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Hillman A, Jones IR, Quinn C, Pentecost C, Stapley S, Charlwood C, Clare L. The precariousness of living with, and caring for people with, dementia: Insights from the IDEAL programme. Soc Sci Med 2023; 331:116098. [PMID: 37480697 DOI: 10.1016/j.socscimed.2023.116098] [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] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 04/17/2023] [Accepted: 07/13/2023] [Indexed: 07/24/2023]
Abstract
This paper uses precarity as a framework to understand the vulnerabilities experienced by those living with or caring for someone living with dementia. Drawing on qualitative interview data from the Improving the Experience of Dementia and Enhancing Active Life (IDEAL) programme, we attend to our participants' reflections on how they manage the condition and the wider circumstances in which this occurs. To interrogate the utility of precarity, we focus on our participants' descriptions of needs and challenges and set these alongside both the wider contexts in which they seek or offer care (formal and informal) and the sets of values attributed to different ways of living with dementia. Building on the work of Portacolone, our analysis identified four interconnected themes: uncertainty; experiences of support and services; independence and personhood; and cumulative pressures and concerns. We develop this analysis by reviewing how our themes reflect, extend, or depart from previously identified markers of precarity and consider the specific ways in which these markers shape the lives of those living with dementia.
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Affiliation(s)
- A Hillman
- Wellcome Centre for Cultures & Environments of Health, University of Exeter, Queen's Building, Streatham Campus, EX4 4QJ, UK.
| | - I R Jones
- Institute for Social and Economic Research and Data (WISERD), Cardiff University, Cardiff, UK.
| | - C Quinn
- Centre for Applied Dementia Studies, University of Bradford, Bradford, UK.
| | - C Pentecost
- The Centre for Research in Ageing and Cognitive Health, Faculty of Health and Life Sciences University of Exeter Medical School, Exeter, UK.
| | - S Stapley
- The Centre for Research in Ageing and Cognitive Health, Faculty of Health and Life Sciences University of Exeter Medical School, Exeter, UK.
| | - C Charlwood
- The Centre for Research in Ageing and Cognitive Health, Faculty of Health and Life Sciences University of Exeter Medical School, Exeter, UK.
| | - L Clare
- The Centre for Research in Ageing and Cognitive Health, Faculty of Health and Life Sciences University of Exeter Medical School, Exeter, UK.
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Large O, Melrose R, Babatunde A, Thomson F, Stapley S. 1317 A QUALITY IMPROVEMENT PROJECT AIMING TO ENHANCE THE RECOGNITION OF INPATIENT WEIGHT LOSS ON AN ELDERLY WARD. Age Ageing 2023. [DOI: 10.1093/ageing/afac322.102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Abstract
Background
Weight loss in the older adult is often multifactorial and can be associated with increased morbidity and mortality. Our quality improvement project focused on nutritional care of patients 75 years or older. This hospital has a standardised Nutrition and Hydration Policy based on NICE guidelines to prevent malnutrition in hospital inpatients including weighing patients every 72 hours, daily screening and food/hydration charts. Our project aimed to increase adherence, with a focus on increasing the percentage of patients being regularly weighed over a 6-month period to 90%.
Methods
Our stakeholder analysis highlighted the multidisciplinary nature of our project, particularly involving the healthcare assistants. The percentage of patients weighed within 72 hours was recorded weekly. The first PDSA cycle introduced the project and gained buy-in from the MDT, highlighting required weights in MDT meetings/board rounds. The second cycle included an education session for doctors. The third cycle involved a poster in each bay aiming to act as a prompt and promote patient and family involvement.
Results
Our run chart shows that following our first two PDSA cycles eight consecutive results were higher than the baseline (40% of patients weighed). Results ranged from 70-90%. Following the third intervention compliance returned to baseline but coincided with significant disruption to the ward structure and team. Our successful intervention of nutritional teaching was then repeated as a fourth PDSA cycle and the mean returned to 80%.
