Being a child with intellectual disabilities in hospital: The need for an individualised approach to care

BACKGROUND

There is limited qualitative research focussed specifically on what it is like for children and young people with intellectual disabilities coming into hospital, with much of the evidence-base being about those with Autism Spectrum Condition or adults with intellectual disabilities.

AIM

To share rich detail of the emotional and physical impact on children and young people with intellectual disabilities of attending hospital, from their own and their parent's perspective.

METHODS

Talking Mats interviews, sticker survey and photography with children and young people with intellectual disabilities, and in-depth interviews, hospital diaries and photography with their parents.

RESULTS AND CONCLUSIONS

The multiple and compounding layers of complexity surrounding hospital care of children and young people with intellectual disabilities resulted in challenges associated with loss of familiarity and routine, undergoing procedures, managing sensory overload, managing pain and having a lack of safety awareness. An individualised approach to their care is needed.

Point of care HbA1c level for diabetes mellitus management and its accuracy among tuberculosis patients: a study in four countries

BACKGROUND

Diabetes mellitus (DM) is common among tuberculosis (TB) patients and often undiagnosed or poorly controlled. We compared point of care (POC) with laboratory glycated haemoglobin (HbA_1c) testing among newly diagnosed TB patients to assess POC test accuracy, safety and acceptability in settings in which immediate access to DM services may be difficult.

METHODS

We measured POC and accredited laboratory HbA_1c (using high-performance liquid chromatography) in 1942 TB patients aged 18 years recruited from Peru, Romania, Indonesia and South Africa. We calculated overall agreement and individual variation (mean ± 2 standard deviations) stratified by country, age, sex, body mass index (BMI), HbA_1c level and comorbidities (anaemia, human immunodeficiency virus [HIV]). We used an error grid approach to identify disagreement that could raise significant concerns.

RESULTS

Overall mean POC HbA_1c values were modestly higher than laboratory HbA_1c levels by 0.1% units (95%CI 0.1-0.2); however, there was a substantial discrepancy for those with severe anaemia (1.1% HbA_1c, 95%CI 0.7-1.5). For 89.6% of 1942 patients, both values indicated the same DM status (no DM, HbA_1c <6.5%) or had acceptable deviation (relative difference <6%). Individual agreement was variable, with POC values up to 1.8% units higher or 1.6% lower. For a minority, use of POC HbA_1c alone could result in error leading to potential overtreatment (n = 40, 2.1%) or undertreatment (n = 1, 0.1%). The remainder had moderate disagreement, which was less likely to influence clinical decisions.

CONCLUSION

POC HbA_1c is pragmatic and sufficiently accurate to screen for hyperglycaemia and DM risk among TB patients.

Pay More Attention: a national mixed methods study to identify the barriers and facilitators to ensuring equal access to high-quality hospital care and services for children and young people with and without learning disabilities and their families

INTRODUCTION

Despite evidence of health inequalities for adults with intellectual disability (ID) there has yet to be a comprehensive review of how well hospital services are meeting the needs of children and young people (CYP) with ID and their families. We do not know how relevant existing recommendations and guidelines are to CYP, whether these are being applied in the paediatric setting or what difference they are making. Evidence of parental dissatisfaction with the quality, safety and accessibility of hospital care for CYP with ID exists. However, the extent to which their experience differs from parents of CYP without ID is not known and the views and experiences of CYP with ID have not been investigated. We will compare how services are delivered to, and experienced by CYP aged 5-15 years with and without ID and their families to see what inequalities exist, for whom, why and under what circumstances.

METHODS AND ANALYSIS

We will use a transformative, mixed methods case study design to collect data over four consecutive phases. We will involve CYP, parents and hospital staff using a range of methods; interviews, parental electronic diary, hospital and community staff questionnaire, patient and parent satisfaction questionnaire, content analysis of hospital documents and a retrospective mapping of patient hospital activity. Qualitative data will be managed and analysed using NVivo and quantitative data will be analysed using parametric and non-parametric descriptive statistics.

ETHICS AND DISSEMINATION

The study will run from December 2015 to November 2018. We have Health Authority Approval (IRAS project ID: 193932) for phase 1 involving staff only and ethical and Health Authority Approval for phases 2-4 (IRAS project ID: 178525). We will disseminate widely to relevant stakeholders, using a range of accessible formats, including social media. We will publish in international peer-reviewed journals and present to professional, academic and lay audiences through national and international conferences.

Individualizing hospital care for children and young people with learning disabilities: it's the little things that make the difference

This ethnographic study sought parent, patient and staff views about the needs of children and young people with learning disability and their families during hospitalization. Reported here are data from 27 staff. The need for individualized care was identified, based on gaining appropriate experience and training, identifying the population, focussing on the "little things", creating a safe, familiar environment and accessing and using appropriate resources. Parents played a central role in staff's delivery of individualized care. A lack of staff experience, knowledge and communication about learning disability can mean they rely on parent's input rather than forming a true partnership with them.

Preclinic investigations accelerate decision-making, reduce delays in treatment and are highly popular with endocrinology patients and staff

OBJECTIVE

Endocrine diagnosis relies on a thorough history, examination and confirmatory biochemical tests. Previously, in our unit, tests were performed after new patients attended clinic. We proposed that diagnosis and management would be improved if this system was inverted.

