679 Trainee Perceptions of Safety in General Surgery Handover – a Quality Improvement Project

Aim

Effective patient handover is an important cornerstone of clinical care and patient safety. The aim of this study was to measure trainee perceptions of handover safety, and to improve the safety of handover.

Method

An anonymous questionnaire was sent to all junior doctors in a general surgery department with a two-stage evening handover, as registrars change over at 17.00 and senior house officers at 20.00.

The intervention involved introduction of a new standard of handover, including a set location and printed patient lists.

Following one month of intervention, a second questionnaire was distributed to assess its impact.

Results

There were 15 respondents to the pre-intervention questionnaire and 16 respondents to the post-intervention questionnaire.

Perception of safety at the 17.00 handover increased from 27% to 56% following the intervention, and at 20.00 this increased from 60% to 88%.

The proportion of respondents who felt that new admissions were handed over well at 17.00 increased from 27% to 38%, with an increase from 67% to 81% for the 20.00 handover.

The proportion of respondents who felt that the ward patients were handed over well at 20.00 increased from 40% to 81%.

The generation of a patient handover list at 20.00 increased from 7% to 25%.

Conclusions

Simple interventions appear to be effective at improving trainee perceptions of safety in patient handover in general surgery.

Ensuring the quality of patient handover must be a priority for all clinicians; however, approaches may need to be tailored to the working shift patterns within a department.

University students' understanding and options of eating disorders: A qualitative study

Background

Eating disorders (EDs) affect 1.25 million people in the UK. Evidence suggests the public perceive EDs as a female issue and display stigma and poor mental health literacy (MHL) towards EDs. There is a high prevalence of EDs in university populations, so it is important to determine the MHL of this at-risk group. Qualitative research exploring the MHL of this population is incomplete.

Aims

To explore university students' beliefs and opinions of EDs, their knowledge of symptoms, treatment and help sources and how these are influenced by biological sex.

Methods

A qualitative study, using semi-structured interviews with seven male and seven female participants. Interviews were analysed using inductive thematic analysis. Analyst triangulation and member validation occurred.

Results

Analysis revealed six themes, each with subthemes: ED characteristics, causes, body image, seeking help, stigma and awareness. Students displayed poor awareness towards ED signs and symptoms, causes and help sources. Students were not stigmatising towards EDs, but many perceived them as a female problem and believed society to be stigmatising. Many referenced informal sources of information such as social media and expressed a desire for ED teaching. Sex did not have a significant influence on knowledge or opinions of EDs in this study, however there were some differences, for example some males were more likely to see EDs as a weakness and to perceive themselves as having low levels of knowledge.

Conclusions

University students show poor awareness of certain aspects of ED-MHL including help sources and symptom recognition. Although students were not stigmatising of EDs themselves, many perceived high levels of public stigma. This, alongside poor knowledge, may delay help-seeking. Campaigns educating students and the public about EDs would aid earlier diagnosis, improving long-term outcomes. Further research into awareness and knowledge in other populations would be beneficial.

Key messages

University students interviewed perceived high levels of public stigma around eating disorders, although not stimatising themselves. Campaigns educating students and the public about EDs would aid earlier diagnosis, improving long-term outcomes.

Experiences and perceptions of dietitians for obesity management: a general practice qualitative study

BACKGROUND

Multi-component lifestyle interventions are the first line treatment for obesity. Dietitians are ideally placed healthcare professionals to deliver such interventions. However, only a small proportion of patients with obesity are referred by general practice to dietitians, and the reasons for this are not clear. The present study aimed to explore general practice healthcare professionals' (GPHCPs) experiences and perceptions of dietitians in the context of obesity management.

METHODS

A convenience sample of GPHCPs practicing in the UK was recruited via a targeted social media strategy, using virtual snowball sampling. Data were collected using semi-structured interviews and analysed using framework analysis.

RESULTS

In total, 20 participants were interviewed (11 general practice nurses and nine general practitioners). Experiences of referring patients with obesity for dietetic intervention resulted in two main themes: (i) access barriers and (ii) the dietetic consult experience. Three themes emerged from participants' perceptions of a role for general practice dietitians: (i) utilising dietetic expertise; (ii) access to dietitian; and (iii) time. Participants experienced barriers to accessing dietitians for obesity management and felt that having a dietitian working within their general practice team would help address this. Having a dietitian embedded within their general practice team was perceived to have the potential to alleviate GPHCPs' clinical time pressures, offer opportunities for upskilling, and may improve patient engagement with obesity management.

CONCLUSIONS

GPHCPs perceived that embedding a dietitian within their general practice team would be valuable and beneficial for obesity management. Our findings provide support for the funding of general practice dietitian roles in the UK.

Development of a group structured education programme to support safe exercise in people with Type 1 diabetes: the EXTOD education programme

AIM

To develop a structured education programme for individuals with Type 1 diabetes who are engaging in regular exercise.

METHOD

A multidisciplinary team of experts in supporting exercise and physical activity for people with Type 1 diabetes, alongside researchers with experience of developing self-management education, developed an exercise programme using the Medical Research Council framework. The programme was informed by a review of the evidence relating to Type 1 diabetes and exercise, the behaviour change literature (including the behaviour change taxonomy), and qualitative interviews with stakeholders. The programme and supporting resources were refined using an iterative process of testing, delivery and collecting feedback from participants and the wider development team.

RESULTS

The outcome of the intervention development was the design of a feasible and acceptable intervention for people with Type 1 diabetes to support safe exercise. The pilot allowed refinement of the intervention prior to testing in a two-site feasibility randomized controlled trial. Key findings from the pilot informed minor restructuring of the timetable (timings and order) and adaptation of supporting educational materials (participant handbook and teaching materials).

CONCLUSION

The 'EXercise in people with Type One Diabetes' (EXTOD) education programme has been developed using robust methodology for the generation of educational interventions. It now needs testing in a randomized controlled trial.

