A time for change and a time for equality--infertility services and the NHS

The provision of infertility services has always provoked controversy. On the one hand, patients' groups and clinicians involved with infertile couples have long campaigned against the 'postcode lottery'. On the other hand, commissioners have been reluctant to commit resources to what they see as a low priority in health care. The issue has been brought back into the news with the government's decision to ask the National Institute of Clinical Excellence to review the inequalities in provision of fertility services. This article sets out the evidence for viewing infertility as an illness that deserves public funding, and argues that assisted conception should be viewed in the same light as other chronic non-life-threatening conditions that are currently funded by the NHS.

Reduction of fine airborne particulates (PM3) in a small city centre office, by altering electrostatic forces

A two stage intervention study was carried out to establish the degree to which a newly developed, electrostatic air cleaning (EAC) system can improve indoor air quality (IAQ) by reducing the number of airborne fine particles. The IAQ and how employees in a city centre office (49 m2) perceived it, was monitored from May until November 1998. The number of fine particles, PM3 (0.3-3.0 microm); number of coarse particles, PM7 (3.0-7.0 microm); number of small positive and negative air ions; relative humidity and temperature were recorded in and out of doors. To assess the employees' perception of any changes in their work environment, a questionnaire was completed. Number of particles, relative humidity and temperature were also recorded in a nearby office, equipped with an identical air processor, where no interventions were made. The results from the first intervention (Stage 1), comparing number of airborne particles outdoors to indoors, gave a 19% reduction for PM3 and a 67% reduction for PM7 (P < 0.001). The reduction in PM3 was inconsistent and not statistically significant (P = 0.3). The reduction in PM7 from outdoors and the removal of PM7 created indoors was achieved by optimizing the existing air moving equipment. The results from the second intervention (Stage 2--with EAC units installed) comparing indoor to outdoor values, gave a further reduction in PM3 of 21% (P < 0.001) and a further 3% reduction for PM7 (P > 0.05). Therefore, at the end of Stage 2, the total reductions in particles from outdoors to indoors were 40% for PM3 and 70% for PM7 (P < 0.001). The Stage 2 results strongly suggest that electrostatic forces, created by the EAC unit(s) improved the removal of PM3, with no further significant improvement in the reduction of PM7. The questionnaire indicated an improvement in the IAQ, as perceived by the employees. The results suggest that the EAC system is effective in reducing PM3 and thereby improving IAQ in an urban office.

Randomized controlled trial of nettle sting for treatment of base-of-thumb pain

There are numerous published references to use of nettle sting for arthritis pain but no randomized controlled trials have been reported. We conducted a randomized controlled double-blind crossover study in 27 patients with osteoarthritic pain at the base of the thumb or index finger. Patients applied stinging nettle leaf (Urtica dioica) daily for one week to the painful area. The effect of this treatment was compared with that of placebo, white deadnettle leaf (Lamium album), for one week after a five-week washout period. Observations of pain and disability were recorded for the twelve weeks of the study. After one week's treatment with nettle sting, score reductions on both visual analogue scale (pain) and health assessment questionnaire (disability) were significantly greater than with placebo (P = 0.026 and P = 0.0027).

Nettle sting of Urtica dioica for joint pain--an exploratory study of this complementary therapy

This exploratory study aims to explore the present use of the common stinging nettle to treat joint pain. Eighteen self-selected patients using the nettle sting of Urtica dioica were interviewed. Information regarding patients' use of nettle therapy was elicited, in particular mode of application, dosage and effects. All except one respondent were sure that netles had been very helpful and several considered themselves cured. No observed side effects were reported, except a transient urticarial rash. This exploratory study suggests nettle sting is a useful, safe and cheap therapy which needs further study. A randomized controlled trial is planned in collaboration with a rheumatology specialist.