DESIGN

Clinicians and chemical pathologists reviewed available guidance and local practice to determine the key tests to confirm or refute most common endocrine disorders. A system was developed for clinicians to categorize new referrals into diagnostic groups: for example, nodular thyroid disease or possible polycystic ovarian syndrome. Standard letters were developed and sent to patients explaining the requirement for tests to be performed prior to first hospital appointment. The letters and requests for investigation sets were standardized for each diagnostic group and generated via a one-click automated method. After one year, clinical outcomes were audited and patients and staff surveyed.

RESULTS

The time from referral to confirming diagnosis and starting treatment was halved: mean 11·8-5·7 weeks (P < 0·001). Acute patients were also discharged from clinic earlier: mean 17 to 10·3 weeks (P < 0·005). Ninety four percent patients surveyed had their tests performed easily prior to attending their appointment. Hundred per cent of patients, 100% of hospital staff and 93% referring general practitioners who responded felt the system improved patient care and should continue.

CONCLUSIONS

Performing investigations prior to new patient appointments is practical, popular with staff and patients and has dramatically improved our referral to treatment statistics by reducing delays prior to diagnosis. This system could be used as a model for other departments.

Why some adults with intellectual disability consult their general practitioner more than others

BACKGROUND

This research identifies factors affecting why some adults with intellectual disability (AWIDs) consult their general practitioner (GP) more than others. Little is known about these factors, despite AWIDs having higher health needs and reduced longevity. Current barriers to accessing health care need to be understood and overcome to achieve improved health outcomes.

METHODS

A secondary analysis of data obtained from a stratified randomised sample of AWIDs participating in a cluster randomised trial of hand held health records. The number of GP consultations was obtained retrospectively for the year preceding initial health interviews from GP records. AWIDs and their carers were given separate health interviews using identical/adapted questions where possible.

RESULTS

Two hundred and one AWIDs and or their carers from 40 practices participated (response rate 64.6%) with GP consultation data extracted for 187 AWIDs. Overall consulting levels were low, 3.2 per annum for women and 2.2 for men. Increased age, gender (women) and type of carer (paid) were all significantly associated with increased consultations. Carers reporting health problems, medications reported by AWIDs, medications recorded in GP records, and pain reported by AWIDs were also significant factors affecting consultations to GP practices after adjustment for age and type of carer.

CONCLUSIONS

Overall consultation rates were lower than expected, and affected by age, gender and type of carer. Targeted interventions are needed to improve attendance and promote health.

Treatment of cervical artery dissection: a systematic review and meta-analysis

BACKGROUND AND PURPOSE

Cervical dissection is an important cause of stroke in the young. This paper presents a systematic review and a meta-analysis to assess the effectiveness of different treatment approaches: antithrombotic drugs, thrombolysis and stenting.

METHODS

Medline and PubMed were searched from 1966 to 8 April 2007. Reference lists were reviewed. Separate searches were performed for treatment with anticoagulation and antiplatelet therapy during the acute phase (within 1 month of symptoms), thrombolysis and stenting.

RESULTS

There were only sufficient data for meta-analysis for the comparison of antiplatelet versus anticoagulation therapy. No randomised trials were identified. 34 non-randomised studies included 762 patients. There was no significant difference in risk of death (antiplatelet 5/268 (1.8%), anticoagulation 9/494 (1.8%), p = 0.88); stroke (antiplatelet 5/268 (1.9%), anticoagulant 10/494 (2.0%), p = 0.66), or stroke and death. Four non-randomised studies of thrombolysis provided insufficient data for assessment of efficacy but complication rates were no greater than thrombolysis for other ischaemic stroke. Six studies included 96 patients undergoing stenting for both acute dissection and chronic complications, providing insufficient data for assessment of efficacy, although complication rates appeared similar to those published for carotid atherosclerosic stenosis.

CONCLUSIONS

There are no data to support the therapeutic superiority of anticoagulants over antiplatelet agents. Thrombolysis in dissection appears safe but more data on efficacy are required. Stenting is technically possible but there are no data to demonstrate efficacy. There is little evidence to support current treatment approaches in cervical dissection. Randomised controlled prospective trials, particularly assessing anticoagulation versus antiplatelet agents, are required.

Imaging of vertebral artery stenosis: a systematic review

BACKGROUND AND PURPOSE

Posterior circulation stroke accounts for 20% of ischaemic strokes. Recent data suggest that the early stroke recurrence risk is high and comparable with carotid artery disease. Vertebral artery stenosis accounts for approximately 20% of posterior circulation stroke, and with endovascular treatment available accurate diagnostic imaging is important. We performed a systematic literature review to validate the accuracy of the non-invasive imaging techniques Duplex ultrasound (DUS), magnetic resonance angiography (MRA) and computed tomographic angiography (CTA) in detecting severe vertebral artery stenosis, with intra-arterial angiography (IAA) as the reference standard.

METHODS

We identified studies that used non-invasive imaging and IAA as the reference standard to determine vertebral artery stenosis and provided adequate data to calculate sensitivity and specificity. We analysed the quality of these studies, looked for evidence of heterogeneity and performed subgroup analysis for different degrees of stenosis.

