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Fox MN, Dickson JM, Burch P, Hind D, Hawksworth L. Delivering relational continuity of care in UK general practice: a scoping review. BJGP Open 2024:BJGPO.2024.0041. [PMID: 38438196 DOI: 10.3399/bjgpo.2024.0041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 02/23/2024] [Accepted: 02/23/2024] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND Relational continuity of care (patients seeing the same GP) is associated with better outcomes for patients, but it has been declining in general practice in the UK. AIM To understand what interventions have been tried to improve relational continuity of care in general practice in the UK. DESIGN & SETTING Scoping review METHOD: An electronic search of MEDLINE, Embase and Scopus from 2002 to the present day was undertaken. Sources of grey literature were also searched. Studies that detailed service-level methods of achieving relational continuity of care with a GP in the UK were eligible for inclusion. Interventions were described narratively in relation to the elements listed in the Template for Intervention Description and Replication (TIDieR). A logic model describing the rationale behind interventions was constructed. RESULTS 17 unique interventions were identified. The interventions used a wide variety of strategies to try to improve relational continuity. This included personal lists, amended booking processes, regular reviews, digital technology, facilitated follow ups, altered appointment times, and use of acute hubs. 12 of the interventions targeted specific patient groups for increased continuity whilst others focused on increasing continuity for all patients. Changes in continuity levels were measured inconsistently using several different methods. CONCLUSION Several different strategies have been used in UK general practices in an attempt to improve relational continuity of care. Whilst there is a similar underlying logic to these interventions, their scope, aims and methods vary considerably. Furthermore, due to a weak evidence base, comparing their efficacy remains challenging.
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Affiliation(s)
- Miglena Nikolaeva Fox
- University of Sheffield, Centre for Health and Related Research Peak Edge PCN and SY ICB Sheffield, Sheffield, United Kingdom
| | - Jon M Dickson
- Sheffield Centre for Health and Related Research, School of Medicine and Population Health, The University of Sheffield, Sheffield, United Kingdom
| | - Patrick Burch
- Centre for Primary Care, University of Manchester, Manchester, United Kingdom
| | - Daniel Hind
- Sheffield Centre for Health and Related Research, School of Medicine and Population Health, The University of Sheffield, Sheffield, United Kingdom
| | - Liv Hawksworth
- Sheffield Centre for Health and Related Research, School of Medicine and Population Health, The University of Sheffield, Sheffield, United Kingdom
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Noble AJ, Morris B, Bonnett LJ, Reuber M, Mason S, Wright J, Pilbery R, Bell F, Shillito T, Marson AG, Dickson JM. 'Knowledge exchange' workshops to optimise development of a risk prediction tool to assist conveyance decisions for suspected seizures - Part of the Risk of ADverse Outcomes after a Suspected Seizure (RADOSS) project. Epilepsy Behav 2024; 151:109611. [PMID: 38199055 DOI: 10.1016/j.yebeh.2023.109611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 12/21/2023] [Accepted: 12/22/2023] [Indexed: 01/12/2024]
Abstract
PURPOSE Suspected seizures present challenges for ambulance services, with paramedics reporting uncertainty over whether or not to convey individuals to emergency departments. The Risk of ADverse Outcomes after a Suspected Seizure (RADOSS) project aims to address this by developing a risk assessment tool utilizing structured patient care record and dispatch data. It proposes a tool that would provide estimates of an individual's likelihood of death and/or recontact with emergency care within 3 days if conveyed compared to not conveyed, and the likelihood of an 'avoidable attendance' occurring if conveyed. Knowledge Exchange workshops engaged stakeholders to resolve key design uncertainties before model derivation. METHOD Six workshops involved 26 service users and their significant others (epilepsy or nonepileptic attack disorder), and 25 urgent and emergency care clinicians from different English ambulance regions. Utilizing Nominal Group Techniques, participants shared views of the proposed tool, benefits and concerns, suggested predictors, critiqued outcome measures, and expressed functionality preferences. Data were analysed using Hamilton's Rapid Analysis. RESULTS Stakeholders supported tool development, proposing 10 structured variables for predictive testing. Emphasis was placed on the tool supporting, not dictating, care decisions. Participants highlighted some reasons why RADOSS might struggle to derive a predictive model based on structured data alone and suggested some non-structured variables for future testing. Feedback on prediction timeframes for service recontact was received, along with advice on amending the 'avoidable attendance' definition to prevent the tool's predictions being undermined by potential overuse of certain investigations in hospital. CONCLUSION Collaborative stakeholder engagement provided crucial insights that can guide RADOSS to develop a user-aligned, optimized tool.
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Affiliation(s)
- Adam J Noble
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, UK.
| | - Beth Morris
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Laura J Bonnett
- Department of Health Data Science, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Markus Reuber
- Department of Neuroscience, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | - Suzanne Mason
- Sheffield Centre for Health and Related Research, School of Medicine and Population Health, University of Sheffield, Sheffield, UK
| | | | | | - Fiona Bell
- Yorkshire Ambulance Service NHS Trust, Wakefield, UK
| | | | - Anthony G Marson
- Department of Pharmacology and Therapeutics, Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, UK
| | - Jon M Dickson
- Population Health, School of Medicine and Population Health, The University of Sheffield, Sheffield, UK
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Goodacre S, Sutton L, Thomas B, Hawksworth O, Iftikhar K, Croft S, Fuller G, Waterhouse S, Hind D, Bradburn M, Smyth MA, Perkins GD, Millins M, Rosser A, Dickson JM, Wilson MJ. Prehospital early warning scores for adults with suspected sepsis: retrospective diagnostic cohort study. Emerg Med J 2023; 40:768-776. [PMID: 37673643 PMCID: PMC10646863 DOI: 10.1136/emermed-2023-213315] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 08/18/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Ambulance services need to identify and prioritise patients with sepsis for early hospital assessment. We aimed to determine the accuracy of early warning scores alongside paramedic diagnostic impression to identify sepsis that required urgent treatment. METHODS We undertook a retrospective diagnostic cohort study involving adult emergency medical cases transported to Sheffield Teaching Hospitals ED by Yorkshire Ambulance Service in 2019. We used routine ambulance service data to calculate 21 early warning scores and categorise paramedic diagnostic impressions as sepsis, infection, non-specific presentation or other presentation. We linked cases to hospital records and identified those meeting the sepsis-3 definition who received urgent hospital treatment for sepsis (reference standard). Analysis determined the accuracy of strategies that combined early warning scores at varying thresholds for positivity with paramedic diagnostic impression. RESULTS We linked 12 870/24 955 (51.6%) cases and identified 348/12 870 (2.7%) with a positive reference standard. None of the strategies provided sensitivity greater than 0.80 with positive predictive value greater than 0.15. The area under the receiver operating characteristic curve for the National Early Warning Score, version 2 (NEWS2) applied to patients with a diagnostic impression of sepsis or infection was 0.756 (95% CI 0.729, 0.783). No other early warning score provided clearly superior accuracy to NEWS2. Paramedic impression of sepsis or infection had sensitivity of 0.572 (0.519, 0.623) and positive predictive value of 0.156 (0.137, 0.176). NEWS2 thresholds of >4, >6 and >8 applied to patients with a diagnostic impression of sepsis or infection, respectively, provided sensitivities and positive predictive values of 0.522 (0.469, 0.574) and 0.216 (0.189, 0.245), 0.447 (0.395, 0.499) and 0.274 (0.239, 0.313), and 0.314 (0.268, 0.365) and 0.333 (0.284, 0.386). CONCLUSION No strategy is ideal but using NEWS2 alongside paramedic diagnostic impression of infection or sepsis could identify one-third to half of sepsis cases without prioritising unmanageable numbers. No other score provided clearly superior accuracy to NEWS2. TRIAL REGISTRATION NUMBER researchregistry5268, https://www.researchregistry.com/browse-the-registry%23home/registrationdetails/5de7bbd97ca5b50015041c33/.
