Postcesarean pelvic floor dysfunction contributes to undisclosed psychosocial morbidity.

OBJECTIVE: To estimate the prevalence and severity of postcesarean pelvic dysfunction. STUDY DESIGN: Using biopsychosocial interviewing at home, 184 postcesarean primiparas were compared to 100 vaginally delivered women regarding symptoms of stress incontinence, anal incontinence and dyspareunia. Delivery details were confirmed from medical records. RESULTS: Comparison of postcesarean vs. vaginally delivered women revealed stress incontinence in 33% vs. 54% and dyspareunia in 27% vs. 46%, both differences reaching statistical significance, unlike anal incontinence, which was manifest in 51% vs. 44%. When compared to emergency cesarean the relative risk of stress incontinence following an elective cesarean was 0.99 (0.71, 1.39), of dyspareunia 1.02 and of anal incontinence 1.05, indicating no statistically significant difference. Thirty (22%) stress incontinent and 4 (3%) fecally incontinent mothers used pads continuously, suggesting severe physical morbidity. Severe dysphoria (depression) was expressed by 41 (35%) stress incontinent mothers, 38 (30%) with dyspareunia and 34 (26%) with anal incontinence; the association of severe dysphoria with dyspareunia was statistically significant (OR = 2.504 [1.362, 4.602]). Few women came forward to seek help. CONCLUSION: Pelvic dysfunction was similar after elective or emergency cesarean. Compared to vaginal delivery, postcesarean stress incontinence and dyspareunia were less frequent but biopsychosocial morbidity could be severe.

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

OBJECTIVE: Evaluations of point of care tests (PCT) are often hampered by a lack of appropriate gold standards. This study aimed to compare the results of a Bayesian statistical analysis and a maximum likelihood method to evaluate the performance of a PCT for Helicobacter pylori in primary care. METHODS: The Helisal Rapid Blood Test (Cortecs Diagnostics) was performed in 311 patients from 6 primary care centers, and a concurrent venous sample was taken for 2 enzyme-linked immunosorbent assays (ELISA) performed at the laboratory, blind to the PCT result. The Bayesian analysis was conducted using Markov Chain Monte Carlo methods (WinBUGS). The performance characteristics of the PCT and the 2 ELISA tests were estimated together with 95% credible intervals (95% CIs). RESULTS: The estimate of prevalence of H. pylori in this population was 64% (95% CI, 59% to 70%), the sensitivity and specificity of the PCT were 89% (84% to 94%) and 84% (77% to 91%), respectively (likelihood ratios positive 5.6, negative 0.13). The equivalent maximum likelihood results were prevalence, 65%; sensitivity, 90%; and specificity, 83%. CONCLUSIONS: The Helisal Rapid Blood Test performed as well as laboratory-based ELISA tests in this cohort of patients. The Bayesian analysis and the maximum likelihood method gave similar results, the Bayesian method also simultaneously estimating 95% CIs.

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

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

Aversion to gaseous euthanasia agents in rats and mice.

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

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

BACKGROUND: Oral anticoagulation monitoring has traditionally taken place in secondary care because of the need for a laboratory blood test, the international normalised ratio (INR). The development of reliable near patient testing (NPT) systems for INR estimation has facilitated devolution of testing to primary care. Patient self-management is a logical progression from the primary care model. This study will be the first to randomise non-selected patients in primary care, to either self-management or standard care. METHOD: The study was a multi-centred randomised controlled trial with patients from 49 general practices recruited. Those suitable for inclusion were aged 18 or over, with a long term indication for oral anticoagulation, who had taken warfarin for at least six months. Patients randomised to the intervention arm attended at least two training sessions which were practice-based, 1 week apart. Each patient was assessed on their capability to undertake self management. If considered capable, they were given a near patient INR testing monitor, test strips and quality control material for home testing. Patients managed their own anticoagulation for a period of 12 months and performed their INR test every 2 weeks. Control patients continued with their pre-study care either attending hospital or practice based anticoagulant clinics. DISCUSSION: The methodology used in this trial will overcome concerns from previous trials of selection bias and relevance to the UK health service. The study will give a clearer understanding of the benefits of self-management in terms of clinical and cost effectiveness and patient preference.