RESULTS

11 studies categorised stenosis into 50-99%. The sensitivity of CTA (single study) and pooled sensitivities of contrast enhanced MRA (CE-MRA) and colour duplex were 100% (95% CI 15.8 to 100), 93.9% (79.8 to 99.3) and 70.2% (54.2 to 83.3), respectively. The specificities for CTA, CE-MRA and colour duplex were 95.2% (83.8 to 99.4), 94.8% (91.1 to 97.3) and 97.7% (95.2 to 99.1). However, specificities for CE-MRA and colour duplex demonstrated significant heterogeneity (p = 0.003 and p = 0.002, respectively).

CONCLUSIONS

CE-MRA and possibly CTA may be more sensitive in diagnosing vertebral artery stenosis than DUS. However, data are limited and further high quality studies comparing DUS, MRA and CTA with IAA are required.

Perineal sensation: an important predictor of long-term outcome in open spina bifida

OBJECTIVES

To see if perineal sensation in infants with open spina bifida is associated with a better long-term outcome, particularly in terms of survival, renal-related deaths and incontinence.

METHODS

We conducted a prospective cohort study on a complete cohort of 117 consecutive patients with open spina bifida, whose backs were closed non-selectively at birth between 1963 and 1971. A meticulous neurological examination in infancy showed that 33 (28%) of them had perineal sensation, defined as intact sensation to pinprick in at least one dermatome on one side in the saddle area (S2-4). Data recorded within 48 h of birth and during six reviews between 1972 and 2002 were used. Details of deaths were obtained from medical records and from the Office of National Statistics.

RESULTS

By December 2005, 57% (67/117) of the cohort had died. There were 50 survivors with a mean age 38 years (range 35-41). More of those with perineal sensation survived than those without (23/33 v 27/84, p<0.001). This difference was mainly caused by 19 renal deaths in those lacking perineal sensation. Crucially there were no renal-related deaths in those with perineal sensation (0/33 v 19/84, p = 0.003). Among the survivors, those with perineal sensation were more likely than the remainder to be continent of urine and faeces (10/23 v 1/27, p<0.001 and 18/23 v 9/27, p = 0.002 respectively). They were also more likely to be able to walk at least 50 m (11/23 v 5/27, p = 0.027) and never to have had pressure sores (15/23 v 9/27, p = 0.025).

CONCLUSIONS

A simple assessment of perineal sensation in infancy predicts long-term outcome in terms of survival, renal prognosis and incontinence in open spina bifida.

Systematic review on urine albumin testing for early detection of diabetic complications

OBJECTIVES

To determine whether microalbuminuria is an independent prognostic factor for the development of diabetic complications and whether improved glycaemic or blood pressure control has a greater influence on the development of diabetic complications in those with microalbuminuria than in those with normoalbuminuria.

DATA SOURCES

Electronic databases up until January 2002.

REVIEW METHODS

A protocol for peer review by an external expert panel was prepared that included selection criteria for data extraction and required two independent reviewers to undertake article selection and review. Completeness was assessed using hand-searching of major journals. Random effects meta-analysis was used to obtain combined estimates of relative risk (RR). Funnel plots, trim and fill methods and meta-regression were used to assess publication bias and sources of heterogeneity.

