. The incidence is still rising and expected to do so for another 10-20 years. A study was conducted in 1996 to examine the past and current incidence rates of mesothelioma in a number of industries and occupations as the basis for predicting future outcomes. Occupational histories of a total of 3758 mesothelioma cases collected by two sequential national schemes--the Australian Mesothelioma Surveillance Program (1979-1985) and Australian Mesothelioma Register (1986-1995)--were reviewed and coded by the authors. The building industry contributed the largest number of cases nationwide followed by shipbuilding and repair, asbestos cement production, crocidolite mining and milling, railway locomotive construction and repair, coal-fired power stations, and other engineering operations. The mean latency between initial occupational asbestos exposure and diagnosis of the disease was 37.4 years (range = 4-66 years) for cases notified between 1979 and 1985, and 41.4 years (range = 6-84 years) for those between 1986 and 1995. Trends for each industry group have been changing considerably in the past 16 years, with the traditional primary asbestos industry cases from crocidolite mining and milling now on the decline and cases from asbestos cement production having plateaued. In contrast, more recently, more cases were observed from the asbestos user industries such as the building industry, and from occupations such as plumbers, carpenters, machinists, and car mechanics. These increases might be a reflection of the longer latency effects of the intermittent and less severe exposures in these larger occupational groups.

Application of an in vitro model to evaluate bioadhesion of fibroblasts and epithelial cells to two different dressings

The cellular component of a healing wound consists of many cell types and the environment in which these cells grow is important to the rate and quality of healing which can be influenced by the type of dressing used. The most commonly used dressings are traditional gauze-type dressings. In many cases these dressings may adhere to the wound surface, and subsequent removal is often traumatic, causing pain and tissue reinjury. Some modern gelling dressings have been developed to overcome this adherence problem. In order to evaluate in more detail cell-dressing interactions, an in vitro model has been developed utilising wound fibroblasts and epithelial cells. Quantitative evaluation of adherence of cells cultured with a traditional gauze or a new gelling dressing has been undertaken using radiolabel and manual counting techniques. Scanning electron microscopy has been used to visualise the cells adherent to dressings allowing evaluation of their adhesion-morphology. The results show differential attachment of cells to viscose and gelling fibres of the dressings; considerably reduced cell adhesion to the gelling fibre was evident, and it was apparent that cells adhered predominantly to the viscose component of the dressing. This model can be used to investigate and compare the adhesion of cells to different dressings and their components.