Aortocaval fistula, a potentially favourable complication of abdominal aortic aneurysm rupture in endovascular repair

Endovascular aneurysm repair is an established treatment for ruptured abdominal aortic aneurysm. Primary aortocaval fistula is an exceedingly rare finding in ruptured abdominal aortic aneurysm, with a reported incidence of less than 1%. The presence of an aortocaval fistula used to be an unexpected finding in open surgical repair which often resulted in massive haemorrhage and caval injury. We present a case of ruptured abdominal aortic aneurysm with an aortocaval fistula that was successfully treated with percutaneous endovascular aneurysm repair under local anaesthesia. Despite a persistent type 2 endoleak the aneurysm sack shrank from 8.4cm to 4.8cm in 12 months. The presence of an aortocaval fistula may have depressurised the aneurysm, resulting in less bleeding retroperitoneally and may have promoted rapid shrinkage of the sac despite the presence of a persistent type 2 endoleak.

Preliminary report: Surgical outcomes following genitoplasty in children with moderate to severe genital atypia

INTRODUCTION

Prior studies of outcomes following genitoplasty have reported high rates of surgical complications among children with atypical genitalia. Few studies have prospectively assessed outcomes after contemporary surgical approaches.

OBJECTIVE

The current study reported the occurrence of early postoperative complications and of cosmetic outcomes (as rated by surgeons and parents) at 12 months following contemporary genitoplasty procedures in children born with atypical genitalia.

STUDY DESIGN

This 11-site, prospective study included children aged ≤2 years, with Prader 3-5 or Quigley 3-6 external genitalia, with no prior genitoplasty and non-urogenital malformations at the time of enrollment. Genital appearance was rated on a 4-point Likert scale. Paired t-tests evaluated differences in cosmesis ratings.

RESULTS

Out of 27 children, 10 were 46,XY patients with the following diagnoses: gonadal dysgenesis, PAIS or testosterone biosynthetic defect, severe hypospadias and microphallus, who were reared male. Sixteen 46,XX congenital adrenal hyperplasia patients were reared female and one child with sex chromosome mosaicism was reared male. Eleven children had masculinizing genitoplasty for penoscrotal or perineal hypospadias (one-stage, three; two-stage, eight). Among one-stage surgeries, one child had meatal stenosis (minor) and one developed both urinary retention (minor) and urethrocutaneous fistula (major) (Summary Figure). Among two-stage surgeries, three children developed a major complication: penoscrotal fistula, glans dehiscence or urethral dehiscence. Among 16 children who had feminizing genitoplasty, vaginoplasty was performed in all, clitoroplasty in nine, external genitoplasty in 13, urethroplasty in four, perineoplasty in five, and total urogenital sinus mobilization in two. Two children had minor complications: one had a UTI, and one had both a mucosal skin tag and vaginal mucosal polyp. Two additional children developed a major complication: vaginal stenosis. Cosmesis scores revealed sustained improvements from 6 months post-genitoplasty, as previously reported, with all scores reported as good or satisfied.

DISCUSSION

In these preliminary data from a multi-site, observational study, parents and surgeons were equally satisfied with the cosmetic outcomes 12 months after genitoplasty. A small number of patients had major complications in both feminizing and masculinizing surgeries; two-stage hypospadias repair had the most major complications. Long-term follow-up of patients at post-puberty will provide a better assessment of outcomes in this population.

CONCLUSION

In this cohort of children with moderate to severe atypical genitalia, preliminary data on both surgical and cosmetic outcomes were presented. Findings from this study, and from following these children in long-term studies, will help guide practitioners in their discussions with families about surgical management.

Exercise to preserve β-cell function in recent-onset Type 1 diabetes mellitus (EXTOD) - a randomized controlled pilot trial

AIM

Residual β-cell function is present at the time of diagnosis with Type 1 diabetes. Preserving this β-cell function reduces complications. We hypothesized that exercise preserves β-cell function in Type 1 diabetes and undertook a pilot trial to address the key uncertainties in designing a definitive trial to test this hypothesis.

METHODS

A randomized controlled pilot trial in adults aged 16-60 years diagnosed with Type 1 diabetes within the previous 3 months was undertaken. Participants were assigned to control (usual care) or intervention (exercise consultation every month), in a 1 : 1 ratio for 12 months. The primary outcomes were recruitment rate, drop out, exercise adherence [weeks with ≥ 150 min of self-reported moderate to vigorous physical activity (MVPA)], and exercise uptake in the control group. The secondary outcomes were differences in insulin sensitivity and rate of loss of β-cell function between intervention and control at 6 and 12 months.

RESULTS

Of 507 individuals who were approached, 58 (28 control, 30 intervention) entered the study and 41 completed it. Participants were largely white European males, BMI 24.8 ± 3.8 kg/m² , HbA_1c 75 ± 25 mmol/mol (9 ± 2%). Mean level of objectively measured MVPA increased in the intervention group (mean 243 to 273 min/week) and 61% of intervention participants reached the target of ≥ 150 min/week of self-reported MVPA on at least 42 weeks of the year. Physical activity levels fell slightly in the control group (mean 277 to 235 min of MVPA/week). There was exploratory evidence that intervention group became more insulin sensitive and required less insulin. However, the rate of loss of β-cell function appeared similar between the groups, although the change in insulin sensitivity may have affected this.

CONCLUSION

We show that it is possible to recruit and randomize people with newly diagnosed Type 1 diabetes to a trial of an exercise intervention, and increase and maintain their exercise levels for 12 months. Future trials need to incorporate measures of greater adherence to exercise training targets, and include more appropriate measures of β-cell function. (Clinical Trials Registry No; ISRCTN91388505).

Prospective assessment of cosmesis before and after genital surgery

INTRODUCTION

Little data exist about the surgical interventions taking place for children with disorders of sex development (DSD). Most studies that have evaluated cosmetic outcomes after genitoplasty have included retrospective ratings by a physician at a single center.

OBJECTIVE

The present study aimed to: 1) describe frequency of sex assignment, and types of surgery performed in a cohort of patients with moderate-to-severe genital ambiguity; and 2) prospectively determine cosmesis ratings by parents and surgeons before and after genital surgery.

