Does post-caesarean dyspareunia reflect sexual malfunction, pelvic floor and perineal dysfunction?

The aim was to define post-caesarean dyspareunia as a sexual and pelvic-perineal symptom. Post-caesarean (80 elective, 104 emergency) and 100 vaginally delivered primiparae had domiciliary interviews at 10 months postpartum. A total of 50 (28% and 27%) post-caesarean and 46 (46%) vaginally delivered, reported dyspareunia. Severely impaired general sexual health occurred in 82 (24% elective, 25% emergency, 35% vaginally delivered) as category 3 (dyspareunia with sexual symptoms) and 27 (10% elective, 7% emergency, 12% vaginally delivered) as category 4 (reduced frequency < 6). The risk of dyspareunia (RR 1.14, CI 0.73, 1.77) or impaired general sexual health (RR 0.93, CI 0.32, 2.74) was similar among those with or without perineal trauma. Both caesarean and perineal scars were associated with sexual malfunction. Primiparae with new incontinence had a lower risk of dyspareunia than impaired general sexual health. Awareness of the associations of post-caesarean dyspareunia and impaired general sexual health with incontinence would facilitate appropriate obstetric decision-making. Further research is indicated.

Postcesarean pelvic floor dysfunction contributes to undisclosed psychosocial morbidity

OBJECTIVE

To estimate the prevalence and severity of postcesarean pelvic dysfunction.

STUDY DESIGN

Using biopsychosocial interviewing at home, 184 postcesarean primiparas were compared to 100 vaginally delivered women regarding symptoms of stress incontinence, anal incontinence and dyspareunia. Delivery details were confirmed from medical records.

RESULTS

Comparison of postcesarean vs. vaginally delivered women revealed stress incontinence in 33% vs. 54% and dyspareunia in 27% vs. 46%, both differences reaching statistical significance, unlike anal incontinence, which was manifest in 51% vs. 44%. When compared to emergency cesarean the relative risk of stress incontinence following an elective cesarean was 0.99 (0.71, 1.39), of dyspareunia 1.02 and of anal incontinence 1.05, indicating no statistically significant difference. Thirty (22%) stress incontinent and 4 (3%) fecally incontinent mothers used pads continuously, suggesting severe physical morbidity. Severe dysphoria (depression) was expressed by 41 (35%) stress incontinent mothers, 38 (30%) with dyspareunia and 34 (26%) with anal incontinence; the association of severe dysphoria with dyspareunia was statistically significant (OR = 2.504 [1.362, 4.602]). Few women came forward to seek help.

CONCLUSION

Pelvic dysfunction was similar after elective or emergency cesarean. Compared to vaginal delivery, postcesarean stress incontinence and dyspareunia were less frequent but biopsychosocial morbidity could be severe.

Screening versus routine practice in detection of atrial fibrillation in patients aged 65 or over: cluster randomised controlled trial

OBJECTIVES

To assess whether screening improves the detection of atrial fibrillation (cluster randomisation) and to compare systematic and opportunistic screening.

DESIGN

Multicentred cluster randomised controlled trial, with subsidiary trial embedded within the intervention arm.

SETTING

50 primary care centres in England, with further individual randomisation of patients in the intervention practices.

PARTICIPANTS

14,802 patients aged 65 or over in 25 intervention and 25 control practices.

INTERVENTIONS

Patients in intervention practices were randomly allocated to systematic screening (invitation for electrocardiography) or opportunistic screening (pulse taking and invitation for electrocardiography if the pulse was irregular). Screening took place over 12 months in each practice from October 2001 to February 2003. No active screening took place in control practices.

MAIN OUTCOME MEASURE

Newly identified atrial fibrillation.

RESULTS

The detection rate of new cases of atrial fibrillation was 1.63% a year in the intervention practices and 1.04% in control practices (difference 0.59%, 95% confidence interval 0.20% to 0.98%). Systematic and opportunistic screening detected similar numbers of new cases (1.62% v 1.64%, difference 0.02%, -0.5% to 0.5%).