Mobility screening in the elderly and resulting referral

The aims of this study were to test the usefulness of the Royal College of General Practitioners' (RCGP) mobility screening questionnaire in Irish general practice and to use it to assess the level of mobility problems in the over-75 year old population. Questionnaire screening survey in six faculty areas of the Irish College of General Practitioners(ICGP) well-spread geographically to be representative of the Irish population. Participants were a random sample of 627 people aged 75 years or over, from the General Medical Services list of 92 volunteer general practitioners. The Royal College of General Practitioners' screening questionnaire for mobility was administered by each person's doctor. Suggested interventions were also noted. 92% felt able to get around the house independently, with 78% able to manage stairs independently. The commonest aid to mobility was a stick, used by 27%. Mental impairment was closely associated with inability to get around the house (86% of those not independent around the house scored less than 8 on the Abbreviated Mental Test Score). Analysis of referral patterns indicated possible deficiencies in the availability of physiotherapy in certain areas. The RCGP mobility screening questionnaire was easy to use, and helpful in detecting problems which might require attention.

Case-finding incontinence in the over-75s

BACKGROUND

The under-reporting of incontinence in older persons is well known. However, the general practitioner's (GP's) knowledge of incontinence in this population is less wall documented.

AIM

To examine the knowledge of Irish GPs regarding incontinence in patients aged over 75, and to examine the relationship between incontinence and cognitive function in this age group.

METHOD

Sixty-four GPs from six faculties of the Irish College of General Practitioners (ICGP), spread geographically over Ireland, administered a questionnaire to 10 of their patients, selected from the General Medical Services list, as part of the ICGP 1993 Care of the Elderly Study. A short test of cognitive function, the AMTS, was administered followed by RCGP (Royal College of General Practitioners) screening questions for incontinence, plus questions with regard to patients' prior reporting of incontinence. GPs were also asked to state their prior knowledge of the incontinence status of the patient and to choose from a list of management options including referral, assigning to a public health nurse, and hospital surgical service.

RESULTS

Data were analysed on 527 patients aged over 75 years. Forty-four per cent of persons over 75 years reported having experienced urinary incontinence; 9% reported having experienced faecal incontinence. GPs reported full knowledge of the incontinence status in only 33% of their patients. The effects of low cognitive function, sex, and age on the probability of wetting were analysed using logistic regression modelling. Female sex and low cognitive score increased the likelihood of ever wetting; increasing age increased the likelihood of daily wetting. Poor sensitivities for these models limit their usefulness in clinical practice.

CONCLUSION

GPs should have a high index of suspicion for incontinence in persons aged over 75. Thorough history-taking, physical examination, and examinations of therapeutic options for individual cases are recommended.

A scoring system for predicting group A streptococcal throat infection

BACKGROUND

Sore throat is very common in general practice and is usually caused by viral infection. Nevertheless, up to 95% of patients may be treated with antibiotics. Previous diagnostic systems have not transferred well from one area to another because of an inability to allow for changing prevalence of streptococcus.

AIM

To measure the occurrence rates of symptoms and signs in sore throat patients with and without streptococcal infection, and to develop a Bayesian scoring system which is easily adapted for prevalence to predict if patients have bacterial infection.

METHOD

Occurrence rates of symptoms and signs were measured for 206 patients with sore throat symptoms over a 3-year period. Bayesian probability scores (B-scores) for each data item were calculated from the ocurrence rates in the patients with positive throat cultures for group A streptococci and the rates in patients with negative throat cultures. The B-score values were then used to predict the probability of positive culture for each patient.

RESULTS

The streptococcal throat B-score system predicted positive culture with a sensitivity of 71% and a specificity of 71%. In comparison, the unaided general practitioners predicted infection with a sensitivity of 61% and a specificity of 65%. If the B-score prediction had been used to decide on treatment, more patients with streptococci present on culture would have been treated with antibiotic (71% instead of 68%) and appreciably fewer patients with negative streptococcal cultures would have been treated (29% instead of 59%).

CONCLUSION

Use of the B-score system could result in significant savings in unnecessary antibiotic prescription, and unnecessary throat swab cultures, while achieving better levels of treatment.