RESULTS

In patients with type 1 or type 2 DM and microalbuminuria there is a RR of all-cause mortality of 1.8 [95% confidence interval (CI) 1.5 to 2.1] and 1.9 (95% CI 1.7 to 2.1) respectively. Similar RRs were found for other mortality end-points, with age of cohort being inversely related to the RR in type 2 DM. In patients with type 1 DM, there is evidence that microalbuminuria or raised albumin excretion rate has only weak, if any, independent prognostic significance for the incidence of retinopathy and no evidence that it predicts progression of retinopathy, although strong evidence exists for the independent prognostic significance of microalbuminuria or raised albumin excretion rate for the development of proliferative retinopathy (crude RR of 4.1, 95% CI 1.8 to 9.4). For type 2 DM, there is no evidence of any independent prognostic significance for the incidence of retinopathy and little, if any, prognostic relationship between microalbuminuria and the progression of retinopathy or development of proliferative retinopathy. In patients with type 1 DM and microalbuminuria there is an RR of developing end-stage renal disease (ESRD) of 4.8 (95% CI 3.0 to 7.5) and a higher RR (7.5, 95% CI 5.4 to 10.5) of developing clinical proteinuria, with a significantly greater fall in glomerular filtration rate (GFR) in patients with microalbuminuria. In patients with type 2 DM, similar RRs were observed: 3.6 (95% CI 1.6 to 8.4) for developing ESRD and 7.5 (95% CI 5.2 to 10.9) for developing clinical proteinuria, with a significantly greater decline in GFR in the microalbuminuria group of 1.7 (95% CI 0.1 to 3.2) ml per minute per year compared with those who were normoalbuminuric. In adults with type 1 or type 2 DM and microalbuminuria at baseline, the numbers progressing to clinical proteinuria (19% and 24%, respectively) and those regressing to normoalbuminuria (26% and 18%, respectively) did not differ significantly. In children with type 1 DM, regression (44%) was significantly more frequent than progression (15%). In patients with type 1 or type 2 DM and microalbuminuria, there is scarce evidence as to whether improved glycaemic control has any effect on the incidence of cardiovascular disease (CVD), the incidence or progression of retinopathy, or the development of renal complications. However, among patients not stratified by albuminuria, improved glycaemic control benefits retinal and renal complications and may benefit CVD. In the effects of angiotensin-converting enzyme (ACE) inhibitors on GFR in normotensive microalbuminuric patients with type 1 DM, there was no evidence of a consistent treatment effect. There is strong evidence from 11 trials in normotensive type 1 patients with microalbuminuria of a beneficial effect of ACE inhibitor treatment on the risk of developing clinical proteinuria and on the risk of regression to normoalbuminuria. Patients with type 2 DM and microalbuminuria, whether hypertensive or not, may obtain additional cardiovascular benefit from an ACE inhibitor and there may be a beneficial effect on the development of retinopathy in normotensive patients irrespective of albuminuria. There is limited evidence that treatment of hypertensive microalbuminuric type 2 diabetic patients with blockers of the renin--angiotensin system is associated with preserved GFR, but also evidence of no differences in GFR in comparisons with other antihypertensive agents. The data on GFR in normotensive cohorts are inconclusive. In normotensive type 2 patients with microalbuminuria there is evidence from three trials (all enalapril) of a reduction in risk of developing clinical proteinuria; in hypertensive patients there is evidence from one placebo-controlled trial (irbesartan) of a reduction in this risk. Intensive compared with moderate blood pressure control did not affect the rate of progression of microalbuminuria to clinical proteinuria in the one available study. There is inconclusive evidence from four trials of any difference in the proportions of hypertensive patients progressing from microalbuminuria to clinical proteinuria when ACE inhibitors are compared with other antihypertensive agents, and in one trial regression was two-fold higher with lisinopril than with nifedipine.

CONCLUSIONS

The most pronounced benefits of glycaemic control identified in this review are on retinal and renal complications in both normoalbuminuric and microalbuminuric patients considered together, with little or no evidence of any greater benefit in those with microalbuminuria. Hence, microalbuminuric status may be a false boundary when considering the benefits of glycaemic control. Classification of a person as normoalbuminuric must not serve to suggest that they will derive less benefit from optimal glycaemic control than a person who is microalbuminuric. All hypertensive patients benefit from blood pressure lowering and there is little evidence of additional benefit in those with microalbuminuria. Antihypertensive therapy with an ACE inhibitor in normotensive patients with microalbuminuria is beneficial. Monitoring microalbuminuria does not have a proven role in modulating antihypertensive therapy while the patient remains hypertensive. Recommendations for microalbuminuria research include: determining rate and predictors of development and factors involved in regression; carrying out economic evaluations of different screening strategies; investigating the effects of screening on patients; standardising screening tests to enable use of common reference ranges; evaluating the effects of lipid-lowering therapy; and using to modulate antihypertensive therapy.

Validation of traction force indicator in ventouse devices

OBJECTIVE

To evaluate whether the traction force indicator in a ventouse device gave an accurate estimation of the force applied.

METHODS

The study was carried out at the Derby City Hospital. An estimate of measurement errors was made by analyzing the standard deviation of the residuals for 30 Kiwi OmniCup devices (Clinical Innovations, Abingdon, Oxfordshire, England) and a standard industrial spring balance.

RESULTS

The measurement errors for the traction forces were very small and acceptable for the OmniCup. The overall estimate of measurement errors was 0.45 kg (1.35 lb).

CONCLUSION

The overall measurement error for the traction force indicator of the OmniCup was found to be very small. Injuries associated the ventouse, such as cephalohematomas and subgaleal hemorrhages, may be minimized if the recommended limits for a safe traction force are not exceeded.

Fall-related risk factors and osteoporosis in women with rheumatoid arthritis

BACKGROUND

Rheumatoid arthritis (RA) is associated with an increased risk of osteoporotic fractures. Whilst numerous studies have demonstrated low bone density in RA, few studies have examined the risk of falling, which is another major contributor to the pathogenesis of fractures (particularly hip fractures).

OBJECTIVES

The aim of this study was to see if fall risk is increased in women with RA, define high-risk subgroups, and determine what proportion of women have increased risk of hip fracture due to osteoporosis and due to increased fall risk.

METHODS

We performed a case-control study of older women with RA (n = 103) compared with women without RA referred for open access bone densitometry (n = 203). We measured bone density using dual-energy X-ray absorptiometry and fall risk factors (visual acuity, ability to perform standups, and heel-toe walking).

RESULTS

More women with RA gave a history of a previous fall compared with controls (54 vs 44%), although this was just short of being statistically significant (difference 10%, 95% CI -2 to 22). Women with RA were more likely to have abnormal heel-toe walking and inability to perform standups compared with controls (P<0.001); however, visual acuity was similar between cases and controls. Femoral neck osteoporosis was found in 31% and increased fall risk in 68% of women with RA. Women with RA who underperformed in heel-toe walking and were unable to do standups had significantly higher ESR, Health Assessment Questionnaire score and tender joint count. RA symptoms/signs localized to the knees and ankles were more likely to be associated with the presence of fall risk factors.