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Affiliation(s)
- Steve Goodacre
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | - Laura Sutton
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | - Ben Thomas
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | - Olivia Hawksworth
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | | | - Susan Croft
- Emergency Department, Northern General Hospital, Sheffield, UK
| | - Gordon Fuller
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | - Simon Waterhouse
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | - Daniel Hind
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | - Mike Bradburn
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | | | | | - Mark Millins
- Yorkshire Ambulance Service NHS Trust, Wakefield, UK
| | - Andy Rosser
- West Midlands Ambulance Service, West Midlands, UK
| | - Jon M Dickson
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
| | - Matthew Joseph Wilson
- Sheffield Centre for Health and Related Research (SCHARR), The University of Sheffield, Sheffield, UK
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Peacock M, Bissell P, Ellis J, Dickson JM, Wardrope A, Grünewald R, Reuber M. 'I just need to know what they are and if you can help me': Medicalization and the search for legitimacy in people diagnosed with non-epileptic attack disorder. Epilepsy Behav 2023; 148:109485. [PMID: 37857031 DOI: 10.1016/j.yebeh.2023.109485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 09/14/2023] [Accepted: 10/07/2023] [Indexed: 10/21/2023]
Abstract
This paper focuses on the struggles for legitimacy expressed by people with non-epileptic attack disorder (NEAD), one of the most common manifestations of functional neurological disorder presenting to emergency and secondary care services. Nonepileptic attacks are episodes of altered experience, awareness, and reduced self-control that superficially resemble epileptic seizures or other paroxysmal disorders but are not associated with physiological abnormalities sufficient to explain the semiological features. "Organic" or medicalized explanations are frequently sought by patients as the only legitimate explanation for symptoms, and consequently, a diagnosis of NEAD is often contested. Drawing on narrative interviews with patients from a small exploratory study and using a sociological perspective, we propose that a psychological account of NEAD does not provide a sufficiently legitimate path into a socially sanctioned sick role. This is a reflection of the dominance of biomedicine and the associated processes of medicalization. These processes are, we argue, the sole route to achieving legitimacy. The stress-based or psychologically oriented explanations offered to patients in contemporary medical models of the etiology of NEAD engender an uncertain identity and social position and fail to provide many patients with an account of the nature or origin of their symptoms that they find satisfactory or convincing. These struggles for legitimacy (shared by others with functional or somatoform conditions) are sharpened by key features of the contemporary healthcare landscape, such as the increasing framing of health through a lens of 'responsibilization'.
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Affiliation(s)
- Marian Peacock
- Edge Hill University, Faculty of Health, Social Care & Medicine, St Helens Road, Ormskirk L39 4QP, UK.
| | | | - Julie Ellis
- Ramsden Building, University of Huddersfield, Queensgate, Huddersfield HD1 3DH, UK.
| | - Jon M Dickson
- The Medical School, The University of Sheffield, Samuel Fox House, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK.
| | - Alistair Wardrope
- Department of Neuroscience, The University of Sheffield, Sheffield, UK; Department of Clinical Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK.
| | - Richard Grünewald
- Academic Neurology Unit, University of Sheffield, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, UK.
| | - Markus Reuber
- Academic Neurology Unit, University of Sheffield, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, UK.
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5
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Dickson JM, Hilton A, Kelsall C, Cormack L. Primary care: the sleeping giant of research delivery. Br J Gen Pract 2023; 73:198-199. [PMID: 37105738 PMCID: PMC10147423 DOI: 10.3399/bjgp23x732573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/29/2023] Open
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Wigglesworth S, Neligan A, Dickson JM, Pullen A, Yelland E, Anjuman T, Reuber M. The incidence and prevalence of epilepsy in the United Kingdom 2013-2018: A retrospective cohort study of UK primary care data. Seizure 2023; 105:37-42. [PMID: 36702018 DOI: 10.1016/j.seizure.2023.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/20/2022] [Accepted: 01/04/2023] [Indexed: 01/07/2023] Open
Abstract
PURPOSE The aim of this study was to update overall incidence and prevalence calculations for epilepsy of the United Kingdom (UK) and its constituent nations (England, Northern Ireland, Scotland, and Wales). METHODS We used data from primary care practices contributing to the Clinical Practice Research Datalink (CRPD), based on the electronic health records of 14 million patients, representing approximately 20% of the population. CPRD contains data from two different health record systems: the Vision clinical system (CPRD GOLD database) and the EMIS Web® clinical system (CPRD Aurum database). We calculated incidence and prevalence rates with 95% confidence intervals (CIs). Data were stratified by age, gender, deprivation, country (England, Scotland, Wales and Northern Ireland) and region (England only). RESULTS In the UK, the estimated overall point prevalence for epilepsy was 9.37 per 1000 persons / year (95% CI 9.34-9.40) and the overall estimated incidence rate was 42.68 per 100,000 person-years (95% 42.18-43.18) using the CPRD GOLD database. In England, the estimated incidence (37.41 (95% CI 36.96-37.83)) and prevalence (8.85 (95% CI 8.83-8.87)) was lower (combined databases) compared to figures for Scotland (incidence 47.76 (95% CI 46.15-49.42)); prevalence 10.13 (95% CI 10.06-10.20)) (CPRD GOLD only), Wales (incidence 54.84 (95% CI 52.79-56.95); prevalence 11.40 (95% CI 11.31-11.49)) (CPRD GOLD only) and Northern Ireland (incidence 46.18 (95% CI 43.13-49.90); prevalence 12.08 (95% CI 11.93-12.23))(combined databases). Prevalence and incidence were higher in more deprived regions. CONCLUSION The prevalence and incidence of epilepsy in the UK is broadly in line with other high income countries, showing the usual pattern of high incidence in the young and the old, with a nadir in middle age. The prevalence of epilepsy has fallen slightly since 2011. There is significant geographical variation (between countries and between regions), and a suggestion of a relationship between deprivation and epilepsy which needs further investigation.