STUDY DESIGN

This prospective, observational study included children aged <2 years of age, with no prior genitoplasty at the time of enrollment, moderate-to-severe genital atypia, and being treated at one of 11 children's hospitals in the United States of America (USA). Clinical information was collected, including type of surgery performed. Parents and the local pediatric urologist rated the cosmetic appearance of the child's genitalia prior to and 6 months after genitoplasty.

RESULTS

Of the 37 children meeting eligibility criteria, 20 (54%) had a 46,XX karyotype, 15 (40%) had a 46,XY karyotype, and two (5%) had sex chromosome mosaicism. The most common diagnosis overall was congenital adrenal hyperplasia (54%). Thirty-five children had surgery; 21 received feminizing genitoplasty, and 14 had masculinizing genitoplasty. Two families decided against surgery. At baseline, 22 mothers (63%), 14 fathers (48%), and 35 surgeons (100%) stated that they were dissatisfied or very dissatisfied with the appearance of the child's genitalia. Surgeons rated the appearance of the genitalia significantly worse than mothers (P < 0.001) and fathers (P ≤ 0.001) at baseline. At the 6-month postoperative visit, cosmesis ratings improved significantly for all groups (P < 0.001 for all groups). Thirty-two mothers (94%), 26 fathers (92%), and 31 surgeons (88%) reported either a good outcome, or they were satisfied (see Summary Figure); there were no significant between-group differences in ratings.

DISCUSSION

This multicenter, observational study showed surgical interventions being performed at DSD centers in the USA. While parent and surgeon ratings were discordant pre-operatively, they were generally concordant postoperatively. Satisfaction with postoperative cosmesis does not necessarily equate with satisfaction with the functional outcome later in life.

CONCLUSION

In this cohort of children with genital atypia, the majority had surgery. Parents and surgeons all rated the appearance of the genitalia unfavorably before surgery, with surgeons giving worse ratings than parents. Cosmesis ratings improved significantly after surgery, with no between-group differences.

Prevalence and predictors of hospital prealerting in acute stroke: a mixed methods study

Background

Thrombolysis can significantly reduce the burden of stroke but the time window for safe and effective treatment is short. In patients travelling to hospital via ambulance, the sending of a ‘prealert’ message can significantly improve the timeliness of treatment.

Objective

Examine the prevalence of hospital prealerting, the extent to which prealert protocols are followed and what factors influence emergency medical services (EMS) staff's decision to send a prealert.

Methods

Cohort study of patients admitted to two acute stroke units in West Midlands (UK) hospitals using linked data from hospital and EMS records. A logistic regression model examined the association between prealert eligibility and whether a prealert message was sent. In semistructured interviews, EMS staff were asked about their experiences of patients with suspected stroke.

Results

Of the 539 patients eligible for this study, 271 (51%) were recruited. Of these, only 79 (29%) were eligible for prealerting according to criteria set out in local protocols but 143 (53%) were prealerted. Increasing number of Face, Arm, Speech Test symptoms (1 symptom, OR 6.14, 95% CI 2.06 to 18.30, p=0.001; 2 symptoms, OR 31.36, 95% CI 9.91 to 99.24, p<0.001; 3 symptoms, OR 75.84, 95% CI 24.68 to 233.03, p<0.001) and EMS contact within 5 h of symptom onset (OR 2.99, 95% CI 1.37 to 6.50 p=0.006) were key predictors of prealerting but eligibility for prealert as a whole was not (OR 1.92, 95% CI 0.85 to 4.34 p=0.12). In qualitative interviews, EMS staff displayed varying understanding of prealert protocols and described frustration when their interpretation of the prealert criteria was not shared by ED staff.

Conclusions

Up to half of the patients presenting with suspected stroke in this study were prealerted by EMS staff, regardless of eligibility, resulting in disagreements with ED staff during handover. Aligning the expectations of EMS and ED staff, perhaps through simplified prealert protocols, could be considered to facilitate more appropriate use of hospital prealerting in acute stroke.

The role of corticosterone and toxicity in the antipredator behavior of the Rough-skinned Newt (Taricha granulosa)

A variety of mechanisms are responsible for enabling an organism to escape a predatory attack, including behavioral changes, alterations in hormone levels, and production and/or secretion of toxins. However, these mechanisms are rarely studied in conjunction with each other. The Rough-skinned Newt (Taricha granulosa) is an ideal organism to examine the relationships between these mechanisms because its behavioral displays and toxin secretion during a predator attack are well documented and readily characterized. While we found no direct relationship between antipredator behavior and endogenous levels of corticosterone (CORT), antipredator behavior was inhibited when exogenous CORT and adrenocorticotropic hormone (ACTH) were administered, resulting in high circulating concentrations of CORT, indicating that CORT may play a role in mediating the behavior. There was no correlation between the animal's toxicity and either CORT or behavior. The results of this study provide evidence that CORT plays an important, yet complex, role in the antipredator response of these amphibians.

A survey investigating the associations between self-management practices and quality of life in cancer survivors

PURPOSE

To explore whether the use of self-management (SM) practices in cancer survivors impact on their health beliefs and quality of life (QoL). This is an important step in attempting to improve cancer survivors' health pathways and their experiences of living with cancer.

METHODS

A cross-sectional, postal survey study was undertaken amongst cancer survivors identified from a teaching hospital in the West Midlands, UK. The questionnaire collected demographic data from respondents and information on the number and types of SM practices-diet, exercise, complementary and alternative medicine (CAM), psychological therapies, support groups and spirituality/religion-cancer survivors used after completing their treatment. Information was also gathered regarding their QoL and internal health locus of control (HLC).

RESULTS

A total of 445 cancer survivors responded to the survey. Multi-linear regression analysis found a positive association between SM uptake and HLC; however, none was found between SM uptake and QoL. Treatment type, ethnicity and age were significantly associated with an increased use of SM practices.