Conclusions
Nutritional care requires multidisciplinary involvement. The educational session had the most impact and in future could be delivered to additional MDT members. Disappointingly the poster did not stimulate patient or family participation. We would like to create an ethos on elderly wards where nutrition routinely features in ward-based comprehensive geriatric assessments. Future plans hope to further engage patients and families as visiting restrictions eased.
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Affiliation(s)
- O Large
- Hull University Teaching Hospitals NHS Trust
| | - R Melrose
- Hull University Teaching Hospitals NHS Trust
| | - A Babatunde
- Hull University Teaching Hospitals NHS Trust
| | - F Thomson
- Hull University Teaching Hospitals NHS Trust
| | - S Stapley
- Hull University Teaching Hospitals NHS Trust
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Payton O, Spurrier E, Stapley S. 1504 Mandatory Reflection as a Learning Tool. Br J Surg 2021. [DOI: 10.1093/bjs/znab259.907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Introduction
Reflection has become a compulsory part of medical training and forms the basis of most trainee portfolios.
Method
We sent an electronic questionnaire to doctors from a range of specialties at various stages of training and asked how often they were involved in reflection, whether this was mandatory, and whether they found this useful.
Results
We received 608 responses, 66% from doctors in training. 90% stated that reflection was mandatory for training. 396 had a pre-set number of reflections they had to meet in a set timeframe. 26% of respondents admitted using formulaic responses in the “majority of occasions” or “always”. 27% admitted to copying and pasting from previous reflections. 20% altered their story to make it relevant to the message they wished to convey. 85% found voluntary reflection useful to some degree.
Conclusions
Although reflection plays it part as a learning aid, making this mandatory, with a set number of reflections seems to detract from its value. There is a risk that this educational tool becomes an exercise in creative writing.
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Affiliation(s)
- O Payton
- Royal Orthopaedic Hospital, Birmingham, United Kingdom
| | - E Spurrier
- Royal centre for Defence Medicine, Birmingham, United Kingdom
- The Royal British Legion Centre for Blast Injury Studies at Imperial College London, London, United Kingdom
| | - S Stapley
- The Royal British Legion Centre for Blast Injury Studies at Imperial College London, London, United Kingdom
- Portsmouth NHS Trust, Portsmouth, United Kingdom
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Stapley S, Colley S, Richards K. 100DEVELOPMENT OF RECREATIONAL THERAPY ROLE WITHIN THE ELDERLY CARE DEPARTMENT. Age Ageing 2018. [DOI: 10.1093/ageing/afy126.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- S Stapley
- Hull Royal Infirmary, Department of Elderly Care
| | - S Colley
- Hull Royal Infirmary, Department of Elderly Care
| | - K Richards
- Hull Royal Infirmary, Department of Elderly Care
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Zeybek B, Li S, Fernandez JW, Stapley S, Silberschmidt VV, Liu Y. Computational modelling of wounded tissue subject to negative pressure wound therapy following trans-femoral amputation. Biomech Model Mechanobiol 2017; 16:1819-1832. [PMID: 28553679 PMCID: PMC5671530 DOI: 10.1007/s10237-017-0921-7] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 05/17/2017] [Indexed: 12/05/2022]
Abstract
Proof-of-concept computational models were developed and applied as tools to gain insights into biomechanical interactions and variations of oxygen gradients of wounded tissue subject to negative pressure wound therapy (NPWT), following trans-femoral amputation. A macro-scale finite-element model of a lower limb was first developed based on computed tomography data, and distributions of maximum and minimum principal stress values we calculated for a region of interest (ROI). Then, the obtained results were applied iteratively as new sets of boundary conditions for a specific spatial position in a capillary sub-model. Data from coupled capillary stress and mass- diffusion sub-models were transferred to the macro-scale model to map the spatial changes of tissue oxygen gradients in the ROI. The −70 mmHg NPWT resulted in a dramatic change of a wound surface area and the greatest relative contraction was observed at −150 mmHg. Tissue lateral to the depth of the wound cavity revealed homogenous patterns of decrease in oxygenation area and the extent of such decrease was dependent on the distance from the wound surface. However, tissue lateral to the width of the wound demonstrated heterogeneous patterns of change, as evidenced by both gradual increase and decrease in the oxygenation area. The multiscale models developed in the current study showed a significant influence of NPWT on both macro-deformations and changes of tissue oxygenation. The patterns of changes depended on the depth of the tissue, the geometry of the wound, and also the location of tissue plane.