CONCLUSION

Active screening for atrial fibrillation detects additional cases over current practice. The preferred method of screening in patients aged 65 or over in primary care is opportunistic pulse taking with follow-up electrocardiography.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN19633732 [controlled-trials.com].

Evaluation by dental students of a communication skills course using professional role-players in a UK school of dentistry

This paper reports student (n = 180) feedback on the role-play teaching methodology used in behavioural sciences teaching at The School of Dentistry in Birmingham (UK). The feedback received on this well-established (since 1995) educational programme was collected via questionnaire (100% response rate), requiring Likert scale and free text responses. Generally students reported that they had enjoyed and valued the session. Over two-thirds (69.7%) of students rated the role-players as 'very real' and over three-quarters (78.9%) rated their feedback as 'very fair'. The data collected from this study will inform future curriculum development. Student feedback was very positive and demonstrated that the cohort (86% of all students studying in years 1, 2 and 3) found the use of professional role-players involved in behavioural sciences teaching to be both acceptable and valuable.

The use of lipid-lowering drugs across ethnic groups in the secondary prevention of ischaemic heart disease: analysis of cross-sectional surveys in England

A secondary analysis of the Health Surveys for England data was performed to explore the use of lipid-lowering drug therapy in people with ischaemic heart disease (IHD) across ethnic groups. There were significant associations with age group, type of IHD, and housing tenure and the taking of lipid-lowering drugs. There was no significant association with ethnic group.

Gender as a variable in the assessment of final year degree-level communication skills

AIM

To investigate possible bias due to gender combination of students, role players and examiners in a high-stakes assessment.

SETTING

Valid oral interactive contextualized examinations (VOICEs) is a long-station OSCE-style exam in general practice (GP). At the time of writing it consisted of 65% of the student's final GP mark.

METHOD

In the VOICE, students undertake six tasks--four vivas and two role-plays. "Patient" roles are taken by professional role players who work regularly on the undergraduate curriculum. During the role-play, the student's clinical competence is assessed by an observing GP examiner. The communication skills marks are awarded by the role player and the examiner together, by negotiation. Data have been recorded detailing the role player's initial marks, the examiner's initial marks and their final (awarded) agreed marks for 1024 consultations.

SAMPLE

512 final year medical students, 28 role players and 48 examiners. There were no inclusion or exclusion criteria. All those present on exam day became part of the data.

RESULTS

There was a significant relationship between gender and performance for some, but not all, stations. Correlations for multiple comparisons removed the significance. Female students perform better across the board than male students. While not always significant, this did affect grading. There was no significant association between the genders of role players and examiners with the question choices. There has been a significant worsening of male results since 1999. Differences exist in the way that pairs of mixed or single genders score students.

Impact of a region-wide approach to improving systems for heart attack care: the West Midlands thrombolysis project

OBJECTIVE

To describe changes in delay to administration of thrombolytic therapy associated with a region-wide audit.

DESIGN

Observational study of patients admitted with suspected myocardial infarction (MI) based on continuous audit.

SUBJECTS

18877 patients admitted to 23 hospitals with suspected MI between April 1995 and March 1998.

RESULTS

Of 11232 patients with a discharge diagnosis of definite MI, 8802 (46.6%) received thrombolytic therapy during hospitalisation, with 5155 patients eligible for treatment on admission to hospital on the basis of established indications. Call-to-needle time for those eligible for treatment on admission fell from median 105 min in the first year of the project to 85 min in year 3 (P<0.001), and door-to-needle time fell from 45 to 35 min (P<0.001). Forty percent of eligible patients were treated within the then current national standard of 90 min from time of call for help, with nearly 49% in the final year and 20% being treated within the new national standard of 60 min, by the third year.

