Injury outcome indicators: the development of a validation tool.

BACKGROUND: Researchers have previously expressed concern about some national indicators of injury incidence and have argued that indicators should be validated before their introduction. AIMS: To develop a tool to assess the validity of indicators of injury incidence and to carry out initial testing of the tool to explore consistency on application. METHODS: Previously proposed criteria were shared for comment with members of the International Collaborative Effort on Injury Statistics (ICE) Injury Indicators Group over a period of six months. Immediately after, at a meeting of Injury ICE in Washington, DC in April 2001, revised criteria were agreed over two days of meetings. The criteria were applied, by three raters, to six non-fatal indicators that underpin the national road safety targets for Canada, New Zealand, and the United Kingdom. Consistency of ratings were judged. CONSENSUS OUTCOME: The development process resulted in a validation tool that comprised criteria relating to: (1) case definition, (2) a focus on serious injury, (3) unbiased case ascertainment, (4) source data for the indicator being representative of the target population, (5) availability of data to generate the indicator, and (6) the existence of a full written specification for the indicator. On application of these criteria to the six road safety indicators, some problems of agreement between raters were identified. CONCLUSION: This paper has presented an early step in the development of a tool for validating injury indicators, as well as some directions that can be taken in its further development.

MRI directed bilateral stimulation of the subthalamic nucleus in patients with Parkinson's disease.

OBJECTIVE: Bilateral chronic high frequency deep brain stimulation (DBS) of the subthalamic nucleus (STN) has emerged as an appropriate therapy for patients with advanced Parkinson's disease refractory to medical therapy. Advances in neuroimaging and neurophysiology have led to the development of varied targeting methods for the delivery of this treatment. Intraoperative neurophysiological and clinical monitoring is regarded by many to be mandatory for accurate STN localisation. We have examined efficacy of bilateral STN stimulation using a predominantly magnetic resonance imaging (MRI)-directed technique. METHODS: DBS leads were stereotactically implanted into the STN using an MRI directed method, with intraoperative macrostimulation used purely for adjustment. The effects of DBS were evaluated in 16 patients followed up to 12 months, and compared with baseline assessments. Assessments were performed in both off and on medication states, and were based on the Unified Parkinson's Disease Rating Scale (UPDRS) and timed motor tests. Functional status outcomes were examined using the PDQ-39 quality of life questionnaire. A battery of psychometric tests was used to assess cognition. RESULTS: After 12 months, stimulation in the off medication state resulted in significant improvements in Activities of Daily Living and Motor scores (UPDRS parts II and III) by 62% and 61% respectively. Timed motor tests were significantly improved in the off medication state. Motor scores (UPDRS part III) were significantly improved by 40% in the on medication state. Dyskinesias and off duration were significantly reduced and the mean dose of L-dopa equivalents was reduced by half. Psychometric test scores were mostly unchanged or improved. Adverse events were few. CONCLUSIONS: An MRI directed targeting method for implantation of DBS leads into the STN can be used safely and effectively, and results are comparable with studies using intraoperative microelectrode neurophysiological targeting. In addition, our method was associated with an efficient use of operating time, and without the necessary costs of microelectrode recording.

Effectiveness and cost effectiveness of counselling in primary care.