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Affiliation(s)
- B Zeybek
- Wolfson School of Mechanical Electrical and Manufacturing Engineering, Loughborough University, Loughborough, UK
| | - S Li
- Wolfson School of Mechanical Electrical and Manufacturing Engineering, Loughborough University, Loughborough, UK
| | - J W Fernandez
- Auckland Bioengineering Institute, Auckland University, Auckland, New Zealand
- Department of Engineering Science, Auckland University, Auckland, New Zealand
| | - S Stapley
- Royal Centre for Defence Medicine, ICT Centre, Birmingham, UK
- Department of Trauma and Orthopedics, Queen Alexandra Hospital, Portsmuth, UK
| | - V V Silberschmidt
- Wolfson School of Mechanical Electrical and Manufacturing Engineering, Loughborough University, Loughborough, UK
| | - Y Liu
- Wolfson School of Mechanical Electrical and Manufacturing Engineering, Loughborough University, Loughborough, UK.
- The Centre of Biological Engineering, Loughborough University, Loughborough, UK.
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Stapley S, Colley S, Harman D. 25THE EFFECT OF AMBIENT LIGHTING IN ELDERLY CARE WARDS ON THE BEHAVIOURAL AND PSYCHOLOGICAL SYMPTOMS OF DEMENTIA: A STAFF AND CARER SURVEY. Age Ageing 2017. [DOI: 10.1093/ageing/afx055.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Mercer SJ, Khan MA, Scott T, Matthews JJ, Henning D, Stapley S. Human factors in contingency operations. J ROY ARMY MED CORPS 2016; 163:78-83. [PMID: 27286782 DOI: 10.1136/jramc-2016-000658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 05/05/2016] [Accepted: 05/10/2016] [Indexed: 11/04/2022]
Abstract
The UK Defence Medical Services are currently supporting contingency operations following a period of intensive activity in relatively mature trauma systems in Iraq and Afghanistan. Among the key lessons identified, human factors or non-technical skills played an important role in the improvement of patient care. This article describes the importance of human factors on Role 2 Afloat, one of the Royal Navy's maritime contingency capabilities, and illustrates how they are vital to ensuring that correct decisions are made for patient care in a timely manner. Teamwork and communication are particularly important to ensure that limited resources such as blood products and other consumables are best used and that patients are evacuated promptly, allowing the facility to accept further casualties and therefore maintain operational capability. These ideas may be transferred to any small specialist team given a particular role to perform.