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Affiliation(s)
- S Wigglesworth
- Former employee of Epilepsy Action, Yeadon, Leeds, United Kingdom.
| | - A Neligan
- Homerton University Hospital Foundation Trust, Homerton Row, London E9 6SR, United Kingdom; DCEE, UCL Queen Square Institute of Neurology, Queen Square, London, WC1N 3BG, United Kingdom
| | - J M Dickson
- Academic Unit of Primary Medical Care, The University of Sheffield, Sheffield, United Kingdom
| | - A Pullen
- Epilepsy Research UK, London, United Kingdom
| | - E Yelland
- Medicines and Healthcare products Regulatory Agency, London, United Kingdom
| | - T Anjuman
- Medicines and Healthcare products Regulatory Agency, London, United Kingdom
| | - M Reuber
- Academic Neurology Unit, University of Sheffield, Sheffield, United Kingdom
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7
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Goodacre S, Thomas B, Smyth M, Dickson JM. Should prehospital early warning scores be used to identify which patients need urgent treatment for sepsis? BMJ 2021; 375:n2432. [PMID: 34663583 DOI: 10.1136/bmj.n2432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield S1 4DA, UK
| | - Ben Thomas
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield S1 4DA, UK
| | - Michael Smyth
- Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Jon M Dickson
- Faculty of Medicine Dentistry and Health, University of Sheffield, Sheffield S10 2HQ, UK
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8
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Quah MCH, Marney BC, Cooper RJ, Dickson JM. Chronic pain and opioid analgesic use: A case report. Clin Case Rep 2021; 9:e04370. [PMID: 34257976 PMCID: PMC8259929 DOI: 10.1002/ccr3.4370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 12/23/2020] [Accepted: 05/07/2021] [Indexed: 11/11/2022] Open
Abstract
Relationship-based medical care is essential in the management of chronic pain. Opioids are often ineffective and can cause significant harm. However, there is significant time pressure, and there are insufficient resources and guidelines for GPs to be able to offer alternatives, putting the NHS at risk of a growing opioid epidemic.
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Affiliation(s)
| | | | - Richard J. Cooper
- School of Health And Related Research (ScHARR)University of SheffieldSheffieldUK
| | - Jon M. Dickson
- The Medical SchoolThe University of SheffieldSheffieldUK
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9
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Burton C, Stone T, Oliver P, Dickson JM, Lewis J, Mason SM. Frequent attendance at the emergency department shows typical features of complex systems: analysis of multicentre linked data. Emerg Med J 2021; 39:3-9. [PMID: 34039641 DOI: 10.1136/emermed-2020-210772] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 03/21/2021] [Accepted: 04/06/2021] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Frequent attendance at the ED is a worldwide problem. We hypothesised that frequent attendance could be understood as a feature of a complex system comprising patients, healthcare and society. Complex systems have characteristic statistical properties, with stable patterns at the level of the system emerging from unstable patterns at the level of individuals who make up the system. METHODS Analysis of a linked dataset of routinely collected health records from all 13 hospital trusts providing ED care in the Yorkshire and Humber region of the UK (population 5.5 million). We analysed the distribution of attendances per person in each of 3 years and measured the transition of individual patients between frequent, infrequent and non-attendance. We fitted data to power law distributions typically seen in complex systems using maximum likelihood estimation. RESULTS The data included 3.6 million attendances at EDs in 13 hospital trusts. 29/39 (74.3%) analyses showed a statistical fit to a power law; 2 (5.1%) fitted an alternative distribution. All trusts' data fitted a power law in at least 1 year. Differences over time and between hospital trusts were small and partly explained by demographics. In contrast, individual patients' frequent attendance was unstable between years. CONCLUSIONS ED attendance patterns are stable at the level of the system, but unstable at the level of individual frequent attenders. Attendances follow a power law distribution typical of complex systems. Interventions to address ED frequent attendance need to consider the whole system and not just the individual frequent attenders.
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Affiliation(s)
- Christopher Burton
- The Academic Unit of Primary Medical Care, The University of Sheffield, Sheffield, UK
| | - Tony Stone
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Phillip Oliver
- The Academic Unit of Primary Medical Care, The University of Sheffield, Sheffield, UK
| | - Jon M Dickson
- The Academic Unit of Primary Medical Care, The University of Sheffield, Sheffield, UK
| | - Jen Lewis
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Suzanne M Mason
- School of Health and Related Research, University of Sheffield, Sheffield, UK
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10
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Hughes-Gooding T, Dickson JM, O'Keeffe C, Mason SM. A data linkage study of suspected seizures in the urgent and emergency care system in the UK. Emerg Med J 2020; 37:605-610. [PMID: 32546473 PMCID: PMC7525779 DOI: 10.1136/emermed-2019-208820] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 04/11/2020] [Accepted: 04/29/2020] [Indexed: 11/04/2022]
Abstract
INTRODUCTION The urgent and emergency care (UEC) system is struggling with increased demand, some of which is clinically unnecessary. Patients suffering suspected seizures commonly present to EDs, but most seizures are self-limiting and have low risk of short-term adverse outcomes. We aimed to investigate the flow of suspected seizure patients through the UEC system using data linkage to facilitate the development of new models of care. METHODS We used a two-stage process of deterministic linking to perform a cross-sectional analysis of data from adults in a large region in England (population 5.4 million) during 2014. The core dataset comprised a total of 739 436 ambulance emergency incidents, 1 033 778 ED attendances and 362 358 admissions. RESULTS A high proportion of cases were successfully linked (86.9% ED-inpatient, 77.7% ED-ambulance). Suspected seizures represented 2.8% of all ambulance service incidents. 61.7% of these incidents led to dispatch of a rapid-response ambulance (8 min) and 72.1% were conveyed to hospital. 37 patients died before being conveyed to hospital and 24 died in the ED (total 61; 0.3%). The inpatient death rate was 0.4%. Suspected seizures represented 0.71% of ED attendances, 89.8% of these arrived by emergency ambulance, 45.4% were admitted and 44.5% of these admissions lasted under 48 hours. CONCLUSIONS This study confirms previously published data from smaller unlinked datasets, validating the linkage method, and provides new data for suspected seizures. There are significant barriers to realising the full potential of data linkage. Collaborative action is needed to create facilitative governance frameworks and improve data quality and analytical capacity.
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Affiliation(s)
- Thomas Hughes-Gooding
- The University of Sheffield Medical School, Sheffield, UK
- Rotherham General Hospitals NHS Trust, Rotherham, UK
| | - Jon M Dickson
- The Academic Unit of Primary Medical Care, The University of Sheffield, Sheffield, UK
| | - Colin O'Keeffe
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Suzanne M Mason
- School of Health and Related Research, The University of Sheffield, Sheffield, UK
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O’Cathain A, Knowles E, Long J, Connell J, Bishop-Edwards L, Simpson R, Coster J, Abouzeid L, Bennett S, Croot E, Dickson JM, Goodacre S, Hirst E, Jacques R, Phillips M, Turnbull J, Turner J. Drivers of ‘clinically unnecessary’ use of emergency and urgent care: the DEUCE mixed-methods study. Health Serv Deliv Res 2020. [DOI: 10.3310/hsdr08150] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
There is widespread concern about the pressure on emergency and urgent services in the UK, particularly emergency ambulances, emergency departments and same-day general practitioner appointments. A mismatch between supply and demand has led to interest in what can be termed ‘clinically unnecessary’ use of services. This is defined by the research team in this study as ‘patients attending services with problems that are classified as suitable for treatment by a lower urgency service or self-care’. This is a challenging issue to consider because patients may face difficulties when deciding the best action to take, and different staff may make different judgements about what constitutes a legitimate reason for service use.