BACKGROUND: Counsellors are prevalent in primary care settings. However, there are concerns about the clinical and cost-effectiveness of the treatments they provide, compared with alternatives such as usual care from the general practitioner, medication or other psychological therapies. OBJECTIVES: To assess the effectiveness and cost effectiveness of counselling in primary care by reviewing cost and outcome data in randomised controlled trials, controlled clinical trials and controlled patient preference trials of counselling interventions in primary care, for patients with psychological and psychosocial problems considered suitable for counselling. SEARCH STRATEGY: The original search strategy included electronic searching of databases (including the CCDAN Register of RCTs and CCTs) along with handsearching of a specialist journal. Published and unpublished sources (clinical trials, books, dissertations, agency reports etc.) were searched, and their reference lists scanned to uncover further controlled trials. Contact was made with subject experts and CCDAN members in order to uncover further trials. For the updated review, searches were restricted to those databases judged to be high yield in the first version of the review: MEDLINE, EMBASE, PSYCLIT and CINAHL, the Cochrane Controlled Trials register and the CCDAN trials register. SELECTION CRITERIA: All controlled trials comparing counselling in primary care with other treatments for patients with psychological and psychosocial problems considered suitable for counselling. Trials completed before the end of June 2001 were included in the review. DATA COLLECTION AND ANALYSIS: Data were extracted using a standardised data extraction sheet. The relevant data were entered into the Review Manager software. Trials were quality rated, using CCDAN criteria, to assess the extent to which their design and conduct were likely to have prevented systematic error. Continuous measures of outcome were combined using standardised mean differences. An overall effect size was calculated for each outcome with 95% confidence intervals. Continuous data from different measuring instruments were transformed into a standard effect size by dividing mean values by standard deviations. In view of the diversity of counselling services in primary care (the range of treatments, patients and practitioners) tests of heterogeneity were done to assess the feasibility of aggregating measures of outcome from trials. Sensitivity analyses were undertaken to test the robustness of the results. MAIN RESULTS: Seven trials were included in the review. The main analyses showed significantly greater clinical effectiveness in the counselling group compared with 'usual care' in the short-term (standardised mean difference -0.28, 95% CI -0.43 to -0.13, n=772, 6 trials) but not the long-term (standardised mean difference -0.09, 95% CI -0.27 to 0.10, n=475, 4 trials). Levels of satisfaction with counselling were high. Four studies reported similar total costs associated with counselling and usual care over the long-term. However, the economic analyses were likely to be underpowered. REVIEWER'S CONCLUSIONS: Counselling is associated with modest improvement in short-term outcome compared to 'usual care', but provides no additional advantages in the long-term. Patients are satisfied with counselling, and it may not be associated with increased costs.

Central chemosensitivity and breathing asleep in unilateral medullary lesion patients: comparisons to animal data.

The rostro-ventrolateral medulla (RVLM) is a site of chemosensitivity in animals; such site(s) have not been defined in humans. We studied the effect of unilateral focal lesions in the rostrolateral medulla (RLM) of man, on the ventilatory CO(2) sensitivity and during awake and sleep breathing. Nine patients with RLM lesions (RLM group), and six with lesions elsewhere (non-RLM group) were studied. The ventilatory CO(2) sensitivity was lower in the RLM compared with the non-RLM group (mean (S.D.), RLM, 1.4 (0.9), non-RLM 3.0 (0.6) L min(-1) mmHg(-1)). In both groups resting breathing was normal. During sleep all RLM patients had frequent arousals, four had significant sleep disordered breathing (SDB), only one non-RLM patient had SDB. Our findings in humans resemble those in animals with focal RVLM lesions. This review provides evidence that in humans there is an area of chemosensitivity in the RLM. We propose that in humans, dorsal displacement of the RVLM area of chemosensitivity in animals, arises from development of the olive plus the consequences of the evolution of the cerebellum/inferior peduncle.

Effectiveness and cost effectiveness of counselling in primary care.