CONCLUSION

The study findings have implications for health care providers, who need to be aware of the links between SM uptake and treatment type, ethnicity and age, when considering how best to incorporate SM into cancer survivors' lives. This can help cancer survivors who may benefit from using specific SM interventions that consider the socio-demographic and treatment-related factors impacting on them. Future research would benefit from assessing the motivations and benefits of cancer survivors of different ages, ethnicities and treatment modalities in terms of their decision-making about SM use. These findings suggest that SM uptake is associated with higher internal HLC in cancer survivors. However, the influence of treatment type, ethnicity and age plays a more significant role in determining SM uptake than HLC. Cancer survivors using SM may be more motivated to utilise SM practices in relation to their age, ethnicity and treatment type, generating positive health outcomes in the process. Policy-makers should be aware of the supportive role SM interventions can play in cancer care and survivorship, with future research focussing on the perceived benefit of these SM interventions to cancer survivors.

Patterns of self-management practices undertaken by cancer survivors: variations in demographic factors

The study purpose was to examine self-management (SM) use among cancer survivors; and to explore variations in uptake of SM in survivorship and whether these differed in relation to age, income, gender, ethnicity, cancer type and treatment type. This is an important area for exploration as SM utilisation has the potential to impact on the health status, health behaviours and quality of life (QoL) of cancer survivors. A postal survey was conducted among 445 cancer survivors identified from a hospital in the West Midlands, UK. Demographic data were collected and respondents were asked to identify which practices across six SM categories - diet, exercise, complementary and alternative medicine (CAM), psychological therapies, support groups and spirituality/religion - they had used (if any). The findings indicate that the large majority (91%) had used some form of SM after their cancer treatment. Exercise (84%) and diet (56%) were the most popular SM interventions for cancer survivors and socio-demographic and cancer-related factors were associated with SM uptake. These findings can form the basis for designing and implementing appropriate SM interventions aimed at improving the health, well-being and QoL of cancer survivors.

Current practice of venous thromboembolism prevention in acute trusts: a qualitative study

OBJECTIVE

To explore the current practice of venous thromboembolism (VTE) prevention in acute trusts.

DESIGN

A qualitative research design was used to explore the perceived current practice of thromboprophylaxis, and knowledge and experience of VTE prevention. Data were collected via interviews with personnel from acute trusts and other relevant organisations and charities. Constant comparison was used to generate themes grounded in the data.

SETTING

The UK.

PARTICIPANTS

17 participants, sampled due to their expertise and knowledge in the field of VTE, were interviewed for the study.

RESULTS

No one felt directly responsible for VTE risk assessment and treatment in acute trusts. There were concerns whether any action takes place based on the risk assessment. Low levels of VTE knowledge existed throughout the system.

CONCLUSIONS

Our study highlights the importance of continuous training to prevent VTE risk assessment being considered a tick box exercise and for clinicians to understand the significance of the procedure to ensure that VTE preventative measures are administered. It is essential that acute trust staff acknowledge that VTE prevention is the responsibility of everyone involved in a patient's care. Concerns remain around prophylaxis treatment, administration and contraindications.

Why members of the public self-test: an interview study

BACKGROUND

A wide range of self-tests are available where contact with a health professional is not necessary.

OBJECTIVE

To investigate factors that influenced members of the public to use self-tests.

METHODS

Questionnaires, sent to 2335 adults from two general practices in North Birmingham, asked whether recipients had used self-tests and sought consent for contacting them about taking part in an interview. Twenty-three people were interviewed, 20 of whom had used self-tests. The interviews were transcribed verbatim, and a thematic analysis was conducted.

RESULTS

The findings were organized around two themes. 'Motivations for self-testing' describes the motivating factors surrounding participants' choices to use self-tests. This appeared to be influenced by a number of factors that were organized into four sub-themes: 'diagnosis or speculation', 'perceived benefits of self-testing', 'general attitudes to and experiences of health care' and 'general attitudes to health'. The second theme called 'experience of self-testing' describes participants' access to, and use of self-tests, and is split into three sub-themes: 'opportunistic awareness and access', 'use and application' and 'impact on life'.

CONCLUSIONS

Overall, self-testing encompasses a broad variety of beliefs and experiences. Some participants saw self-tests as a serious diagnostic tool, whereas others used them out of simple curiosity. Some were motivated by their generally positive attitude to health, but others may have been motivated by negative health care experiences. Some saw self-testing as an empowering process to be proud of, while others seemed to view it as an illegitimate activity that needed to be hidden from professionals.

Systematic review: impact of constipation on quality of life in adults and children

BACKGROUND

Comparison of quality of life (QoL) across disease areas requires the use of appropriate tools. Although many studies have investigated QoL in constipation, most used disease-specific tools that are inappropriate for cross-comparisons.

AIMS

To identify studies of QoL in constipation and to compare these results with other chronic conditions.

METHODS

A comprehensive literature search identified studies in constipation that used a generic QoL tool. Results were statistically pooled where possible and compared with published results using the same tools in other chronic conditions.

RESULTS

A total of 13 qualifying studies were identified, 10 in adults and three in children. Results from eight studies using the SF-36/12 tools were pooled; the remaining five were narratively reported. Mental and physical components of QoL scores were consistently impaired in both adult and child populations, with the greatest impact being seen in secondary care studies. Mental health effects predominated over physical domains. The magnitude of impact was comparable with that seen in patients with allergies, musculoskeletal conditions and inflammatory bowel disease.

CONCLUSIONS

The impact of constipation on QoL is significant and comparable with other common chronic conditions. Improving management may prove to be an effective way of improving QoL for a substantial number of patients.

Prevalence of the use of self-tests by adults in the United Kingdom: a questionnaire survey

BACKGROUND

Self-tests that people can do without a health professional are widely available, but there is little information about how many people have used one. Our aim was to describe the prevalence of use.

METHODS

An initial questionnaire, sent to 8048 adults registered with six general practices in North Birmingham and Warwickshire and Worcestershire, asked whether the person had self-tested. A second questionnaire validated the use for people from the final four practices by asking how each self-test had been obtained and why it had been used.

RESULTS

The age-standardised prevalence of confirmed use for any self-test other than for pregnancy or high blood pressure was 47 (95% confidence interval (CI): 37-57) per 1000 women and 22 (95% CI: 14-30) per 1000 men. If everyone who initially reported use but did not return an eligible second questionnaire had the same rates of confirmed use as eligible responders, this would increase to 95 (95% CI: 81-110) per 1000 women and 55 (95% CI: 41-68) per 1000 men.

