Understanding implementation and uptake in the National Health Service Health Check Programme.

OBJECTIVES: We present findings from a national online survey of uptake and implementation of the National Health Service Health Check (NHSHC) programme. The research aimed to understand national variation in implementation of NHSHCs and to explore the relationship between uptake and different components of implementation. STUDY DESIGN: The study design was a descriptive online survey. METHODS: Data were collected via an online survey between November 2015 and August 2016. The survey was distributed nationally to practice managers in the Midlands and East of England, South of England, North of England and London via local NHSHC leads with the help of the national programme manager. RESULTS: Responses were received from 153 participants, half of who were practice managers (49.7%). Common components of implementation included using postal invitations accompanied by the national leaflet, delivering NHSHCs routinely with other appointments, offering NHSHC outside of working hours and taking blood samples during the consultation. Meaningful exploration of the relationship between uptake and components of implementation was not possible given the inaccuracy of self-reported uptake data, which was confirmed by comparison with public health data in a subsample (n = 18). The comparison also found that a number of practices were reporting more completed health checks than the total number of patients invited, which again indicates problems that may have implications for uptake figures locally and nationally. CONCLUSIONS: Overall, our findings showed considerable variation in the implementation of NHSHCs on a national scale and issues with quality of programme uptake data, which has implications for national reporting for NHSHC.

Breast cancer patients: substance in blood causing acceleration of erythrocyte sedimentation rate.

The frequency distribution curve of the erythrocyte sedimentation rates obtained from a population of 3523 normal females was compared with the distribution found in 544 patients with benign breast disease and that for 385 patients with carcinoma of the breast. No significant difference was found between the normal female population and patients with benign lesions of the breast. This was in contrast to the distorted distribution curve of erythrocyte sedimentation rates exhibited by the population of patients having malignant breast lesions. An unknown substance present in the blood plasma of the cancer patients appears to be responsible for the abnormal sedimentation rate phenomenon.

Psychoneuroendocrine influences on immunocompetence and neoplasia.

Emotional, psychosocial, or anxiety-stimulated stress produces increased plasma concentrations of adrenal corticoids and other hormones though well-known neuroendocrine pathways. A direct consequence of these increased corticoid concentrations is injury to elements of the immunological apparatus, which may leve the subject vulnerable to the action of latent oncogenic viruses, newly transformed cancer cells, or other incipient pathological processes that are normally held in check by an intact immunological apparatus. This article describes studies that examine the adverse effects of increased plasma concentrations of adrenal corticoids on the thymus and thymus-dependent T cells, inasmuch as these elements constitute a major defense system against various neoplastic processes and other pathologies. The studies demonstrate that anxiety-stress can be quantitatively induced and the consequences measured through specific biochemical and cellular parameters, providing that authentic quiescent baselines of these conditions are obtained in the experimental animals by the use of low-stress protective housing and handling techniques.

Mouse mammary tumors: alteration of incidence as apparent function of stress.

Eighty to 100 percent of female mice of the C3H/He strain carrying the Bittner oncogenic virus usually develop mammary tumors within 8 to 18 months after birth when studied under the usual housing and experimental conditions. By subjecting various groups of such mice to environmental circumstances providing different degrees of chronic stress, mammary tumor incidence at 400 days was modified, with incidences ranging from 92 percent under stress to 7 percent in a protected environment. The data suggest that moderate chronic or intermittent stress may predispose such mice to an increased risk of mammary carcinoma, possibly through a resultant compromise of their immunological competence or tumor surveillance system, and that adequate protection from physiological stress may reduce mammary tumor occurrence in mice.

Spontaneous mammary tumors: decrease of incidence in mice infected with an enzyme-elevating virus.

Mice infected with a virus which causes increased activity of lactate dehydrogenase, and of other enzymes in blood plasma, had a significantly lower incidence of spontaneous mammary carcinoma than did controls. When the experiment was terminated at 18 months, the incidence of mammary tumors in controls was 90 percent, and in infected mice, 53 percent.

Improving cardiovascular disease risk communication in the UK national health service health check programme.

OBJECTIVE: To develop and test training to improve practitioners' confidence and perceived understanding when communicating cardiovascular disease (CVD) risk using novel tools and metrics. METHODS: A CVD risk communication training workshop was developed through interviews with patients and practitioners delivering Health Checks, a literature review, NICE guidance and the UK Health Check competency framework. It was pilot-tested with practitioners delivering Health Checks in the UK. Perceived practitioner understanding and confidence were measured before and up to 10 weeks after the workshop, and changes were compared with those in a control group (who received no intervention). Perceived impact was also explored through semi-structured interviews. RESULTS: Sixty-two practitioners (34 intervention, 28 control) took part. Perceived practitioner understanding (p = .030) and perceived patient understanding (p = .007) improved significantly for those delivering Health Checks in the training group compared with controls. Practitioner confidence also improved significantly more in practitioners who attended the training (p = .001). Findings were supported by interviews with a sub-sample of practitioners (n = 13). CONCLUSION: The training workshop improved practitioners' confidence and perceived understanding of CVD risk in Health Checks. PRACTICE IMPLICATIONS: The training is an important step to improving practitioner understanding of CVD risk in Health Checks and should be implemented on a wider scale.