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Affiliation(s)
- Simon J Mercer
- Department of Anaesthesia, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - M A Khan
- Imperial College Healthcare NHS Trust, London, UK
| | - T Scott
- University Hospitals North Staffordshire NHS Trust, Stoke-On-Trent, UK
| | - J J Matthews
- Department of Orthopaedics, Royal Cornwall Hospitals NHS Trust, Truro, UK
| | - Dcw Henning
- Plymouth Hospitals NHS Trust, Plymouth, UK.,Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Academia), Medical Directorate, Birmingham, UK
| | - S Stapley
- Medical Directorate (Research and Academia) ICT Centre, Birmingham, UK
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Penn-Barwell JG, Myatt RW, Bennett PM, Sargeant ID, Bennett P, Fries C, Myatt R, Kendrew J, Midwinter M, Rickard R, Sargeant I, Porter K, Rowlands T, Mountain A, Foster M, Stapley S, Mortiboy D, Bishop J. Medium-term outcomes following limb salvage for severe open tibia fracture are similar to trans-tibial amputation. Injury 2015; 46:288-91. [PMID: 25548111 DOI: 10.1016/j.injury.2014.12.004] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [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] [Received: 06/15/2014] [Revised: 10/19/2014] [Accepted: 12/04/2014] [Indexed: 02/02/2023]
Abstract
Extremity injuries define the surgical burden of recent conflicts. Current literature is inconclusive when assessing the merits of limb salvage over amputation. The aim of this study was to determine medium term functional outcomes in military casualties undergoing limb salvage for severe open tibia fractures, and compare them to equivalent outcomes for unilateral trans-tibial amputees. Cases of severe open diaphyseal tibia fractures sustained in combat between 2006 and 2010, as described in a previously published series, were contacted. Consenting individuals conducted a brief telephone interview and were asked to complete a SF-36 questionnaire. These results were compared to a similar cohort of 18 military patients who sustained a unilateral trans-tibial amputation between 2004 and 2010. Forty-nine patients with 57 severe open tibia fractures met the inclusion criteria. Telephone follow-up and SF-36 questionnaire data was available for 30 patients (61%). The median follow-up was 4 years (49 months, IQR 39-63). Ten of the 30 patients required revision surgery, three of which involved conversion from initial fixation to a circular frame for non- or mal-union. Twenty-two of the 30 patients (73%) recovered sufficiently to complete an age-standardised basic military fitness test. The median physical component score of SF-36 in the limb salvage group was 46 (IQR 35-54) which was similar to the trans-tibial amputation cohort (p=0.3057, Mann-Whitney). Similarly there was no difference in mental component scores between the limb salvage and amputation groups (p=0.1595, Mann-Whitney). There was no significant difference in the proportion of patients in either the amputation or limb salvage group reporting pain (p=0.1157, Fisher's exact test) or with respect to SF-36 physical pain scores (p=0.5258, Mann-Whitney). This study demonstrates that medium term outcomes for military patients are similar following trans-tibial amputation or limb salvage following combat trauma.
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Affiliation(s)
- J G Penn-Barwell
- National Institute of Health Research, Surgical Reconstruction and Microbiology Research Centre (NIHR SRMRC), Birmingham, UK; Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine (RCDM), Birmingham, UK.
| | - R W Myatt
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine (RCDM), Birmingham, UK
| | - P M Bennett
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine (RCDM), Birmingham, UK
| | - I D Sargeant
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine (RCDM), Birmingham, UK; Queen Elizabeth's Hospital, Birmingham, UK
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Abstract
Patients who do not attend ('DNA') health appointments have been identified as a service problem incurring significant costs to the NHS. In order to explore the causes, effects and costs of child DNAs, we carried out a scoping study to map the literature and identify gaps in the research. Given the breadth of issues underpinning DNAs, a scoping study, including research studies, audits, policy documents and conference abstracts, was the most useful way to map the field. To foster public and patient participation, we sought advice from parents participating in the National Children's Bureau's Family Research Advisory Group. From a pool of 1997 items, we found few UK studies with non-attendance of 0-10 year olds as a primary focus, though many more incidentally reported DNA rates. Overall, four topics predominated: the conceptualization of DNAs; the correlates of non-attendance; initiatives to reduce non-attendance; and the relationship between non-attendance and safeguarding. The Family Research Advisory Group identified broadly similar issues, but with a stronger emphasis on communication and practical matters. While there may be circumstances where failing to attend appointments makes little or no difference to a child (or even benefits them) it is likely that there are children whose health or well-being are compromised as a result of failing to attend appointments. Both 'over' and 'under'-attendance can be a source of anxiety to health professionals. Areas where further work is needed include robust evaluation of the effectiveness, cost-effectiveness and maintenance of measures to reduce DNAs and a better understanding of the relationship of safeguarding to non-attendance.