CONCLUSION

An appreciable minority of the population have self-tested for medical conditions.

Healthcare workers' perceptions of the duty to work during an influenza pandemic

Healthcare workers (HCWs) are often assumed to have a duty to work, even if faced with personal risk. This is particularly so for professionals (doctors and nurses). However, the health service also depends on non-professionals, such as porters, cooks and cleaners. The duty to work is currently under scrutiny because of the ongoing challenge of responding to pandemic influenza, where an effective response depends on most uninfected HCWs continuing to work, despite personal risk. This paper reports findings of a survey of HCWs (n = 1032) conducted across three National Health Service trusts in the West Midlands, UK, to establish whether HCWs' likelihood of working during a pandemic is associated with views about the duty to work. The sense that HCWs felt that they had a duty to work despite personal risk emerged strongly regardless of professional status. Besides a strong sense that everyone should pull together, all kinds of HCWs recognised a duty to work even in difficult circumstances, which correlated strongly with their stated likelihood of working. This suggests that HCWs' decisions about whether or not they are prepared to work during a pandemic are closely linked to their sense of duty. However, respondents' sense of the duty to work may conflict with their sense of duty to family, as well as other factors such as a perceived lack of reciprocity from their employers. Interestingly, nearly 25% of doctors did not consider that they had a duty to work where doing so would pose risks to themselves or their families.

The use of herbal medicines by people with cancer in the UK: a systematic review of the literature

BACKGROUND AND AIM

Little is known about the use of herbal medicines by people living with cancer in the UK. This systematic review aimed to estimate the prevalence of herbal medicine use by this group, the characteristics of users, factors motivating use, and attitudes towards herbal remedies.

DESIGN AND METHODS

Fifteen electronic databases were searched. People who were research-active in the field were contacted and asked about further published or unpublished work. All studies identified as relevant to the purpose of the review were assessed. Searches were not restricted by publication type or date.

RESULTS

Of 1288 unique references identified, 11 met the eligibility criteria. Studies were excluded where research had been conducted outside the UK; where information on herbal medicine use was not differentiated from that relating to complementary and alternative therapies more broadly, and where neither prevalence of use nor information on user characteristics was included. Prevalence estimates ranged from 3.1 to 24.9%. Most studies did not obtain information specifically on herbal medicines and only one examined the characteristics and motivations of users of herbal medicines as distinct from complementary and alternative therapies in general.

CONCLUSION

The high degree of heterogeneity of methodology, sample selection and characteristics, and research design resulted in a wide range of estimates of prevalence. Well-designed research is needed to define the evidence base about the herbal medicines taken by people with cancer in the UK, the reasons for use, knowledge about possible effects and potential risks, and where people seek information.

A growth regulatory factor that can both inhibit and stimulate growth

A growth inhibitor that is produced by BSC-1 cells (African green monkey kidney epithelial cells) has been isolated from conditioned medium. It has been purified by gel chromatography and high performance liquid chromatography. It appears to be a protein with a relative molecular mass (Mr) of 24 000. It is extremely active as a growth inhibitor with some cells, but not with others. Approximately 50% inhibition of thymidine incorporation is observed with CCL64 cells at 0.05 ng/ml and with BSC-1 cells at 1 ng/ml. The growth inhibitor induces BSC-1 cells to synthesize and secrete a glycoprotein of approximately 48 000 Mr. It inhibits Na+ accumulation in BSC-1 cells. Recently, in collaboration with R. F. Tucker, G.D. Shipley and H. L. Moses (Mayo Foundation & Medical School), we have found that the growth inhibitor is very similar to and may be identical with transforming growth factor beta (TGF-beta). Our growth inhibitor stimulates colony formation in soft agar by AKR-2B cells, and it competes with TGF-beta in binding to cell surface receptors. TGF-beta, from human platelets, is extremely active as an inhibitor of thymidine incorporation by BSC-1 cells and CCL64 cells. The growth inhibitor/TGF-beta can, therefore, stimulate or inhibit growth, depending on the cells and the growth conditions.

The Birmingham Rehabilitation Uptake Maximisation study (BRUM): a randomised controlled trial comparing home-based with centre-based cardiac rehabilitation

OBJECTIVE

To compare the outcomes of home-based (using the Heart Manual) and centre-based cardiac rehabilitation programmes.

DESIGN

Randomised controlled trial and parallel economic evaluation.

SETTING

Predominantly inner-city, multi-ethnic population in the West Midlands, England.

PATIENTS

525 patients referred to four hospitals for cardiac rehabilitation following myocardial infarction or coronary revascularisation.

INTERVENTIONS

A home-based cardiac rehabilitation programme compared with centre-based programmes.

MAIN OUTCOME MEASURES

Smoking cessation, blood pressure (systolic blood pressure (SBP), diastolic blood pressure (DBP)), total cholesterol (TC) and high-density lipoprotein (HDL)-cholesterol, psychological status (HADS anxiety and depression) and exercise capacity (incremental shuttle walking test, ISWT) measured at 12 months. Health service resource use, quality of life utility and costs were quantified.

RESULTS

There were no significant differences in the main outcomes when the home-based was compared with the centre-based programme at 12 months. Adjusted mean difference (95% CI) for SBP was 1.94 mm Hg (-1.1 to 5.0); DBP 0.42 mm Hg (-1.25 to 2.1); TC 0.1 mmol/l (-0.05 to 0.24); HADS anxiety -0.02 (-0.69 to 0.65); HADS depression -0.35 (-0.95 to 0.25); distance on ISWT -21.5 m (-48.3 to 5.2). The relative risk of being a smoker in the home arm was 0.90. The cost per patient to the NHS was significantly higher in the home arm at 198 pounds, (95% CI 189 to 208) compared to 157 pounds (95% CI 139 to 175) in the centre-based arm. However when the patients' cost of travel was included, these differences were no longer significant. Conclusions A home-based cardiac rehabilitation programme does not produce inferior outcomes when compared to traditional centre-based programmes as provided in the United Kingdom.