Objectives
To identify the drivers of ‘clinically unnecessary’ use of emergency ambulances, emergency departments and same-day general practitioner appointments from patient and population perspectives.
Design
This was a sequential mixed-methods study with three components: a realist review; qualitative interviews (n = 48) and focus groups (n = 3) with patients considered ‘clinically unnecessary’ users of these services, focusing on parents of young children, young adults and people in areas of social deprivation; and a population survey (n = 2906) to explore attitudes towards seeking care for unexpected, non-life-threatening health problems and to identify the characteristics of someone with a tendency for ‘clinically unnecessary’ help-seeking.
Results
From the results of the three study components, we found that multiple, interacting drivers influenced individuals’ decision-making. Drivers could be grouped into symptom related, patient related and health service related. Symptom-related drivers were anxiety or need for reassurance, which were caused by uncertainty about the meaning or seriousness of symptoms; concern about the impact of symptoms on daily activities/functioning; and a need for immediate relief of intolerable symptoms, particularly pain. Patient-related drivers were reduced coping capacity as a result of illness, stress or limited resources; fear of consequences when responsible for another person’s health, particularly a child; and the influence of social networks. Health service-related drivers were perceptions or previous experiences of services, particularly the attractions of emergency departments; a lack of timely access to an appropriate general practitioner appointment; and compliance with health service staff’s advice.
Limitations
Difficulty recruiting patients who had used the ambulance service to the interviews and focus groups meant that we were not able to add as much as we had anticipated to the limited evidence base regarding this service.
Conclusions
Patients use emergency ambulances, emergency departments and same-day general practitioner appointments when they may not need the level of clinical care provided by these services for a multitude of inter-related reasons that sometimes differ by population subgroup. Some of these reasons relate to health services, in terms of difficulty accessing general practice leading to use of emergency departments, and to population-learnt behaviour concerning the positive attributes of emergency departments, rather than to patient characteristics. Social circumstances, such as complex and stressful lives, influence help-seeking for all three services. Demand may be ‘clinically unnecessary’ but completely understandable when service accessibility and patients’ social circumstances are considered.
Future work
There is a need to evaluate interventions, including changing service configuration, strengthening general practice and addressing the stressors that have an impact on people’s coping capacity. Different subgroups may require different interventions.
Study registration
This study is registered as PROSPERO CRD42017056273.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 15. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Alicia O’Cathain
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Emma Knowles
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jaqui Long
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Janice Connell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | - Rebecca Simpson
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Joanne Coster
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | | | - Elizabeth Croot
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jon M Dickson
- Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, UK
| | - Steve Goodacre
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Enid Hirst
- Sheffield Emergency Care Forum, Sheffield, UK
| | - Richard Jacques
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | | | | | - Janette Turner
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Mathieson A, Marson AG, Jackson M, Ridsdale L, Goodacre S, Dickson JM, Noble AJ. Clinically unnecessary and avoidable emergency health service use for epilepsy: A survey of what English services are doing to reduce it. Seizure 2020; 76:156-160. [PMID: 32092677 DOI: 10.1016/j.seizure.2020.02.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Revised: 02/13/2020] [Accepted: 02/17/2020] [Indexed: 10/25/2022] Open
Abstract
PURPOSE Epilepsy is associated with costly unplanned health service use. The UK's National Audits of Seizure Management in Hospital found use was often clinically unnecessary, avoidable and typically led to little benefit for epilepsy management. We systematically identified how services have responded to reduce such use. METHODS We invited England's ambulance services, neuroscience and neurology centres and a random sample of Emergency Departments (EDs) to complete a survey. It asked what innovations they (or services they worked with) had made in the past 5 years or were making, the priority afforded to them, user involvement, what comprised usual practice, and barriers to change. RESULTS 72/87 of invited (82.8 %) services responded. EDs ascribed less priority to reducing emergency hospital use for epilepsy and convulsions, than other service types. Overall, 60 % of services reported a change(s) and/or were planning one. Neurology/neuroscience sites (93.8 %) were most likely to report change; EDs (15.4 %) least likely. Eleven types of change were identified; 5 sought to promote proactive epilepsy care and avert the need for emergency care; 3 focused on the care received from emergency services; and 3 focused on follow-up care ED attendees received. Most were for those with established, rather than new epilepsy and targeted known limitations to current care provision. CONCLUSION Reducing emergency hospital use by PWE is a high priority for most health services in England and a number of new services have been developed. However, they have not been consistently implemented and innovation is lacking in some areas of care.
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Affiliation(s)
- Amy Mathieson
- Department of Health Services Research, University of Liverpool, UK.
| | - Anthony G Marson
- Department of Molecular and Clinical Pharmacology, University of Liverpool. UK
| | - Mike Jackson
- North West Ambulance Service NHS Trust, Bolton, UK
| | - Leone Ridsdale
- Department of Basic and Clinical Neuroscience, King's College London, UK
| | - Steve Goodacre
- School of Health and Related Research, University of Sheffield, UK
| | - Jon M Dickson
- Academic Unit of Primary Medical Care, University of Sheffield, UK
| | - Adam J Noble
- Department of Health Services Research, University of Liverpool, UK
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Cherry MG, Ablett JR, Dickson JM, Powell D, Sikdar S, Salmon P. A qualitative study of the processes by which carers of people with dementia derive meaning from caring. Aging Ment Health 2019; 23:69-76. [PMID: 29105501 DOI: 10.1080/13607863.2017.1393792] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Most individuals with dementia live in the community, receiving care from family or lay carers. Carers' wellbeing, and the quality of the care they provide, partly depends on their ability to derive meaning from caring for someone with dementia. Both carers' previous relationship with their relative and the caregiving process itself contribute to this sense of meaning. However, it remains unclear why some carers derive meaning from these sources, whereas others do not. OBJECTIVE To further explore the processes by which carers derive a sense of meaning from caring. METHODS Representative case sampling was used to recruit a purposive sample of 20 carers for individuals living with dementia. In-depth semi-structured interviews were audio-recorded and transcribed, and analysed using pluralist qualitative methodology. RESULTS A framework of three sources from which carers derived meaning from caring was identified, encompassing: carers' perceptions of how 'right' or 'symmetrical' caring felt in light of their current and previous relationship with the person with dementia; maintenance of a 'protected' sense of self within the care relationship; and carers' perceptions of their 'social connectedness' outside the relationships. CONCLUSION Holistic assessment based on this framework could help to tailor individualised provision of support, foster resilience and safeguard carers' well-being.