CONCLUSIONS

Fall-related risk factors predictive of hip fracture are common in women with RA. Fall risk needs to be considered when RA patients are being treated for osteoporosis and further work needs to be done to help reduce the risk of falling and fracture in women with RA.

Morbidity of transrectal ultrasonography-guided prostate biopsies in patients after the continued use of low-dose aspirin

OBJECTIVE

To determine whether low-dose aspirin increases morbidity after transrectal ultrasonography-guided sextant prostate biopsy.

PATIENTS AND METHODS

In a single-centre prospective cohort study of 200 patients who underwent sextant prostate biopsies, those routinely taking low-dose aspirin were encouraged to continue to do so before and after biopsy. The morbidity in each case was assessed using a standardized questionnaire that patients completed in the 7 days after biopsy. The presence of haematuria, rectal bleeding and haematospermia were recorded. The questionnaire also directed the patient to record fevers, use of analgesia and any further treatment received.

RESULTS

In all, 36 patients took aspirin whilst the other 141 did not. There were no major complications in either group. Of the patients on aspirin, 20 (56%) had haematuria, compared with 83 (59%) of those not taking aspirin (difference 3%, 95% confidence interval, CI, -15 to 21). Overall bleeding (haematuria, rectal bleeding and haematospermia) occurred in 22 patients (61%) of the aspirin group and 105 (74%) of the other group (difference 13%, 95% CI -4 to 31). Comparisons of other morbidities between the groups are also discussed.

CONCLUSIONS

There was no statistically significant difference in the incidence of haematuria or overall bleeding after biopsy between the groups. There is no evidence that aspirin needs to be discontinued before sextant prostate biopsy.

The impact of behavioral counseling on stage of change in fat intake, physical activity, and cigarette smoking in adults at increased risk of coronary heart disease

OBJECTIVES

This study assessed stages of change in fat intake, physical activity, and cigarette smoking during a randomized controlled trial of behavioral counseling.

METHODS

Twenty general practices (primary health care centers) were randomized to lifestyle counseling by behavioral methods or to usual health promotion. A total of 883 patients were selected for the presence of 1 or more of the following risk factors: cigarette smoking, high cholesterol, or a combination of a high body mass index and low physical activity. Stage of change (precontemplation, contemplation, preparation, and action/maintenance) was assessed at baseline and after 4 and 12 months.

RESULTS

The odds of moving to action/maintenance for behavioral intervention vs control patients at 4 months were 2.15 (95% confidence interval [CI] = 1.30, 3.56) for fat reduction, 1.89 (95% CI = 1.07, 3.36) for increased physical activity, and 1.77 (95% CI = 0.76, 4.14) for smoking cessation. The likelihood of achieving action/maintenance was related to baseline stage for all 3 behaviors.

CONCLUSIONS

Brief behavioral counseling based on advice matched to stage of readiness for change may be valuable in encouraging healthy lifestyles among patients in primary care at raised risk of cardiovascular disease.

Sociodemographic and psychological predictors of changes in dietary fat consumption in adults with high blood cholesterol following counseling in primary care

The associations between sociodemographic variables, psychological factors, and changes in dietary fat consumption over 4 months were assessed in a randomized controlled trial of behavioral counseling versus standard advice. Patients were 141 men and 150 women, with an average age of 52.1 years and total cholesterol level of 7.27 mmol/l (278 mg/dl). Smokers, younger patients, and those with greater body mass index had higher fat intake at baseline. Behavioral counseling led to greater reductions in fat intake than did standard advice. Self-efficacy and ratings of benefits of low-fat diets were related to fat consumption at baseline, and changes in these measures were correlated with changes in fat intake. Family support, baseline anticipated regret, and (for the behavioral counseling group only) baseline behavioral intentions predicted reductions in fat intake. The results indicated that psychosocial variables associated cross-sectionally with fat consumption do not necessarily predict change and that factors involved in the process of change and the prediction of change need to be differentiated.

Identifying patients with ischaemic heart disease in general practice: cross sectional study of paper and computerised medical records

OBJECTIVES

To identify patients with ischaemic heart disease by using a practice computer and to estimate the work required to do so.

DESIGN

Cross sectional study. Data from the notes and from the computer records of 1680 patients were used to build a database. This was used to compare different methods of identifying patients with ischaemic heart disease.

SETTING

11 general practices in the Battersea primary care group in south London.

SUBJECTS

1 in 40 random sample of patients aged 45 or older.

MAIN OUTCOME MEASURES

Numbers of patients identified with ischaemic heart disease.

RESULTS

The combination of the Read code for ischaemic heart disease (G3) and a prescription for a nitrate had a 73% sensitivity and a yield (100/positive predictive value) of one case of ischaemic heart disease for every 1.2 sets of notes reviewed. By searching the records of patients also receiving aspirin, atenolol, digoxin, or a statin, the sensitivity was increased to 96% but the yield fell to one in three.

CONCLUSION

Although commonly used to identify cases, a computer search for G3 code or nitrate missed almost 30% of patients with ischaemic heart disease. A substantially higher percentage of patients can be identified by adding other drugs to the search strategy.