CONCLUSION

The proportion of eligible patients receiving thrombolysis within 1 h of the call for help doubled during the 3-year project but the majority of patients still wait longer than 60-min 'call-to-needle'. New systems to reduce delays to administration of thrombolysis to within 60 min of call for help are required, including consideration of pre-hospital treatment.

SMART: self-management of anticoagulation, a randomised trial [ISRCTN19313375]

BACKGROUND

Oral anticoagulation monitoring has traditionally taken place in secondary care because of the need for a laboratory blood test, the international normalised ratio (INR). The development of reliable near patient testing (NPT) systems for INR estimation has facilitated devolution of testing to primary care. Patient self-management is a logical progression from the primary care model. This study will be the first to randomise non-selected patients in primary care, to either self-management or standard care.

METHOD

The study was a multi-centred randomised controlled trial with patients from 49 general practices recruited. Those suitable for inclusion were aged 18 or over, with a long term indication for oral anticoagulation, who had taken warfarin for at least six months. Patients randomised to the intervention arm attended at least two training sessions which were practice-based, 1 week apart. Each patient was assessed on their capability to undertake self management. If considered capable, they were given a near patient INR testing monitor, test strips and quality control material for home testing. Patients managed their own anticoagulation for a period of 12 months and performed their INR test every 2 weeks. Control patients continued with their pre-study care either attending hospital or practice based anticoagulant clinics.

DISCUSSION

The methodology used in this trial will overcome concerns from previous trials of selection bias and relevance to the UK health service. The study will give a clearer understanding of the benefits of self-management in terms of clinical and cost effectiveness and patient preference.

Patterns of child-bearing behaviour amongst female hospital doctors and GPs

BACKGROUND

The number of females entering and graduating from medical school is currently increasing and, as a result, the problems they face if they wish to work as doctors and have a family are becoming more apparent.

METHODS

A questionnaire study of 105 female GPs and 98 female hospital doctors was carried out in Birmingham, UK, to determine doctors' experiences and views of child-bearing whilst working as a doctor.

RESULTS

Of the GP responders, 81% had children compared with 49% of hospital doctors. GPs were shown to work fewer hours than hospital doctors. Problems were identified relating to the everyday difficulties faced whilst working and raising a family.

CONCLUSIONS

The results highlight the need to address the difficulties faced by females pursuing this demanding career.

A comparison of Bayesian and maximum likelihood methods to determine the performance of a point of care test for Helicobacter pylori in the office setting

OBJECTIVE

Evaluations of point of care tests (PCT) are often hampered by a lack of appropriate gold standards. This study aimed to compare the results of a Bayesian statistical analysis and a maximum likelihood method to evaluate the performance of a PCT for Helicobacter pylori in primary care.

METHODS

The Helisal Rapid Blood Test (Cortecs Diagnostics) was performed in 311 patients from 6 primary care centers, and a concurrent venous sample was taken for 2 enzyme-linked immunosorbent assays (ELISA) performed at the laboratory, blind to the PCT result. The Bayesian analysis was conducted using Markov Chain Monte Carlo methods (WinBUGS). The performance characteristics of the PCT and the 2 ELISA tests were estimated together with 95% credible intervals (95% CIs).

RESULTS

The estimate of prevalence of H. pylori in this population was 64% (95% CI, 59% to 70%), the sensitivity and specificity of the PCT were 89% (84% to 94%) and 84% (77% to 91%), respectively (likelihood ratios positive 5.6, negative 0.13). The equivalent maximum likelihood results were prevalence, 65%; sensitivity, 90%; and specificity, 83%.

CONCLUSIONS

The Helisal Rapid Blood Test performed as well as laboratory-based ELISA tests in this cohort of patients. The Bayesian analysis and the maximum likelihood method gave similar results, the Bayesian method also simultaneously estimating 95% CIs.

Hitting the mark: negotiated marking and performance factors in the communication skills element of the VOICE examination

INTRODUCTION

Communication skills assessment is complex. Standardised patient use is widespread, but anxiety exists around the use of role players as assessors of competence in high stakes examinations. This study measures the level of agreement between scoring examiners and role players, and considers their influence on each other. Examiner status and question choices are analysed as variables.