BACKGROUND: There is wide clinician and patient support for counselling in primary care, particularly in the UK. This review examines the effectiveness and cost effectiveness of counselling for psychological and psychosocial problems in the primary care setting. OBJECTIVES: To assess the effects of counselling in primary care by reviewing cost and outcome data for patients with psychological and psychosocial problems considered suitable for counselling. SEARCH STRATEGY: The search strategy included electronic searching of databases (including the CCDAN Register of RCTs and CCTs) along with handsearching of a specialist journal. Published and unpublished sources (clinical trials, books, dissertations, agency reports etc.) were searched, and their reference lists scanned. Contact was made with subject experts and CCDAN members. SELECTION CRITERIA: Randomised and controlled patient preference trials comparing counselling in primary care with usual general practitioner care for patients with psychological and psychosocial problems considered suitable for counselling. Trials completed before the end of April 1998 were included in the review. DATA COLLECTION AND ANALYSIS: Trials were independently assessed by at least two reviewers for appropriateness of inclusion and methdological quality. MAIN RESULTS: Four trials, involving 678 participants, of whom 487 were followed up, were included. Data for psychological symptom levels (four trials) were pooled statistically. Patients receiving counselling had significantly better psychological symptom levels post intervention than patients receiving usual general practitioner care (standardised mean difference -0.30, 95% CI, (-0.49 to - 0.11). The effect remained statistically significant when the results from studies with less rigorous methodology were excluded in a sensitivity analysis. Patients who received counselling tended to be more satisfied with their treatment (three trials). Health service utilisation data were reported in all trials reviewed, but only one trial undertook a cost analysis. No clear cost advantage was associated with either counselling or usual general practice care. REVIEWER'S CONCLUSIONS: Patients who received counselling were more likely to have improved psychological symptom levels than those who did not receive counselling. Levels of satisfaction with counselling were high. There is limited information about the cost effectiveness of counselling, with one study reporting no clear cost advantage with either counselling or general practice care. The four trials included in this review were all pragmatic trials of counselling in primary care in the UK, which reflect the reality of clinical provision in this context. There were methdological weaknesses identified in the studies, which should be taken into account when considering the results. The evidence base will be extended by trials of counselling which are nearing completion.

Delayed cerebral edema and fatal coma after minor head trauma: role of the CACNA1A calcium channel subunit gene and relationship with familial hemiplegic migraine.

Trivial head trauma may be complicated by severe, sometimes even fatal, cerebral edema and coma occurring after a lucid interval ("delayed cerebral edema"). Attacks of familial hemiplegic migraine (FHM) can be triggered by minor head trauma and are sometimes accompanied by coma. Mutations in the CACNA1A calcium channel subunit gene on chromosome 19 are associated with a wide spectrum of mutation-specific episodic and chronic neurological disorders, including FHM with or without coma. We investigated the role of the CACNA1A gene in three subjects with delayed cerebral edema. Two subjects originated from a family with extreme FHM, and one subject was the previously asymptomatic daughter of a sporadic patient with hemiplegic migraine attacks. In all three subjects with delayed severe edema, we found a C-to-T substitution resulting in the substitution of serine for lysine at codon 218 (S218L) in the CACNA1A gene. The mutation was absent in nonaffected family members and 152 control individuals. Haplotype analysis excluded a common founder for both families. Neuropathological examination in one subject showed Purkinje cell loss with relative preservation of granule cells and sparing of the dentate and inferior olivary nuclei. We conclude that the novel S218L mutation in the CACNA1A calcium channel subunit gene is involved in FHM and delayed fatal cerebral edema and coma after minor head trauma. This finding may have important implications for the understanding and treatment of this dramatic syndrome.

Counselling for depression in primary care.