Development of a valid and reliable test to assess trauma radiograph interpretation performance.

OBJECTIVES: The purpose of this investigation was to develop and examine the preliminary validity and reliability among radiographers of a test to assess trauma radiograph interpretation performance suitable for use among health professionals. METHODS: Stage 1 examined 14,159 consecutive appendicular and axial examinations from a hospital emergency department over a 12 month period to quantify a typical anatomical region case-mix of trauma radiographs. A sample of radiographic cases representative of affected anatomical regions was then developed into the Image Interpretation Test (IIT). Stage 2 involved prospective investigations of the IIT's reliability (inter-rater, intra-rater, internal consistency) and validity (concurrent) among 41 radiographers. RESULTS: The IIT included 60 cases. The median (interquartile range) clinical experience of participants was 5 (2-10) years. Case scores were internally consistent (Cronbach's alpha = 0.90). Favourable inter-rater reliability (kappa > 0.70 for 58/60 cases, Intra-class correlation coefficient (ICC) > 0.99 for total score) and intra-rater reliability (kappa > 0.90 for 60/60 cases, ICC > 0.99 for total score) was observed. There was a positive association between radiographers' confidence in image interpretation and IIT score (coefficient = 1.52, r-squared = 0.60, p < 0.001). CONCLUSIONS: The IIT developed during this investigation included a selection of radiographic cases consistent with anatomical regions represented in an adult trauma case-mix. This study has also provided foundational preliminary evidence to support the reliability and validity of the IIT among radiographers. The findings suggest that it is possible to assess image interpretation performance of adult trauma radiographs with this test.

Increased tyrosine phenol-lyase activity in mice following pyridoxal phosphate administration.

A limiting factor in the depletion of plasma tyrosine following tyrosine phenol-lyase injection into normal mice was found to be the availability of an essential cofactor, pyridoxal phosphate. Because of the extremely short half-life of this cofactor, adequate elevation of circulating cofactor levels for prolonged periods by injection of a pyridoxal phosphate solution was not practical. Similarly, long-term diets enriched with pyridoxine and pyridoxal phosphate did not significantly improve the efficiency of the injected holoenzyme. A repository dosage form was devised that consisted of an s.c. implant of pyridoxal phosphate suspended in a spermaceti and peanut oil mixture. Under these conditions a sustained increase in holoenzyme activity levels and a significant resulting decrease in plasma tyrosine levels were obtained.

Candida species and C. albicans biotypes in women attending clinics in genitourinary medicine.

Yeasts were isolated from two or more anatomical sites in 198 women attending genitourinary clinics on at least two occasions. The yeast biotypes isolated concurrently from the vagina and urethra were the same in 138 (99%) of 140 instances, and 94% of 124 concurrent genital and anal isolates were of matching types, whereas only 75% of concurrent genital and oral isolates were of the same type. Mixtures of Candida spp. or C. albicans biotypes were encountered only five times among 545 yeast-positive samples. In instances where Candida spp. were isolated at successive times from the same site in a patient, the same yeast type was encountered on 97 (87%) of 112 occasions when the interval between samples was less than 15 weeks, and on 19 (66%) of 29 occasions when the interval was 15 weeks or more. These data indicate a tendency to carriage of phenotypically consistent types of Candida among most women attending genitourinary clinics.

Prostatitis--clinical and bacterial studies.

Forty men with clinical prostatitis were studied to determine the value of symptomatology and categorization and 30 (75%) were classified as having prostatitis on the basis of prostatic localization studies. Of these 3 (10%) had chronic bacterial prostatitis, 18 (60%) had chronic abacterial prostatitis, and 9 (30%) had prostatodynia. No patient had acute bacterial prostatitis. Although Enterobacteriaciae were isolated from the 3 men with chronic bacterial prostatitis, these bacteria along with Staphlococcus aureus, Streptococcus faecalis, and Chlamydia trachomatis were isolated from a further 6 patients. The mean pH of the expressed prostatic secretion was measured for each group and was found to be 7.6 for those with chronic bacterial prostatitis, 7.1 for chronic abacterial prostatitis, 6.5 for prostatodynia, and 6.9 for those with urethritis suggesting that this test may be of value in the diagnosis of chronic bacterial prostatitis.

Delay in symptom presentation among a sample of older GUM clinic attenders.