METHOD

The valid oral interactive contextualised examination (VOICE) is a general practice examination styled as an objective structured clinical examination (OSCE) of six 15-minute stations, which include two role-played consultations with professional role players. The examination candidates are final year medical students. Clinical components are examined by a general practitioner (GP). Communication skills are assessed by these examiners in conjunction with the role players, through a process of negotiation. Descriptive professionalism/attitude bandings are used as percentage-scoring guidelines. Checklists are not used. For this study, the initial (independently) perceived marks of the two scoring groups and their agreed final (awarded) marks were recorded, along with other variables including gender, performance factors, demographics and the nature of the question. Data represents 512 students undertaking 1024 simulated consultations, examined by 28 role players and 46 examiners. Analysis was carried out using SPSS Version 10.

RESULTS

Results show that the examination and negotiation process is consistent. Role players have a direct influence on scoring. The examiner's background is a significant variable [F9,1014 = 4.207, P < 0.001]. Students perform less well on questions involving higher degrees of clinical information giving. Question choice is not significant [F30,3039 = 1.397, P=0.074].

DISCUSSION

The variables in the examination do not indicate any discrepancy substantial enough to bias a student's grade. Negotiated marking in this context is considered safe and reliable.

Breaking bones, breaking budgets: a clinical and economic evaluation of a prospective, randomized, practice controlled, intervention study in the prevention of accidents in primary care

OBJECTIVE

This longitudinal study was designed to assess the effect of an educational training package for primary health care teams in accident prevention for older people, with reference to the incidence of accidents and their associated economic consequence.

METHODS

Nineteen general practices in the West Midlands serving a population of 138 397 were allocated randomly at the practice level either to receive training or continue normal practice. Study data was collated from the initial telephone call, reporting an accident, to the surgery, advice/treatment given at the practice and/or the community, casualty, inpatient care, written correspondence to the patient's GP and any subsequent follow-up visits for accidents to people aged 65 years or older.

RESULTS

One thousand, six hundred and sixty-six (8.2%) patients aged 65 years or older registered with the participating practices experienced one accident or more, costing the NHS pound 1.4 million. Extrapolated nationally, annual costs to the NHS for accidents to older people amount to pound 568 million. The educational package had no significant impact on the incidence of accidents. A paucity of general safety advice was given [48 (1.8%) occasions].

CONCLUSIONS

Budgets are being eroded and patients are suffering unnecessarily due to lack of accident prevention advice. This should be considered a priority within the primary health care team. Educational packages alone do not appear to be a cost-effective approach to accident prevention in primary care.

A randomised controlled trial of patient self management of oral anticoagulation treatment compared with primary care management

BACKGROUND

The increase in numbers of patients receiving warfarin treatment has led to the development of alternative models of service delivery for oral anticoagulant monitoring. Patient self management for oral anticoagulation is a model new to the UK. This randomised trial was the first to compare routine primary care management of oral anticoagulation with patient self management.

AIM

To test whether patient self management is as safe, in terms of clinical effectiveness, as primary care management within the UK, as assessed by therapeutic international normalised ratio (INR) control.

METHOD

Patients receiving warfarin from six general practices who satisfied study entry criteria were eligible to enter the study. Eligible patients were randomised to either intervention (patient self management) or control (routine primary care management) for six months. The intervention comprised two training sessions of one to two hours duration. Patients were allowed to undertake patient self management on successful completion of training. INR testing was undertaken using a Coaguchek device and regular internal/external quality control tests were performed. Patients were advised to perform INR tests every two weeks, or weekly if a dose adjustment was made. Dosage adjustment was undertaken using a simple dosing algorithm.