The Birmingham Rehabilitation Uptake Maximisation Study (BRUM). Home-based compared with hospital-based cardiac rehabilitation in a multi-ethnic population: cost-effectiveness and patient adherence

OBJECTIVES

To evaluate the relative effectiveness and cost-effectiveness of a home-based programme of cardiac rehabilitation using the Heart Manual, with centre-based programmes. It also sought to explore the reasons for non-adherence to cardiac rehabilitation programmes.

DESIGN

An individually randomised trial, with minimisation for age, gender, ethnicity, initial diagnosis and hospital of recruitment. Participants were followed up after 6, 12 and 24 months by questionnaire and clinical assessment. Individual semistructured interviews were undertaken in the homes of a purposive sample of patients who did not adhere to their allocated programme, and focus groups were undertaken with groups of patients who adhered to the programmes.

SETTING

Four hospitals in predominantly inner-city, multi-ethnic, socio-economically deprived areas of the West Midlands in England, for 2 years from 1 February 2002.

PARTICIPANTS

A total of 525 patients who had experienced a myocardial infarction (MI) or coronary revascularisation within the previous 12 weeks.

INTERVENTIONS

All the rehabilitation programmes included exercise, relaxation, education and lifestyle counselling. All patients were seen by a cardiac rehabilitation nurse prior to hospital discharge and provided with information about their condition and counselling about risk factor modification. The four centre-based programmes varied in length from nine sessions at weekly intervals of education, relaxation and circuit training to 24 individualised sessions over 12 weeks of mainly walking, fixed cycling and rowing with group-based education. The home-based programme consisted of an appropriate version of the Heart Manual, home visits and telephone contact. The Heart Manual was introduced to patients on an individual basis, either in hospital or on a home visit. Home visits by a nurse took place at approximately 1, 6 and 12 weeks after recruitment, with a telephone call at 3 weeks. At the final visit, patients were encouraged to maintain their lifestyle changes and to continue with their exercise programme. Where needed, follow-up was made by a rehabilitation nurse who spoke Punjabi. An audiotape of an abridged version of the Heart Manual in Punjabi accompanied the manual for patients with a limited command of English.

MAIN OUTCOME MEASURES

Primary outcomes were smoking cessation, blood pressure, total and high-density lipoprotein cholesterol, exercise capacity measured by the incremental shuttle walking test and psychological status measured by the Hospital Anxiety and Depression Scale (HADS). Secondary outcomes included self-reported diet, physical activity, cardiac symptoms and quality of life. Health service resource use and costs of rehabilitation programmes from health service and societal perspectives were also measured. Adherence to the physical activity element of the rehabilitation programmes was measured by questionnaire 6, 9 and 12 weeks.

RESULTS

No clinically or statistically significant differences were found in any of the primary or secondary outcome measures between the home- and centre-based groups. Significant improvements in total cholesterol, smoking prevalence, the HADS anxiety score, self-reported physical activity and diet were seen in both arms between baseline and the 6-month follow-up. Five or more contacts with a cardiac rehabilitation nurse were received by 96% of home-based participants, whereas only 56% of centre-based participants attended this many rehabilitation classes. The direct rehabilitation costs to the health service were significantly higher for the home-based programme (mean cost 198 pounds versus 157 pounds for the centre-based programme), but when patient costs were included the mean cost of the centre-based arm rose to 182 pounds. Patients' reasons for not taking up or adhering to cardiac rehabilitation were multifactorial and very individual. Other health problems limited some patients' ability to exercise. Most non-adherers found some aspects of their cardiac rehabilitation programme helpful. Many had adapted advice on rehabilitation and were continuing to exercise in other ways and had made lifestyle changes, particularly to their diet. The home-based patients' lack of motivation to exercise on their own at home was a major factor in non-adherence. The focus groups revealed little diversity of views among patients from each programme. Patients in the hospital programme enjoyed the camaraderie of group exercise and the home-based patients valued the wealth of information and advice in the Heart Manual.

CONCLUSIONS

A home-based cardiac rehabilitation programme for low- to moderate-risk patients does not produce inferior outcomes compared with the traditional centre-based programmes. With the level of home visiting in this trial, the home-based programme was more costly to the health service, but with the difference in costs borne by patients attending centre-based programmes. Different reasons were given by home and hospital cardiac rehabilitation patients for not taking up or adhering to cardiac rehabilitation, with home-based patients often citing a lack of motivation to exercise at home. Social characteristics, individual patient needs and the location of cardiac rehabilitation programmes need to be taken into account in programme design to maximise participation. Research is recommended into cardiac rehabilitation in patients from ethnic minority groups; measurement tools to assess physical activity and dietary change; evaluating the Heart Manual in patients who decline centre-based cardiac rehabilitation; the implementation of home-based programmes in the UK; and strategies that sustain physical activity in the long term.

Predictors of patients' preferences for treatments to prevent heart disease

OBJECTIVES

To determine the relationship between expressed preferences for drug treatment to prevent coronary disease and several participant and general practitioner characteristics among patients attending coronary risk screening.

DESIGN

Face-to-face interviews with patients. At the first interview, a researcher asked participants to imagine six scenarios representing different levels of pretreatment five-year coronary risk. In each case they were asked whether they would choose treatment that would reduce their coronary risk by 30% of pretreatment risk. At the second interview participants were told their coronary risk and asked whether they would choose treatment. Sociodemographic variables were collected to investigate their relationship to patients' treatment preferences.

PARTICIPANTS

Patients identified as likely to be at high coronary risk were invited to attend for risk screening and to participate in the study.

SETTING

13 practices in the West Midlands.

RESULTS

Participants' preferences varied widely: at the first interview 112 (55.2%) of 203 participants preferred treatment at 3% five-year coronary risk but 31 (15.3%) preferred no treatment even at 30% five-year coronary risk. Age, sex, education and drug treatment history did not affect preferences, but lower social class was associated with preferring treatment at lower risk. Preferences expressed at the second interview were generally consistent with preferences at the first interview (kappa = 0.510, 95% CI 0.380 to 0.639).

CONCLUSIONS

Patients attending for coronary risk screening express stable preferences for drug treatment to prevent coronary heart disease. Their preferences vary widely and may be associated with social class.