Sociodemographic and psychological predictors of changes in dietary fat consumption in adults with high blood cholesterol following counseling in primary care

The associations between sociodemographic variables, psychological factors, and changes in dietary fat consumption over 4 months were assessed in a randomized controlled trial of behavioral counseling versus standard advice. Patients were 141 men and 150 women, with an average age of 52.1 years and total cholesterol level of 7.27 mmol/l (278 mg/dl). Smokers, younger patients, and those with greater body mass index had higher fat intake at baseline. Behavioral counseling led to greater reductions in fat intake than did standard advice. Self-efficacy and ratings of benefits of low-fat diets were related to fat consumption at baseline, and changes in these measures were correlated with changes in fat intake. Family support, baseline anticipated regret, and (for the behavioral counseling group only) baseline behavioral intentions predicted reductions in fat intake. The results indicated that psychosocial variables associated cross-sectionally with fat consumption do not necessarily predict change and that factors involved in the process of change and the prediction of change need to be differentiated.

Psychosocial predictors of changes in physical activity in overweight sedentary adults following counseling in primary care

BACKGROUND

Increasing regular physical activity in adults at elevated risk of cardiovascular disease is an important target for preventive medicine. This study evaluated demographic, social and cognitive predictors of self-reported changes in physical activity after 4 and 12 months in a randomized trial of behavioral counseling in primary care.

METHOD

Data were analyzed from 234 male and 271 female sedentary patients with a body mass index of 25-35 (age 49.1 years, SD 11.2 years), who had been counseled by nurses in general practice using stage-matched behavioral methods or standard health promotion and who were reassessed after 4 months. A total of 187 men and 231 women were reassessed after 12 months.

RESULTS

Physical activity at baseline was associated with educational status, having a partner who exercised, perceived barriers, and self-efficacy. Changes over 4 months were greater with behavioral counseling, in non-smokers and in patients with higher ratings of motivation to change and self-efficacy at baseline. Changes over 12 months were greater with behavioral counseling and were predicted in the behavioral group by social support variables, perceived benefits, and barriers. Stage of readiness to change predicted increased activity at 4 but not 12 months.

CONCLUSIONS

Social support and cognitive variables predict increased physical activity following counseling in primary care of sedentary overweight adults. Different factors are relevant to short- and long-term modifications in behavior.

Condom promotion in women attending inner city general practices for cervical smears: a randomized controlled trial

BACKGROUND

Although condom promotion schemes have been widely piloted in UK general practices, there have been no rigorous evaluations of their effectiveness.

OBJECTIVES

To see if a practice-based sexual health education intervention increases the number of women having smears who are given condoms and advice on avoiding STDs. To see if this low cost intervention affects subsequent condom use.

METHOD

We conducted a cluster randomized trial of condom promotion in 1382 women aged <35 years attending 28 South London general practices for cervical smear tests.

RESULTS

More women in intervention than control practices reported receiving advice on avoiding sexually transmitted infections (27% versus 10%) and being given condoms (28% versus 1%, P < 0.05). However, there was no difference in subsequent condom use, even in the 22% of women reporting >/=2 sexual partners in the previous year.

CONCLUSIONS

To provide evidence of effectiveness, future interventions may need to be more intensive or focus on higher risk groups.

Influence of postal distribution of the Royal College of Radiologists' guidelines, together with feedback on radiological referral rates, on X-ray referrals from general practice: a randomized controlled trial

BACKGROUND

The Royal College of Radiologists (RCR) have produced regularly updated guidelines on radiological referrals since 1990. A small study in 1992 showed postal distribution of guidelines reduced general practitioners' referrals over the subsequent 9 weeks. However there have been no randomized trials of the longer term effects of radiological guidelines and feedback on referral rates on X-ray requests from primary care.

OBJECTIVES

To see if the introduction of radiological guidelines into general practices together with feedback on referral rates reduces the number of GP radiological requests over one year; and to explore GPs'attitudes to the guidelines.

METHODS

Sixty-nine practices referring patients to St George's Healthcare Trust were randomly allocated to intervention or control groups. In February 1995 a GP version of the RCR guidelines was sent to each GP in the 33 practices in the intervention group. After 9 months intervention, practices were sent revised guidelines with individual feedback on the number of examinations requested in the past 6 months. The total number of requests per practice was compared for the year before and the year after the introduction of the guidelines. Control practices were sent the guidelines at the end of the study. All doctors were sent a questionnaire about the guidelines.

RESULTS

A total of 43 778 radiological requests were made during the two years 1994-1996. In practices receiving the guidelines there was a 20% reduction in requests for spinal examinations compared with control practices (P < 0.05). This corresponded to the effect reported by GPs. There was also a 10% difference between the groups in the total number of requests made, but due to wide interpractice variation in referral rates this failed to reach statistical significance.

CONCLUSIONS

Introduction of radiological guidelines together with feedback on referral rates was effective in reducing the number of requests for spinal examinations over one year. Wider use of GP-orientated guidelines with regular updating and feedback might save costs and reduce unnecessary irradiation of patients.