Prior research undertaken with predominantly youthful populations has established that delay between symptom recognition and health-care presentation is a common feature of sexually transmitted infection (STI) related illness behaviour. However, it is not known whether similar behaviours are exhibited by older populations with genitourinary symptoms. The present analyses therefore aim to clarify this issue by focusing upon (1) extent of delay behaviour, (2) reasons for delay behaviour and (3) variables predicting delay behaviour among a sample of genitourinary medicine (GUM) clinic attenders aged over 50 years. A self-administered questionnaire study linked to patient note data was undertaken within 3 GUM clinics in the Trent region between January 1997 and March 1998 (Sheffield, Nottingham and Leicester). Of 121 symptomatic older attenders with suspected STI, 43.8% (n=53) waited over 2 weeks between symptom recognition and clinic attendance. Reasons given for delay included wanting to 'wait and see' if symptoms improved and being embarrassed or afraid to attend clinic. A logistic regression analysis identified that delay behaviour was predicted by history of HIV testing. Comparisons with previous research undertaken in this field indicate that levels of delay behaviour reported by this older sample are higher than those exhibited by youthful populations with genitourinary symptoms. This finding has significant implications for health-care professionals working both within a GUM setting, and with older people, especially when viewed in the context of an ageing population.

Isolated microscopic haematuria in the genitourinary clinic: the value of renal biopsy.

Isolated microscopic haematuria is a common finding in the genitourinary clinic. The conventional approach to investigation includes urological referral for cystourethroscopy if renal imaging is normal. However the diagnostic yield is very low; in particular urothelial malignancy at age < 40 years is rare. Glomerular disease is increasingly recognized as a common cause of microscopic haematuria. In this study 50 patients with persistent microscopic haematuria detected at a genitourinary clinic underwent renal biopsy. Twelve (24%) had an abnormal biopsy--IgA nephropathy 6 (12%), thin membrane nephropathy 3 (6%), other glomerulonephritis 3 (6%). In 7 others no abnormality was found but information was incomplete as electron microscopy was unavailable. It is important to establish these diagnoses since some patients will develop progressive renal disease. In this clinical setting renal biopsy will give diagnostic and prognostic information, protects from repeated urological investigation, and allows reassurance if renal histology is normal. Renal biopsy is recommended for patients age < 40 years with persistent microscopic haematuria. An algorithm for the investigation of microscopic haematuria is presented.

Exploring the sexual histories of older GUM clinic attenders.

Little is known either of the factors motivating clinic attendance in later life, or the sexual health histories of older clinic attenders. A self-administered questionnaire study linked to patient note data aiming to explore these issues was undertaken within 3 genitourinary medicine (GUM) clinics in the Trent region. Participants comprised 224 individuals aged 50 years and older attending the 3 clinics during the study period. The majority of study participants were attending the clinic with a suspected sexually transmitted infection (STI) (n = 145, 64.7%) and approximately half (n=119, 53.1%) were first-time GUM clinic attenders. Data available for participants recruited from the Sheffield clinic indicated that, although the majority of participants reported having had only one sexual partner during the last 12 months, a significant minority reported considerably higher numbers of partners, including those classed 'higher risk' for STI acquisition. These data indicate that older people engage in behaviours that place them at risk of STI acquisition and many attend GUM clinics for the first time in later life.

Epidemiology of vaginal Candida infection: significance of numbers of vaginal yeasts and their biotypes.

The prevalence, quantity and biotypes of vaginal yeasts were determined for 1082 randomly selected nonpregnant patients attending two genitourinary medicine clinics. The overall yeast prevalence was 22.1% with a geometric mean of 40 and a median of 75 yeast colonies per positive isolate (on 5-cm Petri dishes). There was no statistically significant variation in prevalence, quantity or biotype of yeasts with the patients' age, season of the year, stage of the menstrual cycle, recent antibiotic history, contraceptive use or main diagnosis (excluding candidosis). A clinical score for Candida infection, based on symptoms of pruritus and signs of Candida vulvovaginitis, showed significant variation with the prevalence and quantity of yeast isolates. Unequivocal clinical evidence of candidosis was strongly associated with high concentrations of vaginal yeasts. There was also some association between certain groups of Candida albicans biotypes and the clinical score. These observations reemphasize the need for consideration of both clinical and mycological factors in establishing a diagnosis of vulvovaginal Candida infection. It is suggested that isolation of fewer than 10 yeast colonies from a vaginal swab is usually unlikely to indicate an infection requiring treatment.

Quantification of Candida albicans morphology in vaginal smears.

The morphology index (Mi) of Candida albicans cells was determined by microscopic image analysis in vaginal smears from 26 patients. The morphology of the cells typically showed a broad distribution of forms, but the mean Mi was greater than 2.0 in 23/26 instances, indicating a preponderance of pseudohyphal and hyphal forms. No association could be found between Mi and the clinical assessment of signs or symptoms of Candida infection. Comparison of these 26 patients with 43 others who had Candida-positive vaginal smears but with fewer than 15 fungal cells in the smear revealed significantly lower scores for vulvovaginal symptoms among the latter.