BACKGROUND: There is wide clinician and patient support for counselling in primary care, particularly in the UK. This review examines the effectiveness and cost effectiveness of counselling for psychological and psychosocial problems in the primary care setting. OBJECTIVES: To assess the effects of counselling in primary care by reviewing cost and outcome data for patients with psychological and psychosocial problems considered suitable for counselling. SEARCH STRATEGY: The search strategy included electronic searching of databases (including the CCDAN Register of RCTs and CCTs) along with handsearching of a specialist journal. Published and unpublished sources (clinical trials, books, dissertations, agency reports etc.) were searched, and their reference lists scanned. Contact was made with subject experts and CCDAN members. SELECTION CRITERIA: Randomised and controlled patient preference trials comparing counselling in primary care with usual general practitioner care for patients with psychological and psychosocial problems considered suitable for counselling. Trials completed before the end of April 1998 were included in the review. DATA COLLECTION AND ANALYSIS: Trials were independently assessed by at least two reviewers for appropriateness of inclusion and methdological quality. MAIN RESULTS: Four trials, involving 678 participants, of whom 487 were followed up, were included. Data for psychological symptom levels (four trials) were pooled statistically. Patients receiving counselling had significantly better psychological symptom levels post intervention than patients receiving usual general practitioner care (standardised mean difference -0.30, 95% CI, (-0.49 to - 0.11). The effect remained statistically significant when the results from studies with less rigorous methodology were excluded in a sensitivity analysis. Patients who received counselling tended to be more satisfied with their treatment (three trials). Health service utilisation data were reported in all trials reviewed, but only one trial undertook a cost analysis. No clear cost advantage was associated with either counselling or usual general practice care. REVIEWER'S CONCLUSIONS: Patients who received counselling were more likely to have improved psychological symptom levels than those who did not receive counselling. Levels of satisfaction with counselling were high. There is limited information about the cost effectiveness of counselling, with one study reporting no clear cost advantage with either counselling or general practice care. The four trials included in this review were all pragmatic trials of counselling in primary care in the UK, which reflect the reality of clinical provision in this context. There were methdological weaknesses identified in the studies, which should be taken into account when considering the results. The evidence base will be extended by trials of counselling which are nearing completion.

First wave PMS pilots: a critical analysis of documentation.

Contracts and interim local evaluation reports for the 14 first wave PMS pilots in Northern and Yorkshire region were analysed by documentary analysis. Both contracts and reports were found to vary considerably in size and scope. Most contracts contained aims and objectives that were too broad or vague to guide project management and they lacked useful milestones. This made it difficult to identify criteria for measuring success. The local evaluation reports were also of variable quality. It is recommended that contracts should be accompanied by a development plan containing specific objectives, timescale and process for implementation as well as an evaluation strategy. The relative importance of different targets should be agreed and specified at the outset, to allow weighting of partial success, where some objectives, but not others, are achieved. Project milestones would be made explicit and measurable in the development plan. More clarity in contracts and evaluation for future pilots is essential.

'I always seem to be there'--a qualitative study of frequent attenders.

BACKGROUND: Much is still unknown about the consultation behaviour of frequent attenders, including why they consult as often as they do and why they consult in the patterns that they do. AIM: To determine why frequent attenders to general practice consult in the patterns that they do. METHOD: A qualitative study based on semi-structured interviews. Twenty-eight frequent attenders were purposively sampled from three practices; 13 exhibited a 'burst and gap' pattern of attendance and 15 exhibited a 'regular' pattern of attendance. RESULTS: A two-part model is proposed. The first part encompasses each individual decision to consult and is based around eight questions that may be asked as part of the decision-making process (these concern the perception of the general practitioner's [GP's] role, past experience of symptoms and consulting, comparison with others' consulting, relationship with the GP, balancing fears, lay consulting, individual reasons, and whether it was a symptom that they would not normally consult for). The second part determines the pattern of consulting and has four major themes: predominantly medical reasons for attending, experience of what happens during the consultation, accessibility of the GP, and periods of not consulting. Two further themes are proposed: 'multiplicity', whereby the reasons for consulting lead to further consulting for related and unrelated problems, and 'passivity', whereby consulting seems to be out of control. CONCLUSIONS: The reasons underpinning each individual decision to consult were complex. The control that GPs were perceived to have over the pattern of consulting, for example concerning prescribing, review visits, and in addressing further help-seeking behaviour, may provide more possibilities for developing intervention strategies than targeting frequent attenders themselves. An understanding of the processes behind the consulting behaviour of frequent attenders may lead to more functional consultations and better clinical care as a result.

Socio-economic characteristics of adult frequent attenders in general practice: secondary analysis of data.