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

AIM: To investigate possible bias due to gender combination of students, role players and examiners in a high-stakes assessment. SETTING: Valid oral interactive contextualized examinations (VOICEs) is a long-station OSCE-style exam in general practice (GP). At the time of writing it consisted of 65% of the student's final GP mark. METHOD: In the VOICE, students undertake six tasks--four vivas and two role-plays. "Patient" roles are taken by professional role players who work regularly on the undergraduate curriculum. During the role-play, the student's clinical competence is assessed by an observing GP examiner. The communication skills marks are awarded by the role player and the examiner together, by negotiation. Data have been recorded detailing the role player's initial marks, the examiner's initial marks and their final (awarded) agreed marks for 1024 consultations. SAMPLE: 512 final year medical students, 28 role players and 48 examiners. There were no inclusion or exclusion criteria. All those present on exam day became part of the data. RESULTS: There was a significant relationship between gender and performance for some, but not all, stations. Correlations for multiple comparisons removed the significance. Female students perform better across the board than male students. While not always significant, this did affect grading. There was no significant association between the genders of role players and examiners with the question choices. There has been a significant worsening of male results since 1999. Differences exist in the way that pairs of mixed or single genders score students.

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

INTRODUCTION: Communication skills assessment is complex. Standardised patient use is widespread, but anxiety exists around the use of role players as assessors of competence in high stakes examinations. This study measures the level of agreement between scoring examiners and role players, and considers their influence on each other. Examiner status and question choices are analysed as variables. METHOD: The valid oral interactive contextualised examination (VOICE) is a general practice examination styled as an objective structured clinical examination (OSCE) of six 15-minute stations, which include two role-played consultations with professional role players. The examination candidates are final year medical students. Clinical components are examined by a general practitioner (GP). Communication skills are assessed by these examiners in conjunction with the role players, through a process of negotiation. Descriptive professionalism/attitude bandings are used as percentage-scoring guidelines. Checklists are not used. For this study, the initial (independently) perceived marks of the two scoring groups and their agreed final (awarded) marks were recorded, along with other variables including gender, performance factors, demographics and the nature of the question. Data represents 512 students undertaking 1024 simulated consultations, examined by 28 role players and 46 examiners. Analysis was carried out using SPSS Version 10. RESULTS: Results show that the examination and negotiation process is consistent. Role players have a direct influence on scoring. The examiner's background is a significant variable [F9,1014 = 4.207, P < 0.001]. Students perform less well on questions involving higher degrees of clinical information giving. Question choice is not significant [F30,3039 = 1.397, P=0.074]. DISCUSSION: The variables in the examination do not indicate any discrepancy substantial enough to bias a student's grade. Negotiated marking in this context is considered safe and reliable.

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

OBJECTIVE: To describe changes in delay to administration of thrombolytic therapy associated with a region-wide audit. DESIGN: Observational study of patients admitted with suspected myocardial infarction (MI) based on continuous audit. SUBJECTS: 18877 patients admitted to 23 hospitals with suspected MI between April 1995 and March 1998. RESULTS: Of 11232 patients with a discharge diagnosis of definite MI, 8802 (46.6%) received thrombolytic therapy during hospitalisation, with 5155 patients eligible for treatment on admission to hospital on the basis of established indications. Call-to-needle time for those eligible for treatment on admission fell from median 105 min in the first year of the project to 85 min in year 3 (P<0.001), and door-to-needle time fell from 45 to 35 min (P<0.001). Forty percent of eligible patients were treated within the then current national standard of 90 min from time of call for help, with nearly 49% in the final year and 20% being treated within the new national standard of 60 min, by the third year. CONCLUSION: The proportion of eligible patients receiving thrombolysis within 1 h of the call for help doubled during the 3-year project but the majority of patients still wait longer than 60-min 'call-to-needle'. New systems to reduce delays to administration of thrombolysis to within 60 min of call for help are required, including consideration of pre-hospital treatment.

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

OBJECTIVE: This longitudinal study was designed to assess the effect of an educational training package for primary health care teams in accident prevention for older people, with reference to the incidence of accidents and their associated economic consequence. METHODS: Nineteen general practices in the West Midlands serving a population of 138 397 were allocated randomly at the practice level either to receive training or continue normal practice. Study data was collated from the initial telephone call, reporting an accident, to the surgery, advice/treatment given at the practice and/or the community, casualty, inpatient care, written correspondence to the patient's GP and any subsequent follow-up visits for accidents to people aged 65 years or older. RESULTS: One thousand, six hundred and sixty-six (8.2%) patients aged 65 years or older registered with the participating practices experienced one accident or more, costing the NHS pound 1.4 million. Extrapolated nationally, annual costs to the NHS for accidents to older people amount to pound 568 million. The educational package had no significant impact on the incidence of accidents. A paucity of general safety advice was given [48 (1.8%) occasions]. CONCLUSIONS: Budgets are being eroded and patients are suffering unnecessarily due to lack of accident prevention advice. This should be considered a priority within the primary health care team. Educational packages alone do not appear to be a cost-effective approach to accident prevention in primary care.