Changes in myocardial perfusion abnormalities by positron emission tomography after long-term, intense risk factor modification

OBJECTIVE

To quantify changes in size and severity of myocardial perfusion abnormalities by positron emission tomography (PET) in patients with coronary artery disease after 5 years of risk factor modification.

DESIGN

Randomized controlled trial.

SETTING

Outpatient community setting.

INTERVENTION

Randomization of patients to risk factor modification consisting of very low-fat vegetarian diet, mild to moderate exercise, stress management, and group support (experimental group, n = 20) or to usual care by their own physicians, consisting principally of antianginal therapy (control group, n = 15).

MAIN OUTCOME MEASURES

Quantitative coronary arteriography and PET at baseline and 5 years after randomization. Automated, objective measures of size and severity of perfusion abnormalities on rest-dipyridamole PET images and of stenosis severity on arteriograms were made by computer algorithms.

RESULTS

Size and severity of perfusion abnormalities on dipyridamole PET images decreased (improved) after risk factor modification in the experimental group compared with an increase (worsening) of size and severity in controls. The percentage of left ventricle perfusion abnormalities outside 2.5 SDs of those of normal persons (based on 20 disease-free individuals) on the dipyridamole PET image of normalized counts worsened in controls (mean +/- SE, + 10.3% +/- 5.6%) and improved in the experimental group (mean +/- SE, -5.1% +/- 4.8%) (P = .02); the percentage of left ventricle with activity less than 60% of the maximum activity on the dipyridamole PET image of normalized counts worsened in controls (+13.5% +/- 3.8%) and improved in the experimental group (-4.2% +/- 3.8%) (P = .002); and the myocardial quadrant on the PET image with the lowest average activity expressed as a percentage of maximum activity worsened in controls (-8.8% +/- 2.3%) and improved in the experimental group (+4.9% +/- 3.3%) (P = .001). The size and severity of perfusion abnormalities on resting PET images were also significantly improved in the experimental group as compared with controls. The relative magnitude of changes in size and severity of PET perfusion abnormalities was comparable to or greater than the magnitude of changes in percent diameter stenosis, absolute stenosis lumen area, or stenosis flow reserve documented by quantitative coronary arteriography.

CONCLUSIONS

Modest regression of coronary artery stenoses after risk factor modification is associated with decreased size and severity of perfusion abnormalities on rest-dipyridamole PET images. Progression or regression of coronary artery disease can be followed noninvasively by dipyridamole PET reflecting the integrated flow capacity of the entire coronary arterial circulation.

Referrals to Irish accident and emergency departments

A prospective survey of samples of thirty consecutive referrals from general practitioners in fifteen European Countries (the European study of Referrals from Primary Care), found that Irish doctors sent a higher proportion (20.6%) of referrals to Accident and Emergency (A&E) Departments than in any other country in the study. Further analysis of the Irish sample showed that 57% of these patients were referred to specialists other than Emergency and Trauma (E&T) (i.e. 12.7% of all referrals). These referrals were mostly for acute medical or surgical conditions requiring inpatient treatment. More non-E&T referrals were sent by doctors closer than 10 km from hospital (26.8% of all their referrals), as compared with doctors 10 km or further from hospital (8.1% of all their referrals). Doctors older than 40 years sent more non-E&T referrals to A&E Departments (16.9% of all their referrals) as compared with those aged 40 years or younger (9.6% of all their referrals). In contrast, referrals to Emergency and Trauma specialists were associated with greater distance to hospital, as doctors closer than 10 km from hospital made only 1.6% of all referrals to the E&T specialty, while doctors 10 km or further from hospital made 12.5% of all referrals to E&T specialists. The author recommends that referrals to non-trauma specialists in the Republic of Ireland should go directly to these specialists, as in all other countries in Europe, thus freeing Emergency and Trauma specialists for their proper Accident and Emergency function.