RESULTS

Seventy eight of 206 (38%) patients were eligible for inclusion and, of these, 35 (45%) declined involvement or withdrew from the study. Altogether, 23 intervention and 26 control patients entered the study. There were no significant differences in INR control (per cent time in range: intervention, 74%; control, 77%). There were no serious adverse events in the intervention group, with one fatal retroperitoneal haemorrhage in the control group. Costs of patient self management were significantly greater than for routine care (pound 90 v pound 425/patient/year).

CONCLUSION

These are the first UK data to demonstrate that patient self management is as safe as primary care management for a selected population. Further studies are needed to elucidate whether this model of care is suitable for a larger population.

Degrees of aversion shown by rats and mice to different concentrations of inhalational anaesthetics

The distress associated with the induction of anaesthesia with halothane, isoflurane, enflurane and carbon dioxide was investigated in rats and mice by measuring the level of aversion they displayed on exposure to low, medium and high concentrations of these agents. The animals were exposed to each agent in a test chamber containing air or gas mixtures, which they were able to enter and leave at will, and the level of aversion was assessed in terms of the initial withdrawal and total dwelling times in the chamber. Comparisons between the anaesthetic and air-control treatments indicated that concentrations of the agents recommended for the rapid and efficient induction of anaesthesia were associated with some degree of aversion. Carbon dioxide was by far the most aversive gas for both rats and mice, with the least aversive being halothane for rats, and halothane and enflurane for mice. With all the anaesthetics, the level of aversion increased as the concentration increased.

Aversion to gaseous euthanasia agents in rats and mice

Despite euthanasia being the most common of all procedures carried out on laboratory animals, the potential distress associated with gaseous agents has received little interest until recently, with growing concern over use of carbon dioxide as a humane method of euthanasia. The distress associated with exposure to carbon dioxide, argon, and carbon dioxide-argon mixtures was investigated in rats and mice by measuring the degree of aversion on exposure to low, medium, and high concentrations of these agents. Animals were exposed to the various concentrations in a test chamber containing air or gas mixtures that they were able to enter and leave at will. Aversion was assessed, using measurements of initial withdrawal time and total dwelling time in the test chamber, as they were the most sensitive measurements of aversion. Comparisons between euthanasia agent and control (air) treatments indicated that concentrations of agents recommended for rapid and efficient induction are associated with some degree of aversion. Carbon dioxide and the carbon dioxide-argon mixtures were more aversive than was argon for rats and mice. These findings suggest that induction with carbon dioxide either alone or in combination with argon is likely to cause considerable distress before the loss of consciousness in rodents, which is unacceptable considering that effective and more humane alternatives are available.

First year medical students' perceptions and use of complementary and alternative medicine

OBJECTIVES

To explore First Year medical students' rating of CAM therapies following a core teaching session. To determine the influence of student gender and previous experience of CAM and therapist/teacher gender and professional background on ratings.

DESIGN

Survey; self-administered questionnaire following a teaching session.

SETTING

First Year medical students Behavioural Science module CAM teaching session, University of Birmingham Medical School, UK.

RESULTS

One hundred and fifty (71.0%) students completed a questionnaire. 56 (37.3%) students had previous experience of CAM, particularly where a family member already used it (P = < 0.001). Aromatherapy (29/56, 51.7%) and homoeopathy (17/56, 30.3%) were the most common therapies listed. Females were more likely than males to have used aromatherapy (P = 0.038) or reflexology (P = 0.007). Students using aromatherapy were more likely to have self treated (P = 0.01). Of 82 episodes of CAM use, most (67/82,81.7%) were stated to have been helpful. Hypnotherapy (P = 0.003) and aromatherapy (P = 0.015) were most helpful. Following the teaching session students rated therapies observed on a 10 point scale, 1 (extremely sceptical) to 10 (totally convinced). All were rated above the mid-point; highest rated was chiropractic (median score = 8), lowest, reflexology (median score = 5.06). Students who had previously used hypnotherapy gave it higher scores (P = 0.018). Students whose family used CAM were more likely to rate aromatherapy highly (P = .027) and to give homoeopathy a low score (P = 0.003).