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Affiliation(s)
- M G Cherry
- a Department of Psychological Sciences , University of Liverpool , Liverpool , United Kingdom of Great Britain and Northern Ireland.,b Liverpool Cancer Psychology Service, Linda Mccartney Centre , Royal Liverpool University Hospital , Liverpool , United Kingdom of Great Britain and Northern Ireland
| | - J R Ablett
- b Liverpool Cancer Psychology Service, Linda Mccartney Centre , Royal Liverpool University Hospital , Liverpool , United Kingdom of Great Britain and Northern Ireland.,c Division of Clinical Psychology , University of Liverpool , Liverpool , United Kingdom of Great Britain and Northern Ireland
| | - J M Dickson
- a Department of Psychological Sciences , University of Liverpool , Liverpool , United Kingdom of Great Britain and Northern Ireland.,d Psychology Department (Building 30) , Edith Cowan University , Joondalup , Australia
| | - D Powell
- e Arise Clinical Psychology Liverpool , Liverpool , United Kingdom of Great Britain and Northern Ireland
| | - S Sikdar
- f Older Adults' Mental Health Team , South Sefton Community Resource Centre , Liverpool , United Kingdom of Great Britain and Northern Ireland
| | - P Salmon
- c Division of Clinical Psychology , University of Liverpool , Liverpool , United Kingdom of Great Britain and Northern Ireland
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Narice BF, Delaney B, Dickson JM. Endometrial sampling in low-risk patients with abnormal uterine bleeding: a systematic review and meta-synthesis. BMC Fam Pract 2018; 19:135. [PMID: 30060741 PMCID: PMC6066914 DOI: 10.1186/s12875-018-0817-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Accepted: 07/10/2018] [Indexed: 11/10/2022]
Abstract
BACKGROUND One million women per year seek medical advice for abnormal uterine bleeding (AUB) in the United Kingdom. Many low-risk patients who could be managed exclusively in primary care are referred to hospital based gynaecology services. Performing endometrial sampling (ES) in the community may improve care, reduce the rate of referrals and minimise costs. We aimed to search and synthesise the literature on the effectiveness of ES (Pipelle versus other devices) in managing AUB in low-risk patients. METHODS We undertook an electronic literature search in MEDLINE via OvidSP, Scopus, and Web of Science for relevant English-language articles from 1984 to 2016 using a combination of MeSH and keywords. Two reviewers independently pre-selected 317 articles and agreed on 60 articles reporting data from over 7300 patients. Five themes were identified: sample adequacy, test performance, pain and discomfort, cost-effectiveness, and barriers and complications of office ES. RESULTS Pipelle seems to perform as well as dilation and curettage and, as well or better than other ES devices in terms of sampling adequacy and sensitivity. It also seems to be better regarding pain/discomfort and costs. However, Pipelle can disrupt the sonographic appearance of the endometrium and may be limited by cervical stenosis, pelvic organ prolapse and endometrial atrophy. CONCLUSIONS The current evidence supports the use of Pipelle in the management of low-risk women presenting in the outpatient setting with symptomatic AUB when combined with clinical assessment and ultrasound scanning. However, the implications of its widespread use in primary care are uncertain and more research is required.
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Affiliation(s)
- Brenda F. Narice
- Clinical Research Fellow in Obstetrics & Gynaecology; Academic Unit of Reproductive and Developmental Unit, University of Sheffield, Sheffield, S10 2SF UK
| | - Brigitte Delaney
- Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, S5 7AU UK
| | - Jon M. Dickson
- Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, S5 7AU UK
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Dickson JM, Asghar ZB, Siriwardena AN. Pre-hospital ambulance care of patients following a suspected seizure: A cross sectional study. Seizure 2018; 57:38-44. [DOI: 10.1016/j.seizure.2018.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 03/02/2018] [Accepted: 03/07/2018] [Indexed: 10/17/2022] Open
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Grunewald R, Dickson J, Hick J, Jacques R, Campbell M, Morley R, Reuber M, Dickson JM, Hick J, Jacques R, Grünewald RA, Campbell MJ, Morley R, Reuber M. 1800 Uk unscheduled admissions for adults with suspected seizures. J Neurol Neurosurg Psychiatry 2017. [DOI: 10.1136/jnnp-2017-abn.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Dickson JM, Delaney B, Connor ME. Primary care endometrial sampling for abnormal uterine bleeding: a pilot study. J Fam Plann Reprod Health Care 2017; 43:296-301. [PMID: 28823998 DOI: 10.1136/jfprhc-2017-101735] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 06/19/2017] [Accepted: 07/11/2017] [Indexed: 11/04/2022]
Abstract
AIM To design and evaluate a pilot service for primary care endometrial sampling (PCES). DESIGN Retrospective analysis of data from two service evaluations. SETTING General practices and the gynaecology department in a large city in the UK. METHODS These were two-fold: (1) To design the new service we identified all the endometrial samples taken in the city's gynaecology department in 2012/2013 and estimated the proportion of these with abnormal uterine bleeding (AUB) that would be suitable for PCES. (2) To evaluate the new PCES service we analysed data from the first year of activity. RESULTS (1) A total of 1894 endometrial samples were taken in hospital in 2012/2013. An estimated 424 (22.4%) of these were from patients with AUB who fitted the criteria for PCES. (2) In the first year of the PCES service 108 samples were taken by general practitioners (GPs). Initial management of these patients was exclusively in primary care in 97.2% (104/108) of cases; most patients were treated with the Mirena intrauterine system (79/109; 73.1%) and there were no cases of hyperplasia or cancer. CONCLUSIONS Most premenopausal patients with AUB could potentially be managed in primary care without referral to hospital if endometrial sampling (ES) was made available to appropriately trained and supported GPs. However, this study was limited by its retrospective, non-interventional design, and more research is required to demonstrate safety and cost-effectiveness.
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Affiliation(s)
- Jon M Dickson
- The University of Sheffield, The Academic Unit of Primary Medical Care, Northern General Hospital, Sheffield, UK
| | - Brigitte Delaney
- The University of Sheffield, The Academic Unit of Primary Medical Care, Northern General Hospital, Sheffield, UK
| | - Mary E Connor
- Department of Obstetrics and Gynaecology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Affiliation(s)
- Jon M Dickson
- The Academic Unit of Primary Medical Care, The University of Sheffield, Sheffield, UK
| | - Suzanne M Mason
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Andy Bailey
- Information Services - Strategy & Operations, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Abstract
OBJECTIVES Suspected seizures are a common reason for emergency calls to ambulance services. Prehospital management of these patients is an important element of good quality care. The aim of this study, conducted in a regional ambulance service in the UK, was to quantify the number of emergency telephone calls for suspected seizures in adults, the associated costs, and to describe the patients' characteristics, their prehospital management and their immediate outcomes. DESIGN Quantitative cross-sectional study using routinely collected data and a detailed review of the clinical records of a consecutive series of adult patients (≥ 16 years). SETTING A regional ambulance service within the National Health Service in England. PARTICIPANTS Cross-sectional data from all 605,481 adult emergency incidents managed by the ambulance service from 1 April 2012 to 31 March 2013. We selected a consecutive series of 178 individual incidents from May 2012 for more detailed analysis (132 after exclusions and removal of non-seizure cases). RESULTS Suspected seizures made up 3.3% of all emergency incidents. True medical emergencies were uncommon but 3.3% had partially occluded airways, 6.8% had ongoing seizure activity and 59.1% had clinical problems in addition to the seizure (29.1% involving injury). Emergency vehicles were dispatched for 97.2% of suspected seizures, the seizure had terminated on arrival in 93.2% of incidents, 75% of these patients were transported to hospital. The estimated emergency management cost per annum of suspected seizures in the English ambulance services is £45.2 million (€64.0 million, $68.6 million). CONCLUSIONS Many patients with suspected seizures could potentially be treated more effectively and at lower cost by modifying ambulance call handling protocols. The development of innovative care pathways could give call handlers and paramedics alternatives to hospital transportation. Increased adoption of care plans could reduce 999 calls and could increase the rates of successful home or community treatment.