OBJECTIVE: This study was carried out to determine the effect of a range of socio-economic features on frequent attendance in general practice from a large database of general practice consultations using two definitions of frequent attendance. METHODS: Secondary analyses were carried out of data from the Fourth National Survey of Morbidity in General Practice covering 60 general practices in England and Wales. A total of 283 842 adult patients and their consultations between September 1991 and August 1992 were examined. The main outcome measure was the odds ratio of being a frequent attender (95% confidence intervals). RESULTS: Using a definition of 12+ consultations/year, men were less likely to be frequent attenders (OR 0.14, 95% CI 0.13-0.17); however, the difference between men and women lessens with age. Patients who were more likely to be frequent attenders included those who were divorced or widowed (1.41, 1.31-1.51); from social classes IIIM (1.23, 1.17-1.29) and IV/V (1.33, 1.26-1.41); South Asian people (1.38, 1.16-1.65); or unemployed (1.61, 1.46-1.77). Other factors signifying isolation or poverty were also linked to frequent attendance. Using the definition of '6+ consultations for minor problems' produced broadly similar results although the relative weight of the factors showed some differences. CONCLUSIONS: Socio-economic factors were important indicators of frequent attendance in general practice. Results were very similar using either definition, suggesting that both are valid for further work. Furthermore, frequent attendance is a complex process associated with many factors outside the control of the GP.

What do GPs need to know? The use of knowledge in general practice consultations.

In the course of the consultation in primary care, the general practitioner integrates knowledge of different types that are drawn from different sources. As a consequence of the way practitioners develop expertise, this use of knowledge is often hidden from the conscious mind of the practitioner and often hidden from direct observation. On the other hand, understanding of this use of knowledge is crucial to several necessary developments of the profession of general practice. A method involving collaboration between researcher and practitioner sheds new light on this knowledge-in-use.

First step: report on a pilot course for personal and professional development.

OBJECTIVE: To describe a pilot course in personal and professional development, entitled 'Becoming a doctor: the first step' and our suggestions for what might be incorporated into future courses. SETTING AND CONTEXT: Leeds Medical School begins a new curriculum in September 1999 with a proportion of the first 3 years being devoted to a new module on personal and professional development. This module will include courses involving communication skills, ethics, working in groups and early patient contact through community visits. Some of these topics were piloted in a short course for first-year medical students in 1998. LEARNING METHODS: The course ran for 9 weeks and was largely experiential. The group facilitators came from diverse health and social care backgrounds. A variety of learning methods were used, concentrating on self-reflection, discussion, community visits and information gathering. EVIDENCE FOR EFFECTIVENESS: The views of both facilitators and students were analysed. Students particularly appreciated the community visits and group work. The facilitators were positive about the course overall while suggesting improvements, including their own involvement in future development of the course. CONCLUSIONS: The pilot course has helped us to focus on objectives for the new curriculum and to plan the new course. In particular there is a need for more attention to be given to the involvement of facilitators in course development.

Survey of the prescribing of chemoprophylaxis to index cases of invasive meningococcal disease.

Chemoprophylaxis is given to contacts of cases of invasive meningococcal disease to reduce the risk of secondary cases by eradicating carriage. In the United Kingdom index cases are also recommended to receive chemoprophylaxis. This is usually undertaken by the clinical team managing the case. One hundred and fifty cases of probable meningococcal infection notified to the consultants in communicable disease control in a local health authority were reviewed to identify the proportion receiving chemoprophylaxis and to examine the final clinical outcome, in terms of diagnosis, of each case. Twenty-five per cent of notified cases (37) did not receive chemoprophylaxis and this proportion varied significantly between three local hospitals. We estimate that 15 of the 37 index cases who did not receive chemoprophylaxis were likely to have had invasive meningococcal disease.

Frequent attenders' consulting patterns with general practitioners.