Range of self-tests available to buy in the United Kingdom: an Internet survey

We aimed to describe the availability in the United Kingdom of self-tests that are used to diagnose or screen for conditions without involving a health professional. A systematic Internet search identified 104 unique self-tests related to 24 named conditions including cancers, chronic conditions and infections. These self-tests require various samples including blood obtained using a lancet. The samples are processed at home with results available in minutes or sent to a laboratory for processing with results returned to the individual by e-mail or post. Prices per self-test and condition range from < Pounds 1 to Pounds 76. Self-tests are readily available, and further work is needed to assess their impact.

Systematic review: the effectiveness of hypnotherapy in the management of irritable bowel syndrome

AIM

To systematically review the literature evaluating hypnotherapy in the management of irritable bowel syndrome (IBS).

METHODS

Electronic databases were searched (Cochrane Library, Medline, CINAHL, AMED, Embase, PsycINFO, CISCOM, TRIP and the Social Science Citation index), bibliographic references scanned and main authors contacted. No restrictions were placed on language or publication year. Eligible studies involved adults with IBS using single-component hypnotherapy. All studies, except single case or expert opinion, were sought and all patient-related outcomes eligible.

RESULTS

Out of 299 unique references identified, 20 studies (18 trials of which four were randomized, two controlled and 12 uncontrolled) and two case series were eligible. These tended to demonstrate hypnotherapy as being effective in the management of IBS. Numbers of patients included were small. Only one trial scored more than four out of eight on internal validity.

CONCLUSION

The published evidence suggests that hypnotherapy is effective in the management of IBS. Over half of the trials (10 of 18) indicated a significant benefit. A randomized placebo-controlled trial of high internal validity is necessary to establish the effectiveness of hypnotherapy in the management of IBS. Until such a trial is undertaken, this form of treatment should be restricted to specialist centres caring for the more severe forms of the disorder.

Factors influencing clinicians' decisions to prescribe medication to prevent coronary heart disease

BACKGROUND AND OBJECTIVE

There are variations between individual clinicians as to the thresholds at which preventive treatment for coronary heart disease (CHD) should commence. Patients' decisions may be influenced by clinicians' recommendations. Free text comments added by respondents to closed questionnaires may identify areas which are of real concern to them about the topic being studied. The study aimed to identify issues voluntarily raised by clinicians surrounding the decision to prescribe preventive treatment for CHD.

METHODS

An analysis was undertaken of the free text comments made by cardiologists, general practitioners and practice nurses who responded to a closed question postal questionnaire in which they were asked to identify at which level of pretreatment risk they would offer treatment.

RESULTS AND DISCUSSION

A similar percentage of respondents in each professional group provided free text comments. Clinicians' concerns centred on five main themes around prescribing decisions: the risks and benefits of treatment, the patient's role in treatment decisions, patient characteristics, costs to patients, and costs to the health services. Different issues may be of more concern to some professional groups than others.

CONCLUSION

In addition to the use of risk assessment tools and guidelines, clinicians' actual prescribing behaviour may be influenced by more subjective factors. Patients at similar risk may receive different advice depending on the individual clinician they consult.

Preliminary psychometric evaluation of the Child Health Ratings Inventory (CHRIs) and Disease-Specific Impairment Inventory-Hematopoietic Stem Cell Transplantation (DSII-HSCT) in parents and children

PURPOSE

To describe the initial results of the Child Health Ratings Inventory (CHRIs), 20-item generic health-related quality of life (HRQL) instrument and the 10-item disease-specific (DS) module, the Disease Specific Impairment Inventory-Hematopoietic Stem Cell Transplantation (DSII-HSCT), for children and adolescents, ages 5-18 years and their parents following HSCT.

STUDY DESIGN

Using cross sectional design, 122 children with a median age of 11 years (range 5.0-18 years) completed the questionnaire (CHRIs + DSII-HSCT) with research assistance. Seventy-four parents independently completed a parallel version of the questionnaire; health care providers assigned a global clinical severity rating.

RESULTS

The generic core includes four domains: physical, role, and emotional functioning, and energy. The DS module has three domains: worry, hassles, and body image. The Cronbach's alpha for parents and for older children (8 years and over) exceeded 0.70 for all generic and DS domains. While the range of alpha coefficients was lower for younger children, ages 5-7 year, only the alpha coefficient for one domain (energy) was less than 0.70. The instrument satisfactorily discriminated between clinically important groups: those early in the transplant process (< 6 months) versus those later (> 12 months) and by provider-assigned clinical severity ratings.

CONCLUSION

results suggest that the CHRIs generic core and its DSII-HSCT module is a promising measure of HRQL after pediatric HSCT. Although parent and child reports were moderately correlated and revealed complementary results, the unique perspectives of both raters provide a more complete picture of HRQL. Longitudinal application is underway to further characterize the measurement properties of the CHRIs and to determine the instrument's responsiveness and sensitivity to change over time in this vulnerable population.

Self-monitoring of blood glucose in non-insulin-treated diabetic patients: a longitudinal evaluation of its impact on metabolic control

AIMS

In the framework of a nationwide outcomes research programme, we assessed the impact of self-monitoring of blood glucose (SMBG) on metabolic control over 3 years in patients with Type 2 diabetes mellitus (DM2) not treated with insulin.

METHODS

The study involved 1896 patients who completed, at 6-month intervals for 3 years, a questionnaire investigating SMBG practice. Clinical information was collected by participating clinicians at the same time intervals. The predictive value of SMBG frequency on long-term metabolic control was estimated using multilevel analysis. The impact of SMBG on metabolic control was also evaluated in distinct and homogeneous subgroups of patients showing different likelihood of performing SMBG, identified using a tree-growing technique (RECPAM).