CONCLUSIONS

A short CAM teaching session early in the curriculum can inform students about the relationship of CAM with current medical practice. It can be used as a 'taster' prior to selection of Special Study Module choices in later years.

Does the Birmingham model of oral anticoagulation management in primary care work outside trial conditions?

The effectiveness of the Birmingham model of primary care oral anticoagulation management has previously been demonstrated within a randomised controlled trial. The aim of this study was to assess the effectiveness of the Birmingham model in routine care. All patients from 12 primary care centres attending either practice-based or hospital-based anticoagulation clinics were retrospectively followed up from October 1996 to March 1998. Outcome measures were therapeutic International Normalised Ratio (INR) control, haemorrhagic and thrombotic episodes, and recall frequency; 452 patients who had two or more INR results during the follow-up period were investigated. There were no significant differences between practice-based and hospital-based populations in terms of the percentage time in range, (69% and 64% respectively). The proportion of tests in range was significantly higher in the practice-based group (61% practice-based, 57% hospital-based; P = 0.015). There was no difference between the two populations in terms of mean follow-up time (36 days in each group). There were no significant differences between groups for the number of clinical outcomes per patient. This study confirmed that, within these practices, oral anticoagulation management is safe and effective using the Birmingham model.

European survey of primary care physician perceptions on heart failure diagnosis and management (Euro-HF)

AIMS

To survey a random sample of primary care physicians across six European countries regarding their perceptions of diagnostic and prescribing issues in heart failure, and to consider factors that might be associated with physician under-performance.

METHODS AND RESULTS

Qualitative, postal questionnaire-based, validated survey in the native tongue of a random sample of 200 primary care physicians in each of five European countries (France, Germany, Italy, The Netherlands and Spain) and of 250 U.K. primary care physicians. Respondents provided: details of practice characteristics; the usual way a diagnosis of heart failure was established; access to investigations; names of drugs prescribed in heart failure, with estimates of the proportion of patients supplied with particular classes; and physician attitudes regarding the evidence base (in terms of benefits and risks) for treatments used. Outcomes were physician perceptions and attitudes about heart failure diagnosis and treatment. Adjusted response rates varied from 17% (France) to 56% (Britain). Primary care physicians underestimate the prevalence of heart failure. Most patients are diagnosed on symptoms and signs alone, with only 32% having further investigations or referral. Although most primary care physicians stated they prescribe ACE inhibitors in heart failure, this was for only 47-62% of patients, and at doses below those identified as effective in trials. Most prescribing doctors (91%) believe there is strong evidence of reduced mortality in heart failure patients using ACE inhibitors, but 51% also consider ACE inhibitors have substantial risks with their use.

CONCLUSION

Limitations of the data include the general problem of questionnaires, whether responses accord with actual clinical practice, and, specific to these data, the low response rate in some countries (although the study does provide information from nearly 300 randomly selected primary care physicians across Europe). New preliminary insights include exposition of the 'low tech' approach to heart failure diagnosis across Europe: doctors report the use of symptoms and signs alone; the lack of direct (open) access to objective investigations, such as echocardiography, which almost guarantees that misdiagnoses will occur; and the under-utilization and under-dosing with ACE inhibitors. The main factor influencing under-use would appear to be the exaggerated perceptions of treatment risk amongst primary care physicians that dominate the widespread and accurate knowledge of treatment benefits.

Oral anticoagulation management in primary care with the use of computerized decision support and near-patient testing: a randomized, controlled trial

BACKGROUND

There is increased pressure on primary care physicians to monitor oral anticoagulation.

OBJECTIVE

To test the null hypothesis that oral anticoagulation care can be provided at least as well in primary care through a nurse-led clinic, involving near-patient testing and computerized decision support software, compared with routine hospital management based on a variety of clinical outcome measures.