Link between the CSF shunt and achievement in adults with spina bifida

OBJECTIVES

A few enterprising adults with shunt treated spina bifida live independently in the community, have a job in competitive employment, and drive to work in their own car. By contrast others with similar disability but lacking their motivation remain dependent on care and supervision. The aim of this study was to identify events in the history of their shunt which may have influenced their subsequent achievement.

METHODS

Between June 1963 and January 1971 117 babies born in East Anglia with open spina bifida had their backs closed regardless of the severity of their condition. When reviewed in 1997 every case was ascertained. Sixty had died and the 57 survivors had a mean age of 30. These were assigned to two groups: achievers and non-achievers, according to their attainments in independence, employment, and use of a car.

RESULTS

Of the 57 survivors nine had no shunt and eight of these were achievers. All were of normal intelligence (IQ>/=80) and only one was severely disabled. Of the 48 with shunts only 20 were achievers (OR 11.2, 95% confidence interval (95% CI) 1.3-96.8). Lack of achievement in these 48 was associated with revisions of the shunt, particularly when revisions were performed after the age of 2. Sixteen patients had never required a revision and 11 (69%) were achievers; 10 had had revisions only during infancy and five (50%) were achievers; 22 had had revisions after their second birthday and only four (18%) were achievers (p<0.001). Elective revisions were not performed in this cohort and in 75% of patients revisions had been preceded by clear symptoms of raised intracranial pressure.

CONCLUSION

Revisions of the shunt, particularly after the age of 2, are associated with poor long term achievement in adults with spina bifida.

Behavioural counselling in general practice for the promotion of healthy behaviour among adults at increased risk of coronary heart disease: randomised trial

OBJECTIVE

To measure the effect of behaviourally oriented counselling in general practice on healthy behaviour and biological risk factors in patients at increased risk of coronary heart disease.

DESIGN

Cluster randomised controlled trial.

PARTICIPANTS

883 men and women selected for the presence of one or more modifiable risk factors: regular cigarette smoking, high serum cholesterol concentration (6.5-9.0 mmol/l), and high body mass index (25-35) combined with low physical activity.

INTERVENTION

Brief behavioural counselling, on the basis of the stage of change model, carried out by practice nurses to reduce smoking and dietary fat intake and to increase regular physical activity.

MAIN OUTCOME MEASURES

Questionnaire measures of diet, exercise, and smoking habits, and blood pressure, serum total cholesterol concentration, weight, body mass index, and smoking cessation (with biochemical validation) at 4 and 12 months.

RESULTS

Favourable differences were recorded in the intervention group for dietary fat intake, regular exercise, and cigarettes smoked per day at 4 and 12 months. Systolic blood pressure was reduced to a greater extent in the intervention group at 4 but not at 12 months. No differences were found between groups in changes in total serum cholesterol concentration, weight, body mass index, diastolic pressure, or smoking cessation.

CONCLUSIONS

Brief behavioural counselling by practice nurses led to improvements in healthy behaviour. More extended counselling to help patients sustain and build on behaviour changes may be required before differences in biological risk factors emerge.

A cognitive distortion associated with eating disorders: thought-shape fusion

OBJECTIVES

The primary objective of this study was to describe and investigate a cognitive distortion associated with eating psychopathology. This distortion, termed 'thought-shape fusion', is said to occur when merely thinking about eating a forbidden food increases the person's estimate of their shape or weight, elicits a perception of moral wrongdoing and makes the person feel fat.

DESIGN

Two studies were conducted. The first was a psychometric study and the second utilized a within-participants experimental design.

METHODS

In Study 1, thought-shape fusion was assessed in a sample of 119 undergraduate students using a questionnaire. In Study 2, 30 students with high thought-shape fusion scores participated in an experiment designed to elicit the distortion.

RESULTS

Thought-shape fusion was found to be significantly associated with measures of eating disorder psychopathology. The questionnaire used to measure thought-shape fusion had high internal consistency, a good factor structure accounting for 46.2% of the variance and predictive validity. The results from Study 2 indicated that the distortion can be elicited under experimental conditions, produces negative emotional reactions and prompts the urge to engage in corrective behaviour (e.g. neutralizing/checking). This corrective behaviour promptly reduces the negative reactions.

CONCLUSION

The results of the two studies indicate that the concept of thought-shape fusion is coherent, unifactorial and measurable. It is associated with eating disturbance and elicits negative emotional and behavioural responses.

How many surgery appointments should be offered to avoid undesirable numbers of 'extras'?

BACKGROUND

Patients seen as 'extras' (or 'fit-ins') are usually given less time for their problems than those in pre-booked appointments. Consequently, long queues of 'extras' should be avoided.

AIM

To determine whether a predictable relationship exists between the number of available appointments at the start of the day and the number of extra patients who must be fitted in. This might be used to help plan a practice appointment system.

METHOD

Numbers of available appointments at the start of the day and numbers of 'extras' seen were recorded prospectively in 1995 and 1997 in one group general practice. Minimum numbers of available appointments at the start of the day, below which undesirably large numbers of extra patients could be predicted, were determined using logistic regression applied to the 1995 data. Predictive values of the minimum numbers calculated for 1995, in terms of predicting undesirable numbers of 'extras', were then determined when applied to the 1997 data.