BACKGROUND: Despite the growing literature on frequent attendance, little is known about the consulting patterns of frequent attenders with different doctors. To develop appropriate intervention strategies and to improve the clinical care of frequent attenders, a full understanding of these consulting patterns is essential. AIMS: This paper has three aims: to determine whether frequent attenders consult more with some doctors than others; to determine how many different doctors frequent attenders consult with; and to determine whether frequent attenders exhibit greater continuity of care than non-frequent attenders. METHOD: Analysis of a validated dataset of 592,028 consultations made by 61,055 patients from four practices over 41 months. Comparisons between the consulting patterns of the frequent attenders, defined as the most frequently consulting 3% of the population by practice, with non-frequent attenders and the overall practice populations. RESULTS: There was considerable variation in the numbers and proportions of consultations with frequent attenders between individual doctors. Most of the frequent attenders consulted with most or all of the doctors within practices over the timeframe. Frequent attenders exhibited more continuity of care than non-frequent attenders. CONCLUSION: The reasons why some doctors have more consultations with frequent attenders is unclear. Some doctors may actively encourage frequent attendance. While many frequent attenders have clear allegiances to one doctor, many also consult widely with a large number of doctors. The consequences of such behaviour are unknown. These findings have important implications in the development of appropriate interventions for reducing problematic frequent attendance.

Unilateral focal lesions in the rostrolateral medulla influence chemosensitivity and breathing measured during wakefulness, sleep, and exercise.

OBJECTIVES: The rostrolateral medulla (RLM) has been identified in animals as an important site of chemosensitivity; in humans such site(s) have not been defined. The aim of this study was to investigate the physiological implications of unilateral lesions in the lower brainstem on the control of breathing. METHODS: In 15 patients breathing was measured awake at rest, asleep, during exercise, and during CO(2) stimulation. The lesions were located clinically and by MRI; in nine patients they involved the RLM (RLM group), in six they were in the pons, cerebellum, or medial medulla (Non-RLM group). All RLM group patients, and three non-RLM group patients had ipsilateral Horner's syndrome. RESULTS: Six of the RLM group had a ventilatory sensitivity to inhaled CO(2) (V/P(ET) CO(2)) below normal (group A: V/P(ET) CO(2), mean, 0.87; range 0.3-1.4 l. min(-1)/mm Hg). It was normal in all of the non-RLM group (group B: V/P(ET) CO(2), mean, 3.0; range, 2.6-3.9 min(-1)/mmHg). There was no significant difference in breathing between groups during relaxed wakefulness (V, group A: 7.44 (SD 2.5) l.min(-1); group B: 6.02 (SD 1.3) l.min(-1); P(ET) CO(2), group A: 41.0 (SD 4.2) mm g; group B: 38.3 (SD2.0) mm Hg) or during exercise (V/VO(2): group A: 21 (SD 6. 0) l.min(-1)/l.min(-1); group B: 24 (SD 7.3) l.min(-1)/l.min(-1)). During sleep, all group A had fragmented sleep compared with only one patient in group B (group A: arousals, range 13 to > 60 events/hour); moreover, in group A there was a high incidence of obstructive sleep apnoea associated with hypoxaemia. CONCLUSION: Patients with unilateral RLM lesions require monitoring during sleep to diagnose any sleep apnoea. The finding that unilateral RLM lesions reduce ventilatory sensitivity to inhaled CO(2) is consistent with animal studies. The reduced chemosensitivity had a minimal effect on breathing awake at rest or during exercise.

The dietary intake of chemical residues in Brisbane adults.

The purpose of this work was to integrate existing chemical residue and food consumption data for individuals to improve estimates of the dietary intake of chemical residues in the population of Brisbane. Previous estimates of intakes from the Australian Market Basket Survey (AMBS) have been based on energy-adjusted 'hypothetical national diets' and so allow no assessment of variation in intakes between individuals or groups. Data on concentration of fenitrothion, chlorpyrifos-methyl, pirimiphos-methyl, heptachlor and dieldrin in selected foods were taken from reports of the AMBS. Food consumption data were based upon the National Dietary Survey of Adults (NDSA) 1983; the same data from which the hypothetical diets are derived. The distribution of estimated 24-hour intakes was adjusted to represent usual intakes. Mean intakes of all residues were about one third those reported previously. None of the observed diets contained levels of residues that were greater than the Acceptable Daily Intakes. These findings support reassurances to the public that residues of agricultural chemicals monitored in the AMBS do not pose a health risk.