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Affiliation(s)
- Jon M Dickson
- Academic Unit of Primary Medical Care, The University of Sheffield, Samuel Fox House, Northern General Hospital, Sheffield, UK
| | - Louise H Taylor
- The Medical School, The University of Sheffield, Sheffield, UK
| | - Jane Shewan
- Research and Development, Yorkshire Ambulance Service NHS Trust, Wakefield, UK
| | - Trevor Baldwin
- Emergency Operations Centre, Yorkshire Ambulance Service NHS Trust, Wakefield, UK
| | - Richard A Grünewald
- Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Markus Reuber
- Academic Neurology Unit, The University of Sheffield, Sheffield, UK
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20
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Affiliation(s)
- Simon Bell
- Sheffield Teaching Hospital NHS Trust, Sheffield, UK
| | | | | | - Daniel Blackburn
- Sheffield Teaching Hospital NHS Trust, Sheffield, UK University of Sheffield, Sheffield, UK
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21
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Osborne A, Taylor L, Reuber M, Grünewald RA, Parkinson M, Dickson JM. Pre-hospital care after a seizure: Evidence base and United Kingdom management guidelines. Seizure 2014; 24:82-7. [PMID: 25264355 DOI: 10.1016/j.seizure.2014.09.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 08/08/2014] [Accepted: 09/01/2014] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Seizures are a common presentation to pre-hospital emergency services and they generate significant healthcare costs. This article summarises the United Kingdom (UK) Ambulance Service guidelines for the management of seizures and explores the extent to which these guidelines are evidence-based. METHODS Summary of the Clinical Practice Guidelines of the UK Joint Royal Colleges Ambulance Liaison Committee relating to the management of seizures. Review of the literature relating to pre-hospital management of seizure emergencies. RESULTS Much standard practice relating to the emergency out of hospital management of patients with seizures is drawn from generic Advanced Life Support (ALS) guidelines although many patients do not need ALS during or after a seizure and the benefit of many ALS interventions in seizure patients remains to be established. The majority of studies identified pertain to medical treatment of status epilepticus. These papers show that benzodiazepines are safe and effective but it is not possible to draw definitive conclusions about the best medication or the optimal route of administration. CONCLUSION The evidence base for current pre-hospital guidelines for seizure emergencies is incomplete. A large proportion of patients are transported to hospital after a seizure but many of these may be suitable for home management. However, there is very little research into alternative care pathways or criteria that could be used to help paramedics avoid transport to hospital. More research is needed to improve care for people after a seizure and to improve the cost-effectiveness of the healthcare systems within which they are treated.
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Affiliation(s)
- Andrew Osborne
- Academic Unit of Primary Medical Care, The Medical School, The University of Sheffield, Samuel Fox House, Northern General Hospital, Herries Road, Sheffield S5 7AU, South Yorkshire, United Kingdom.
| | - Louise Taylor
- Academic Unit of Primary Medical Care, The Medical School, The University of Sheffield, Samuel Fox House, Northern General Hospital, Herries Road, Sheffield S5 7AU, South Yorkshire, United Kingdom.
| | - Markus Reuber
- Academic Neurology Unit, The University of Sheffield, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, South Yorkshire, United Kingdom.
| | - Richard A Grünewald
- Academic Neurology Unit, The University of Sheffield, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, South Yorkshire, United Kingdom.
| | - Martin Parkinson
- Yorkshire Ambulance Service NHS Trust, Springhill 2, Brindley Way, Wakefield 41 Business Park, Wakefield WF2 0XQ, West Yorkshire, United Kingdom.
| | - Jon M Dickson
- Academic Unit of Primary Medical Care, The Medical School, The University of Sheffield, Samuel Fox House, Northern General Hospital, Herries Road, Sheffield S5 7AU, South Yorkshire, United Kingdom.
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Abstract
BACKGROUND We ran a peer-assisted learning programme for teaching clinical examination amongst graduate-entry medical students. We had three objectives: (1) to provide a forum for using peer-assisted learning to deliver the medical schools' clinical examination curriculum using the techniques of deliberate practice; (2) to obtain feedback on the programme using the nominal group technique; (3) to use the feedback to provide a means of improving the programme in subsequent years. METHODS The syllabus was based on the medical school's first year curriculum for clinical examination, and was drawn-up by one of the faculty members. The peer tutors were given a large degree of autonomy to run the programme as they thought best. At the end of the programme we used the nominal group technique to generate feedback. RESULTS Final-year graduate-entry students are capable of organising a high-quality peer-assisted learning programme to teach clinical examination based on the medical school's curriculum. DISCUSSION The nominal group technique provided an excellent method of generating structured feedback from the peer tutees, which required minimal resources and only a few hours of input from a neutral facilitator. The feedback session generated 14 specific suggestions for improving the programme in future years. These suggestions will be passed on to the peer tutors for next year, and in this way the feedback cycle is engrained in the programme.
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Affiliation(s)
- Jon M Dickson
- Macmillan Palliative Care Unit, Northern General Hospital, Sheffield, UK.
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23
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Dickson JM, Warren DJ, Chapman ALN, Anoop U, Hayat H, Bhattacharya D. Spontaneous abscess of the lumbar spine presenting as subacute back pain. BMJ Case Rep 2010; 2010:2010/sep23_1/bcr1120092505. [PMID: 22778378 DOI: 10.1136/bcr.11.2009.2505] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 52-year-old lady was admitted with back pain, fever and reduced sensation in her left leg. Soon after admission she developed acute urinary retention. She underwent urgent MRI of the spine which showed an epidural abscess compressing the thecal sac which was treated with neurosurgical decompression and intravenous/oral antibiotics. Cultures from theatre grew Staphylococcus aureus sensitive to flucloxacillin. After 12 weeks of intravenous/oral antibiotics, she was discharged without any neurological disability.
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Affiliation(s)
- Jon M Dickson
- SHO (GP VTS1), Health Care of the Elderly, Northern General Hospital, Sheffield, UK.
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Farrow TFD, Dickson JM, Grünewald RA. A six-year follow-up MRI study of complicated early childhood convulsion. Pediatr Neurol 2006; 35:257-60. [PMID: 16996398 DOI: 10.1016/j.pediatrneurol.2006.04.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2006] [Revised: 03/23/2006] [Accepted: 04/17/2006] [Indexed: 11/26/2022]
Abstract
We have previously reported a greater than 50% prevalence of structural brain abnormalities in children within 2 weeks of first complicated early childhood convulsion, including significant hippocampal asymmetry unrelated to edema. In a 6-year follow-up study, 8 of the original 17 subjects were reimaged to determine any developments in hippocampal pathology. Three subjects manifested significantly greater asymmetry, and two exhibited a modest increase in asymmetry at follow-up compared with that present at initial magnetic resonance imaging. Two of the remaining three subjects manifested no change in the degree of hippocampal asymmetry that was already evident at initial scan, whereas in the final case, apparent resolution of previously identified (slight) hippocampal asymmetry had occurred. Elevated hippocampal T2 relaxation times did not consistently accord with smaller hippocampal volumes. These results suggest that complicated early childhood convulsion may be less benign than often supposed.