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Affiliation(s)
- L Arai
- School of Health and Social Care, Teesside University, Middlesbrough, Tees Valley, UK
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Reece S, Stapley S, Harman D. 25 * AN AUDIT TO EVALUATE THE USE OF A DEMENTIA DIAGNOSTIC ASSESSMENT (DDA) TOOL TO IMPROVE IDENTIFICATION, ASSESSMENT AND REFERRAL OF PATIENTS WITH UNDIAGNOSED DEMENTIA IN SECONDARY CARE. Age Ageing 2014. [DOI: 10.1093/ageing/afu036.25] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Stapley S, Peters TJ, Neal RD, Rose PW, Walter FM, Hamilton W. The risk of oesophago-gastric cancer in symptomatic patients in primary care: a large case-control study using electronic records. Br J Cancer 2012; 108:25-31. [PMID: 23257895 PMCID: PMC3553533 DOI: 10.1038/bjc.2012.551] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background: Over 15 000 new oesophago-gastric cancers are diagnosed annually in the United Kingdom, with most being advanced disease. We identified and quantified features of this cancer in primary care. Methods: Case–control study using electronic primary-care records of the UK patients aged ⩾40 years was performed. Cases with primary oesophago-gastric cancer were matched to controls on age, sex and practice. Putative features of cancer were identified in the year before diagnosis. Odds ratios (ORs) were calculated for these features using conditional logistic regression, and positive predictive values (PPVs) were calculated. Results: A total of 7471 cases and 32 877 controls were studied. Sixteen features were independently associated with oesophago-gastric cancer (all P<0.001): dysphagia, OR 139 (95% confidence interval 112–173); reflux, 5.7 (4.8–6.8); abdominal pain, 2.6 (2.3–3.0); epigastric pain, 8.8 (7.0–11.0); dyspepsia, 6 (5.1–7.1); nausea and/or vomiting, 4.9 (4.0–6.0); constipation, 1.5 (1.2–1.7); chest pain, 1.6 (1.4–1.9); weight loss, 8.9 (7.1–11.2); thrombocytosis, 2.4 (2.0–2.9); low haemoglobin, 2.4 (2.1–2.7); low MCV, 5.2 (4.2–6.4); high inflammatory markers, 1.7 (1.4–2.0); raised hepatic enzymes, 1.3 (1.2–1.5); high white cell count, 1.4 (1.2–1.7); and high cholesterol, 0.8 (0.7–0.8). The only PPV >5% in patients ⩾55 years was for dysphagia. In patients <55 years, all PPVs were <1%. Conclusion: Symptoms of oesophago-gastric cancer reported in secondary care were also important in primary care. The results should inform guidance and commissioning policy for upper GI endoscopy.
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Affiliation(s)
- S Stapley
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, UK
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14
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Abstract
OBJECTIVE To identify the routes patients with ovarian cancer take between first symptom presentation and diagnosis. DESIGN Cohort study. SETTING The study took place in 39 general practices in Devon, UK. POPULATION All ovarian cancer patients identified in the practices, with a diagnosis between 2000 and 2007 inclusive. METHODS All patients had their cancer symptoms, referrals, and diagnoses identified and dated using their doctors' records. MAIN OUTCOME MEASURES Numbers of patients taking specific routes to diagnosis, together with the time taken to diagnosis. RESULTS Three main routes to diagnosis emerged. The first was the expected route of outpatient referral: 195 (92% of the total) had at least one of the seven ovarian cancer symptoms or an abdominal mass. A total of 123 (58%) were referred to a specialist, although only 65 (31%) were referred to a gynaecologist. Thirty-five (17%) were initially investigated within primary care by ultrasound scanning, and a further 35 (17%) were admitted as emergencies. The interval from first symptom to referral was similar across the different pathways, with a median (interquartile range) time between the first symptom presenting to primary care and first investigation or referral being 2.5 (0, 27.5) days. The median interval from first symptom reported in primary care to diagnosis was 74.5 (32, 159) days. CONCLUSIONS Only a minority of ovarian cancer patients follow the expected route to diagnosis, of urgent referral to a gynaecologist. In most women, GPs rapidly identified the need to investigate. Avoidable delays generally occurred after the decision to investigate was made.