RESULTS

Overall, 22% of the patients were on diet alone and 78% were treated with oral agents; 41% practiced SMBG > or = 1/week (10.3% > or = 1/day). The analysis of metabolic control according to the frequency of SMBG failed to show any significant impact of this practice on HbA1c levels over 3 years. Similarly, changes in SMBG frequency during the study were not related to significant changes in HbA1c levels. RECPAM analysis led to the identification of eight classes, characterized by substantial differences in the likelihood of performing SMBG with a frequency of at least 1/week. Nevertheless, in none of the RECPAM classes identified, did SMBG predict a better metabolic control over 3 years of follow-up. In those RECPAM classes indicating that SMBG was mainly performed to avoid hypoglycaemic episodes, SMBG was associated with a decrease in the frequency of hypoglycaemic episodes during the study.

CONCLUSIONS

In a large sample of non-insulin-treated Type 2 diabetic patients, the performance and frequency of SMBG did not predict better metabolic control over 3 years. We could not identify any specific subgroups of patients for whom SMBG practice was associated with lower HbA1c levels during the study.

Parkinson's disease, Alzheimer's disease and motor neurone disease: identifying a common mechanism

Although Alzheimer's disease, Parkinson's disease, and motor neurone disease are distinct disorders, there could be a common neurodegenerative mechanism that characterises the death of selective neurone populations in each case. We propose that this mechanism could be an aberrantly activated, developmental process involving a non-classical, non-enzymatic action of acetylcholinesterase mediated via a short linear motif near the C-terminal end of the molecule. Since this motif has a highly conserved homology with part of the amyloid precursor protein, it may be particularly attractive as a target for novel therapeutic strategies in neurodegeneration.

The impact of blood glucose self-monitoring on metabolic control and quality of life in type 2 diabetic patients: an urgent need for better educational strategies

OBJECTIVE

The role of self-monitoring of blood glucose (SMBG) in type 2 diabetes is still a matter of debate. In the framework of a nationwide outcomes research program, we investigated the frequency of SMBG and its association with metabolic control and quality of life (QoL).

RESEARCH DESIGN AND METHODS

The study involved 3,567 patients with type 2 diabetes who were recruited by 101 outpatient diabetes clinics and 103 general practitioners. Patients completed a questionnaire investigating SMBG practice and QoL (diabetes-related stress, diabetes health distress, diabetes-related worries, and Centers for Epidemiologic Studies-Depression scale).

RESULTS

Data on SMBG were available for 2,855 subjects (80% of the entire study population). Overall, 471 patients (17%) stated that they tested their blood glucose levels at home > or =1 time per day, 899 patients (31%) tested their blood glucose levels > or =1 time per week, and 414 patients (14%) tested their blood glucose levels <1 time per week, whereas 1,071 patients (38%) stated that they never practiced SMBG. A higher frequency of SMBG was associated with better metabolic control among subjects who were able to adjust insulin doses, whereas no relationship was found in all other patients, irrespective of the kind of treatment. Multivariate analyses showed that an SMBG frequency > or =1 time per day was significantly related to higher levels of distress, worries, and depressive symptoms in non-insulin-treated patients.

CONCLUSIONS

Our findings suggest that SMBG can have an important role in improving metabolic control if it is an integral part of a wider educational strategy devoted to the promotion of patient autonomy. In patients not treated with insulin, self-monitoring is associated with higher HbA(1c) levels and psychological burden. Our data do not support the extension of SMBG to this group.

Optimal methods for guideline implementation: conclusions from Leeds Castle meeting

BACKGROUND

Quality problems in medical care are not a new finding. Variations in medical practice as well as actual medical errors have been pointed out for many decades. The current movement to write practice guidelines to attempt to correct these deviations from recommended medical practice has not solved the problem.

OBJECTIVE

In order to gain greater acceptance of these guidelines and to change the behavior of health care providers, the science of guideline implementation must be understood better.

RESEARCH DESIGN

A group of experts who have studied the problem of implementation in Europe and the United States was convened. This meeting summary enumerates the implementation methods studied to date, reviews the theories of behavioral change, and makes recommendation for effecting better implementation guidelines.

RESULTS

A research agenda was proposed to further our knowledge of effective evidence-based implementation.

The relationship between physicians' self-reported target fasting blood glucose levels and metabolic control in type 2 diabetes. The QuED Study Group--quality of care and outcomes in type 2 diabetes

OBJECTIVE

To investigate the relationship between beliefs of physicians relative to intensive metabolic control in type 2 diabetes and levels of HbA1c obtained in a sample of their patients.

RESEARCH DESIGN AND METHODS

Physicians' beliefs were investigated through a questionnaire sent to a sample of self-selected clinicians participating in a nationwide initiative aimed at assessing the relationship between the quality of care delivered to patients with type 2 diabetes and their outcomes. At the same time, physicians were asked to collect clinical data on a random sample of their patients, stratified by age (<65 vs. > or = 65 years). Mean HbA1c levels in the study population were thus evaluated according to target fasting blood glucose (FBG) used by their physicians.

RESULTS

Of 456 physicians, 342 (75%) returned the questionnaire. Among the responders, 200 diabetologists and 99 general practitioners (GPs) recruited 3,297 patients; 2,003 of whom were always followed by the same physician and 1,294 of whom were seen by different physicians in the same structure on different occasions. Only 14% of the respondents used target FBG levels < or = 6.1 mmol/l, whereas 38% pursued values >7.8 mmol/l, with no statistically significant difference between diabetologists and GPs. The analysis of the relationship between FBG targets and metabolic control, restricted to those patients always seen by the same physician, showed a strong linear association, with mean HbA1c values of 7.0 +/- 1.6 for patients in the charge of physicians pursuing FBG levels < or = 6.1 mmol/l and 7.8 +/- 1.8 for those followed by physicians who used target values >7.8 mmol/l. After adjusting for patients' and physicians' characteristics, the risk of having HbA1c values > 7.0% was highly correlated with physicians' beliefs. Patients followed by different physicians in the same unit showed a risk of inadequate metabolic control similar to that of patients followed by physicians adopting a nonaggressive policy.

CONCLUSIONS

Doctors adopt extremely heterogeneous target FBG levels in patients with type 2 diabetes, which in turn represent an important independent predictor of metabolic control. To improve patient outcomes, physicians-centered educational activities aimed at increasing the awareness of the potential benefits of a tight metabolic control in patients with type 2 diabetes are urgently needed.