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Affiliation(s)
- Tom F D Farrow
- Department of Academic Clinical Psychiatry, University of Sheffield, Sheffield, United Kingdom.
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Dickson JM, Wilkinson ID, Howell SJL, Griffiths PD, Grünewald RA. Idiopathic generalised epilepsy: a pilot study of memory and neuronal dysfunction in the temporal lobes, assessed by magnetic resonance spectroscopy. J Neurol Neurosurg Psychiatry 2006; 77:834-40. [PMID: 16574726 PMCID: PMC2117498 DOI: 10.1136/jnnp.2005.086918] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND The memory deficits in patients with temporal lobe epilepsy (TLE) are associated with epileptogenic lesions of the temporal lobes, especially hippocampal sclerosis. Memory deficits have been extensively studied in TLE, but the presence of pre-existing temporal lobe abnormality has confounded studies on the relationship between memory dysfunction and seizure activity. Idiopathic generalised epilepsy (IGE) is characterised by primary generalised seizures and is found to occur in the absence of any macroscopic brain abnormalities. IGE is therefore ideal for investigations on the effects of seizure activity on memory and cognition. AIM AND METHODS Magnetic resonance spectroscopy (MRS) and neuropsychological testing were used to investigate the relationship between epileptic seizures, memory performance and neuronal dysfunction in the temporal lobes of a group of patients with IGE. 30 patients and 15 healthy controls participated in the study. RESULTS Patients with IGE were found to perform worse than controls on tests of speed of information processing, general cognitive performance and a range of memory tests, including face recognition, word recognition, verbal recall and complex figure recall. The performance of the patient group on the visual recognition and verbal recall sections of the Doors and People Test was found to correlate with MRS ratios of N-acetyl aspartate:choline and N-acetyl aspartate:creatine in the temporal lobes. CONCLUSION This result supports the hypothesis that memory deficits in epilepsy may be due to neuronal dysfunction secondary to epileptic activity itself in the absence of any macroscopic lesions in the temporal lobes.
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Affiliation(s)
- J M Dickson
- Department of Biomedical Science, University of Sheffield, Sheffield, UK.
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Dickson JM, Weavers HM, Mitchell N, Winter EM, Wilkinson ID, Van Beek EJR, Wild JM, Griffiths PD. The effects of dehydration on brain volume -- preliminary results. Int J Sports Med 2005; 26:481-5. [PMID: 16037892 DOI: 10.1055/s-2004-821318] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
In adults the cranium is a rigid bony vault of fixed size and therefore the intra-cranial volume is a constant which equals the sum of the volume of the brain, the intra-cranial volume of CSF and the intra-cranial volume of blood. There can be marked changes in the volumes of these three intra-cranial compartments which may influence susceptibility to brain damage after head injury. This is the first study to investigate the relationship between dehydration and changes in the volume of the brain and the cerebral ventricles. Six healthy control subjects underwent magnetic resonance imaging of the brain before and after a period of exercise in an environmental chamber. The subjects lost between 2.1 % and 2.6 % of their body mass due to water loss through sweating. We found a correlation between the degree of dehydration and the change in ventricular volume (r=0.932, p=0.007). The changes in ventricular volume caused by dehydration were much larger than those seen in day-to-day fluctuations in a normally hydrated healthy control subject.
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Affiliation(s)
- J M Dickson
- Department of Biomedical Science, The University of Sheffield, Sheffield, UK.
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Reynders HJ, Broks P, Dickson JM, Lee CE, Turpin G. Investigation of social and emotion information processing in temporal lobe epilepsy with ictal fear. Epilepsy Behav 2005; 7:419-29. [PMID: 16176889 DOI: 10.1016/j.yebeh.2005.07.013] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2005] [Revised: 07/17/2005] [Accepted: 07/19/2005] [Indexed: 11/24/2022]
Abstract
This study examined whether patients with temporal lobe epilepsy (TLE) and ictal fear (IF) show emotion recognition deficits similar to those associated with amygdala damage. Three groups of patients (13 with TLE and IF, 14 with TLE and nonfear auras (non-IF), and 10 with idiopathic generalized epilepsy (IGE)) completed tests of visual and face processing, face emotion recognition and social judgment, together with measures of psychological adjustment (Hospital Anxiety and Depression Scale; SCL-90-R) and Quality of Life (QOLIE-31). All three epilepsy groups had fear recognition deficits, with relatively greater impairments in the IF group. Fear recognition deficits were associated with impaired social judgment of trustworthiness, duration of epilepsy, and a measure of quality of life. Social cognition impairments previously associated with amygdala dysfunction are also a feature of the neuropsychology of TLE, and extend the hypothesis in that they may additionally play a role in IGE.
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Affiliation(s)
- Hazel J Reynders
- Neurosciences Directorate, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, UK.
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28
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Wilkinson ID, Hadjivassiliou M, Dickson JM, Wallis L, Grünewald RA, Coley SC, Widjaja E, Griffiths PD. Cerebellar abnormalities on proton MR spectroscopy in gluten ataxia. J Neurol Neurosurg Psychiatry 2005; 76:1011-3. [PMID: 15965215 PMCID: PMC1739706 DOI: 10.1136/jnnp.2004.049809] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Gluten sensitivity can manifest with ataxia. The metabolic status of the cerebellum was investigated in 15 patients with gluten ataxia and 10 controls using proton MR spectroscopy. Significant differences were present in mean N-acetyl aspartate levels at short echo time and N-acetyl aspartate/choline ratios at long echo time between the patient and control groups. These data support the hypothesis that cerebellar neuronal physiology differs between patients with gluten ataxia and healthy controls.
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Affiliation(s)
- I D Wilkinson
- Academic Unit of Radiology, University of Sheffield, Sheffield, England.
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Abstract
The substantia nigra (SN) pars compacta is arranged somatotopically. Symptoms of idiopathic Parkinson's disease (IPD) are caused by a lesion in this nucleus, which spreads in a stereotyped spatio-temporal pattern during the course of the disease. We investigated the order of somatic symptom progression in a group of 30 patients with IPD to determine if progression of symptoms was consistent with ordered spread of pathology through the SN pars compacta. Thirty outpatients with IPD were interviewed retrospectively about the progression of their symptoms using a semi-structured questionnaire. All the patients experienced somatic symptom progression in one of two distinct patterns, which was dependent on the location of the initial symptom. The typical pattern of progression for patients with lower limb onset was: (i) foot, (ii) leg, (iii) arm, (iv) hand, (v) face, (vi) voice and (vii) swallowing. For patients whose first symptom was in the upper limb progression to the face and lower limbs occurred roughly simultaneously or sequentially, with the typical pattern of progression: (i) hand/arm, (ii) foot/leg and face, (iii) speech and (iv) swallowing. These patterns of disease progression may reflect two distinct patterns of neuropathology within the SN pars compacta. Although the sample size was relatively small, this is the first time this phenomenon has been described in a full-length article.
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Affiliation(s)
- Jon M Dickson
- Academic Neurology Unit, Royal Hallamshire Hospital, Glossop Road, Sheffield S10 2JF, UK.