METHODS

A randomized, controlled trial in 12 primary care practices in Birmingham, England (9 intervention and 3 control). Two control populations were used: patients individually randomly allocated as controls in the intervention practices (intrapractice controls) and all patients in control practices (interpractice controls). Intervention practices' patients were randomized to the intervention (practice-based anticoagulation clinic) or control (hospital clinic) group. The main outcome measure was therapeutic control of the international normalized ratio.

RESULTS

Three hundred sixty-seven patients were recruited (122 intervention patients, 102 intrapractice control patients, and 143 interpractice control patients). Standard measures of control of the international normalized ratio (point prevalence) showed no significant difference between the intervention and control groups. Data on proportion of time spent in the international normalized ratio range showed significant improvement for patients in the intervention group (paired t test, P =.008).

CONCLUSIONS

Nurse-led anticoagulation clinics can be implemented in novice primary care settings by means of computerized decision support software and near-patient testing. Care given by this model is at least as good as routine hospital follow-up. The model is generalizable to primary health care centers operating in developed health care systems.

A primary care evaluation of three near patient coagulometers

AIM

To compare the reliability and relative costs of three international normalised ratio (INR) near patient tests.

MATERIALS

Protime (ITC Technidyne), Coaguchek (Boehringer Mannheim), and TAS (Diagnostic Testing).

METHODS

All patients attending one inner city general practice anticoagulation clinic were asked to participate, with two samples provided by patients not taking warfarin. A 5 ml sample of venous whole blood was taken from each patient and a drop immediately added to the prepared Coaguchek test strip followed by the Protime cuvette. The remainder was added to a citrated bottle. A drop of citrated blood was then placed on the TAS test card and the remainder sent to the reference laboratory for analysis. Parallel INR estimation was performed on the different near patient tests at each weekly anticoagulation clinic from July to December 1997.

RESULTS

19 patients receiving long term warfarin treatment provided 62 INR results. INR results ranged from 0.8-8.2 overall and 1.0-5.7 based on the laboratory method. Taking the laboratory method as the gold standard, 12/62 results were < 2.0 and 2/62 were > 4.5. There were no statistical or clinically significant differences between results from the three systems, although all near patient tests showed slightly higher mean readings than the laboratory, and 19-24% of tests would have resulted in different management decisions based on the machine used in comparison with the laboratory INR value. The cost of the near patient test systems varied substantially.

CONCLUSIONS

All three near patient test systems are safe and efficient for producing acceptable and reproducible INR results within the therapeutic range in a primary care setting. All the systems were, however, subject to operator dependent variables at the time of blood letting. Adequate training in capillary blood sampling, specific use of the machines, and quality assurance procedures is therefore essential.

A major sporting event does not necessarily mean an increased workload for accident and emergency departments. Euro96 Group of Accident and Emergency Departments

AIM

To determine whether there were any changes in attendance at accident and emergency departments that could be related to international football matches (Euro96 tournament).

METHOD

Fourteen accident and emergency departments (seven adjacent to and seven distant from a Euro96 venue) provided their daily attendance figures for a nine week period: three weeks before, during, and after the tournament. The relation between daily attendance rates and Euro96 football matches was assessed using a generalised linear model and analysis of variance. The model took into account underlying trends in attendance rates including day of the week.

RESULTS

The 14 hospitals contributed 172 366 attendances (mean number of daily attendances 195). No association was shown between the number of attendances at accident and emergency departments and the day of the football match, whether the departments were near to or distant from stadia or the occurrence of a home nation match. The only observed independent predictors of variation were day of the week and week of the year. Attendance rates were significantly higher on Sunday and/or Monday; Monday was about 9% busier than the daily average. Increasing attendance was observed over time for 86% of the hospitals.

CONCLUSION

Large sports tournaments do not increase the number of patients attending accident and emergency departments. Special measures are not required for major sporting events over and above the capacity of an accident and emergency department to increase its throughput on other days.