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Kernick D, Stapley S, Campbell J, Hamilton W. What happens to new-onset headache in children that present to primary care? A case-cohort study using electronic primary care records. Cephalalgia 2010; 29:1311-6. [PMID: 19911465 DOI: 10.1111/j.1468-2982.2009.01872.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The aim was to describe the consulting behaviour and clinical outcomes of children presenting with headache in primary care. This was a historical cohort study using data from the UK General Practitioner Research Database. Cases were children aged 5-17 years who presented to primary care with primary headache (migraine, tension-type headache, cluster headache) or undifferentiated headache (no further descriptor). Controls were age, sex and practice matched. Their records were examined for consultations, referrals, relevant treatments and specific diseases in the subsequent year. Children with headache (n = 48 575) were identified and matched to controls. At presentation, 9321 (19.2%) of headaches were labelled primary, 549 (1.1%) secondary and 38 705 (79.7%) received no formal diagnosis. Of the latter group, 2084 (5.4%) received a primary headache diagnosis in the subsequent year. Following a diagnosis of migraine, 258 (3.5%) had received a triptan and 1598 (21%) were using propranolol or pizotifen. Total consultations were higher in cases than in controls in the year before the headache: cases ages 5-8 years, mean (s.d.) 5.0 (4.0) consultations; controls 4.0 (3.5) consultations. In 1 year controls had 43 430 consultations, of which 256 (0.6%) were for headache, of whom 64 (25%) were referred to secondary care. Headache was a risk factor for benign and malignant tumours, cerebrovascular disease, primary disorders of raised intracranial pressure and depression. This risk was reduced if a diagnosis of a primary headache disorder could be made. Although there is an increased likelihood of a serious pathology with headache presentations, the risk is small particularly if a diagnosis of a primary headache is made. General practitioners are likely to be underdiagnosing migraine. This study can inform management guidelines for new presentations of headache in primary care, particularly when a secondary pathology is suspected.
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Affiliation(s)
- D Kernick
- Primary Care Research Group, Peninsula College of Medicine and Dentistry, St Luke's Campus, University of Bristol, Bristol, UK.
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16
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Kernick D, Stapley S, Goadsby PJ, Hamilton W. What happens to new-onset headache presented to primary care? A case-cohort study using electronic primary care records. Cephalalgia 2008; 28:1188-95. [PMID: 18771496 DOI: 10.1111/j.1468-2982.2008.01674.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In the UK, 4% of general practitioner consultations are for headache, yet the natural history of these presentations is unknown. The objective of this study was to describe the outcome of new headache presentations to the general practitioner. This was a prospective case-control study in adults over a period of 1 year using data from the General Practitioner Research Database, UK. Records of patients who presented with primary headache (migraine, tension-type headache, cluster headache) or undifferentiated headache (no further descriptor) were examined for the subsequent year for subarachnoid haemorrhage, primary brain tumour, benign space-occupying lesion, temporal arteritis, stroke and transient ischaemic attack. We identified 21,758 primary headaches and 63,921 undifferentiated headaches. The likelihood ratio was 29 (9.9, 92) for a subarachnoid haemorrhage after an undifferentiated headache and increased with age. The 1-year risk of a malignant brain tumour with new undifferentiated headache was 0.15%, rising to 0.28% above the age of 50 years. For primary headache the risk was 0.045%. The risk for a benign space-occupying lesion was 0.05% for an undifferentiated and 0.009% for a primary headache. The risk of temporal arteritis was the highest of the conditions studied, 0.66% in the undifferentiated and 0.18% in the primary headache group. Accepting the limitations of this approach, our data can inform management guidelines for new presentations of headache in primary care and confirm the need for follow-up, even if a primary headache diagnosis is made.