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Wignall EL, Dickson JM, Vaughan P, Farrow TFD, Wilkinson ID, Hunter MD, Woodruff PWR. Smaller hippocampal volume in patients with recent-onset posttraumatic stress disorder. Biol Psychiatry 2004; 56:832-6. [PMID: 15576059 DOI: 10.1016/j.biopsych.2004.09.015] [Citation(s) in RCA: 143] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2004] [Revised: 09/10/2004] [Accepted: 09/15/2004] [Indexed: 12/01/2022]
Abstract
BACKGROUND Previous structural magnetic resonance (MR) research in patients with posttraumatic stress disorder (PTSD) has found smaller hippocampal volumes in patients compared with control subjects. These studies have mostly involved subjects who have had PTSD for a number of years, such as war veterans or adult survivors of childhood abuse. Patients with recent-onset PTSD have rarely been investigated. To our knowledge only one other study has investigated such a group. The aim of this study was to compare hippocampal volumes of patients with recent onset PTSD and nontrauma-exposed control subjects. METHODS Fifteen patients with PTSD, recruited from an accident and emergency department, were compared with 11, non-trauma-exposed, healthy control subjects. Patients underwent a structural MR scan soon after trauma (mean time = 158 +/- 41 days). Entire brain volumes, voxel size 1 x 1 x 1 mm, were acquired for each subject. Point counting and stereology were used to measure the hippocampal and amygdala volume of each subject. RESULTS Right-sided hippocampal volume was significantly smaller in PTSD patients than control subjects after controlling for effects of whole brain volume and age. Neither left nor total hippocampal volume were significantly smaller in the PTSD group after correction. Whole brain volume was also found to be significantly smaller in patients. There were no differences in amygdala or white matter volumes between patients and control subjects. CONCLUSIONS This result replicates previous findings of smaller hippocampal volumes in PTSD patients, but in an underinvestigated population, suggesting that either smaller hippocampal volume is a predisposing factor in the development of PTSD or that damage occurs within months of trauma, rather than a number of years. Either of these two hypotheses have significant implications for the treatment of PTSD. For instance, if it could be shown that screening for hippocampal volume may, in some cases, predict those likely to develop clinical PTSD.
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Affiliation(s)
- Emma L Wignall
- SCANLab, Academic Clinical Psychiatry, Northern General Hospital, Sheffield, South Yorkshire, UK
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Dickson JM, Weavers HM, Mitchell N, Winter EM, Wilkinson ID, VanBeek EJR, Griffiths PD. Choice of cross size in stereology--a cautionary note. Neuroradiology 2003; 45:896-9. [PMID: 13680031 DOI: 10.1007/s00234-003-1091-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2003] [Accepted: 07/23/2003] [Indexed: 11/29/2022]
Abstract
The stereological method of cross-counting based on the Cavalieri principle is widely used in neuroimaging to estimate the volume of cerebral structures. Although superficially simple, the stereological technique is validated by arcane mathematical proofs, so the cross size is determined by most investigators on a pragmatic basis with the assumption that the volume calculated is independent of the cross size used. We used three cross sizes (8x8, 5x5 and 3x3 voxels) to estimate the brain volume of six healthy control subjects. The volume estimate using a cross size of 3x3 was 9% larger than with a cross size of 5x5 and the latter was 15% larger than with a cross size of 8x8. We conclude that cross size significantly affects whole brain volume estimates and this result is presumably applicable to other structures whose cross-sectional areas form complex shapes. Investigators should be aware of this fact, especially when trying to make direct comparisons between volume estimates derived from the stereological method using different cross sizes.
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Affiliation(s)
- J M Dickson
- Department of Biomedical Science, Alfred Denny Building, University of Sheffield, Western Bank, Sheffield, S10 2TN, UK.
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Griffiths A, Dickson JM, Griffiths CH. Determination of the Coefficient of Diffusion of Potassium Chloride by an Analytical Method. ACTA ACUST UNITED AC 2002. [DOI: 10.1088/1478-7814/28/1/308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Dickson JM, Vincze E, Grant MR, Smith LA, Rodber KA, Farnden KJ, Reynolds PH. Molecular cloning of the gene encoding developing seed L-asparaginase from Lupinus angustifolius. Plant Mol Biol 1992; 20:333-6. [PMID: 1391778 DOI: 10.1007/bf00014503] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
A genomic sequence encoding Lupinus angustifolius L-asparaginase has been obtained, and is the first report of this gene from a plant source. The 3.2 kb of DNA sequenced contains a 1136 bp 5' flanking sequence, four exons and three introns. Intron-exon borders were mapped by comparing the genomic sequence with that of a L. arboreus cDNA. Primer extension analysis revealed transcription start sites 16 bp and 13 bp 5' of the initiating ATG for L. angustifolius and L. arboreus, respectively. The 5' flanking region contained sequences associated with seed-specific expression.
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Affiliation(s)
- J M Dickson
- Immunology and Plant Molecular Biology Unit, Department of Scientific and Industrial Research-Fruit and Trees, Palmerston North, New Zealand
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Abstract
One hundred seventy-four youthful psychiatric inpatients were given the Draw-A-Person Test (DAP) as part of an assessment battery. Sex of person drawn was compared to subject's sex, Achenbach aggression and delinquency scores, and scores on Children's Inventory of Anger and Nowicki-Strickland Locus of Control Scale. The sex of the person drawn was also compared to family composition, specifically whether or not the child came from an intact family with both a male and female parent or role model. Results support drawing of a same-sexed individual as normative, regardless of age or sex. Adolescent girls and young boys were the only groups that differed significantly from this norm. Personality measures and family composition were not significantly related to the tendency to draw same versus opposite sex.
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Abstract
The importance of the physical therapist in the ICU nursery is in early detection and intervention, which is often critical to the success of treatment in any field of medicine or remedial education. Based on information about neurological development, movement is often the first and possibly only external indicator that development of an infant is abnormal. Movement is an area of special interest for which the physical therapist has the potential of having much expertise for providing early identification and intervention. Research is needed to validate this role. Neonatology is a young, rapidly growing medical specialty that deserves input from an allied health profession that can provide valuable knowledge and services to complement and expand the complex treatment of the high-risk newborn.
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Holliday R, Pukkila PJ, Dickson JM, Spanos A, Murray V. Relationships between the correction of mismatched bases in DNA and mutability. Cold Spring Harb Symp Quant Biol 1979; 43 Pt 2:1317-23. [PMID: 290445 DOI: 10.1101/sqb.1979.043.01.151] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Brown GA, Kuelling BL, Dickson JM. Objective measurement of motor skill acquisition. Phys Ther 1973; 53:864-6. [PMID: 4719854 DOI: 10.1093/ptj/53.8.864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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Abstract
A system for care and maintenance of the common vampire bat in captivity is reported, which results in easy handling and a thriving breeding colony. A method for anaesthetising bats and collecting saliva is described.
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Hamerton JL, Dickson JM, Pollard CE, Grieves SA, Short RV. Genetic intersexuality in goats. J Reprod Fertil Suppl 1969; 7:Suppl 7:25-51. [PMID: 5272213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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