RESULTS

Numbers of extra patients seen correlated negatively with available appointments at the start of the day for all days of the week, with coefficients ranging from -0.66 to -0.80. Minimum numbers of available appointments below which undesirably large numbers of extras could be predicted were 26 for Mondays and four for the other week-days. When applied to 1997 data, these minimum numbers gave positive and negative predictive values of 76% and 82% respectively, similar to their values for 1995, despite increases in patient attendance and changes in the day-to-day pattern of surgery provision between the two years.

CONCLUSION

A predictable relationship exists between the number of available appointments at the start of the day and the number of extras who must be fitted in, which may be used to help plan the appointment system for some years ahead, at least in this relatively stable suburban practice.

How does the content of consultations affect the recognition by general practitioners of major depression in women?

BACKGROUND

Major depression is a common and disabling condition. However, for many reasons, the condition is not recognized in about half of the patients with major depression.

AIM

The aim of the study was to establish whether the content of general practice consultations affected general practitioners' recognition of major depressive illness in women patients.

METHOD

The 30-item general health questionnaire was used as a first stage screening instrument for psychiatric morbidity. Patients newly recognized as depressed by their general practitioner and those not recognized as depressed who scored 11 or more on the questionnaire were interviewed, usually within three days of consulting their general practitioner, using the combined psychiatric interview. Videorecordings of the consultations for these two groups of women were analysed; analyses were based on mentions of physical, psychiatric and social symptoms and on whether the first mention of a psychiatric symptom was within the first four mentions of any symptoms (early in the consultation) or after four mentions of any symptoms (late) or if psychiatric symptoms were not mentioned.

RESULTS

A paired sample of 72 women with major depression was obtained from patients consulting 36 general practitioners, each general practitioner providing one patient whom he or she had correctly recognized as being depressed and one patient whose depression had not been recognized. Women with major depression were about five times more likely to have their depression recognized if they mentioned their psychiatric symptoms early in the consultation compared with those who either left it later to mention such symptoms or never mentioned them. Major depression was more likely to be recognized if no physical illness was present. After adjusting for physical illness, depression was 10 times less likely to be recognized if the first psychiatric symptom was mentioned late in the consultation, or not mentioned at all, than if it was mentioned early in the consultation.

CONCLUSION

General practitioners need to remember that patients who present with symptoms of physical illness may also have depression. They also need to remember to give equal importance diagnostically to mentions of symptoms at whatever point they occur in the consultation, regardless of the presence or absence of physical illness.

Patient characteristics associated with the labelling of asthma

Patient characteristics associated with the asthma label were investigated in 262 children, aged 8 years, who reported wheezing illness in the previous 12 months. Children were first identified by a screening questionnaire administered to the parents of all 8 year old schoolchildren in Croydon, south London. Interviews were conducted with those reported to have had a wheezing illness in the previous 12 months to obtain details of the child's illness, medical care, demographic and socioeconomic characteristics. Multivariate analysis showed that the likelihood of being labelled asthmatic was increased in those who had a parental history of hayfever [odds ratio (OR) = 2.24, 95% confidence interval (CI) = 1.22-4.14] or at least two allergic provoking factors (OR = 3.83, 95% CI = 1.44-10.15). No significant associations were found between asthma labelling and children's socioeconomic characteristics or use of general practitioner services. These findings suggest that wheeze is likely to be labelled asthma when the clinical history suggests an allergic aetiology.

Why do general practitioners recognize major depression in one woman patient yet miss it in another?

The aim of this study was to establish whether psychiatric patient characteristics and the presence of physical illness affected general practitioners' recognition of major depressive illness in women patients. The 30-item general health questionnaire was used as a first stage screening instrument for psychiatric morbidity and each patient selected was interviewed, usually within three days of consulting their general practitioner, using the combined clinical interview. A sample of 72 women with major depressive disorder was obtained from patients consulting 36 general practitioners mainly from the south west Thames region of England, each general practitioner providing one patient he or she had correctly recognized as being depressed and one patient whose depression had not been recognized. Few differences were found between the groups with recognized and unrecognized depression in their psychiatric or physical features. More patients with unrecognized depression experienced physical illness and were tired. Patients with serious physical disease were five times more likely not to be recognized as depressed than those without physical disease. Patients with recognized depression described a more distinct quality to their depressed mood. Women with unrecognized major depression are similar to those women whose major depression is recognized by their general practitioner. These findings require further elaboration by process and content analysis of the women's consultations.

Relationship between smoking, weight and attitudes to weight in adolescent schoolgirls

A total of 1,932 schoolgirls aged 11-18 from seven schools in the South London area were surveyed using questionnaires which addressed eating patterns, body weight history, attitudes to body weight and shape, menstrual history and current smoking behaviour. They were also weighed and their height was measured. Twelve per cent of the girls were regular smokers and 10% smoked seven or more cigarettes over a 4 day period. Amongst girls aged 14 and over, 15% smoked regularly and a further 9% occasionally. A significant relationship was found between smoking and weight. Smokers were more likely to be moderately overweight in relation to their peers and to have been worried about their weight at some stage. There were differences between girls in state schools and those in independent schools with regard to smoking behaviour and weight. The findings have implications for anti-smoking strategies and health education generally.