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Affiliation(s)
- D Kernick
- St Thomas Medical Group, Exeter, UK.
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17
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Stapley S, Peters TJ, Sharp D, Hamilton W. The mortality of colorectal cancer in relation to the initial symptom at presentation to primary care and to the duration of symptoms: a cohort study using medical records. Br J Cancer 2006; 95:1321-5. [PMID: 17060933 PMCID: PMC2360591 DOI: 10.1038/sj.bjc.6603439] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The association between the staging of colorectal cancer and mortality is well known. Much less researched is the relationship between the duration of symptoms and outcome, and whether particular initial symptoms carry a different prognosis. We performed a cohort study of 349 patients with primary colorectal cancer in whom all their prediagnostic symptoms and investigation results were known. Survival data for 3–8 years after diagnosis were taken from the cancer registry. Six features were studied: rectal bleeding, abdominal pain, diarrhoea, constipation, weight loss, and anaemia. Two of these were significantly associated with different staging and mortality. Rectal bleeding as an initial symptom was associated with less advanced staging (odds ratio from one Duke's stage to the next 0.50, 95% confidence interval 0.31, 0.79; P=0.003) and with reduced mortality (Cox's proportional hazard ratio (HR) 0.56 (0.41, 0.79); P=0.001. Mild anaemia, with a haemoglobin of 10.0–12.9 g dl−1, was associated with more advanced staging (odds ratio 2.2 (1.2, 4.3); P=0.021) and worse mortality (HR 1.5 (0.98, 2.3): P=0.064). When corrected for emergency admission, sex, and the site of the tumour, the HR for mild anaemia was 1.7 (1.1, 2.6); P=0.015. No relationship was found between the duration of symptoms and staging or mortality.
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Affiliation(s)
- S Stapley
- CAPER Research Practices, Halford Wing, Dean Clarke House, Exeter, EX1 1PQ, UK
| | - T J Peters
- Academic Unit of Primary Health Care, Department of Community Based Medicine, University of Bristol, The Grange, 1 Woodland Road, Bristol, BS8 1AU, UK
| | - D Sharp
- Academic Unit of Primary Health Care, Department of Community Based Medicine, University of Bristol, The Grange, 1 Woodland Road, Bristol, BS8 1AU, UK
| | - W Hamilton
- CAPER Research Practices, Halford Wing, Dean Clarke House, Exeter, EX1 1PQ, UK
- Academic Unit of Primary Health Care, Department of Community Based Medicine, University of Bristol, The Grange, 1 Woodland Road, Bristol, BS8 1AU, UK
- Academic Unit of Primary Health Care, Department of Community Based Medicine, University of Bristol, The Grange, 1 Woodland Road, Bristol, BS8 1AU, UK. E-mail:
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Abstract
It is important that drugs which are used to protect bone from the osteoporotic effects of estrogen deficiency should not affect plasma lipids adversely. Effects of a) norethisterone acetate and b) tamoxifen citrate on plasma cholesterol and on bone conservation in rats with normal plasma 17B-estradiol and in rats made estrogen-deficient with the LHRH agonist, buserelin are reported. Tamoxifen halved total plasma cholesterol (p < 0.01), whereas norethisterone did not lower plasma cholesterol. Furthermore tamoxifen fully protected bone from estrogen-deficiency osteopenia whereas norethisterone conserved bone less well. Reductions in cholesterol elicited by tamoxifen were similar in estrogen-deficient rats and in rats with normal ovarian function. This is the first report in the rat that tamoxifen has lipid-lowering actions. It is suggested the rat may be useful for future investigations of the lipid-lowering mechanisms of tamoxifen.
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Affiliation(s)
- E Gold
- Department of Medicine, University of Otago, Dunedin, New Zealand
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