Shared decision-making in back pain consultations: an illusion or reality?

PURPOSE: Amid a political agenda for patient-centred healthcare, shared decision-making is reported to substantially improve patient experience, adherence to treatment and health outcomes. However, observational studies have shown that shared decision-making is rarely implemented in practice. The purpose of this study was to measure the prevalence of shared decision-making in clinical encounters involving physiotherapists and patients with back pain. METHOD: Eighty outpatient encounters (comprising 40 h of data) were observed audio-recorded, transcribed verbatim and analysed using the 12-item OPTION scale. The higher the score, the greater is the shared decision-making competency of the clinicians. RESULTS: The mean OPTION score was 24.0% (range 10.4-43.8%). CONCLUSION: Shared decision-making was under-developed in the observed back pain consultations. Clinicians' strong desire to treat acted as a barrier to shared decision-making and further work should focus on when and how it can be implemented.

Laboratory markers predict bone loss in Crohn's disease: relationship to blood mononuclear cell function and nutritional status.

BACKGROUND: Crohn's disease is associated with reduced bone density. The power of simple markers of systemic inflammation to identify higher rates of bone loss, in Crohn's disease, is uncertain. This relationship and the role of circulating (peripheral blood) mononuclear cells were investigated in a case-control study. METHODS: Urinary deoxypyridinoline/creatinine and serum osteocalcin concentrations were compared in male and premenopausal females with "active" Crohn's disease (C-reactive protein > or = 10 and/or erythrocyte sedimentation rate > or = 20) (n = 22) and controls with "quiescent" Crohn's disease (C-reactive protein < 10 and erythrocyte sedimentation rate < 20) (n = 21). No patients were receiving corticosteroid therapy. Production of tumour necrosis factor-alpha, interferon-gamma and prostaglandin E(2) by peripheral blood mononuclear cells were measured. RESULTS: Active Crohn's disease was associated with a higher deoxypyridinoline/creatinine (P = 0.02) and deoxypyridinoline/creatinine:osteocalcin ratio (P =0.01) compared with quiescent Crohn's disease, but similar osteocalcin (P = 0.24). These were not explained by vitamin D status, dietary intake or nutritional status. However, production of interferon-gamma by concanavalin A-stimulated peripheral blood mononuclear cells was lower in active Crohn's disease (P = 0.02) and correlated negatively with the deoxypyridinoline/creatinine:osteocalcin ratio (r = -0.40, P = 0.004). CONCLUSION: In Crohn's disease, raised C-reactive protein and erythrocyte sedimentation rate may indicate higher rates of bone loss and, if persistent, the need to assess bone mass even where disease symptoms are mild. This may be partly explained by altered production of interferon-gamma by peripheral blood mononuclear cells.

Essential fatty acid status in paediatric Crohn's disease: relationship with disease activity and nutritional status.

BACKGROUND: Active paediatric Crohn's disease is associated with nutritional deficiencies and altered nutrient intake. The availability of essential fatty acids (linoleic and alpha-linolenic acids) or their derivatives (arachidonic and eicosapentaenoic acids) may alter in plasma and cell membrane phospholipid in protein-energy malnutrition in children and in Crohn's disease in adults. AIM: To investigate the relationship of fatty acid phospholipid profiles with disease activity and nutritional status in paediatric Crohn's disease. METHODS: The fatty acid (proportionate) composition of plasma and erythrocyte phosphatidylcholine was determined in 30 patients (10.3-17.0 years) stratified into active and quiescent Crohn's disease (paediatric Crohn's disease activity index) and high and low body mass (body mass index centile). RESULTS: In plasma phosphatidylcholine, active disease activity was associated with a lower level of alpha-linolenic acid compared with that in quiescent disease (P < 0.05). A body mass index below the 50th centile was associated with active Crohn's disease, low linoleic and alpha-linolenic acids and high arachidonic acid (P < 0.05) in plasma phosphatidylcholine, and low alpha-linolenic acid in erythrocyte phosphatidylcholine. These findings could not be explained through differences in habitual dietary fat intake. CONCLUSION: In paediatric Crohn's disease, a low body mass index centile and high disease activity are associated with altered profiles of essential fatty acids and their derivatives, which may reflect altered metabolic demand.

Clinical outcome and bromodeoxyuridine derived proliferation indices in 100 colonic and rectal carcinomas.

AIM: In vivo labelling of human colonic and rectal tumours with bromodeoxyuridine (BrdUrd) and analysis by flow cytometry (FCM) allows the labelling index (LI), S phase duration (Ts) and the potential doubling time (Tpot) of the tumour to be estimated in vivo. METHODS: The data for a series of 100 tumour specimens from 97 patients with colonic and rectal carcinoma was reported in 1991, and correlated with Dukes' classification and histological differentiation. RESULTS: This study reports the eventual outcome of the 97 patients after 12 years. There were no significant associations between proliferation data of the index tumours and patient outcome. No adverse events were identified which could be attributed to the use of the halogenated pyrimidine label in vivo. CONCLUSION: Dynamic cell proliferation indices provide detailed information on the cell kinetics of colorectal tumours but these do not correlate with clinical prognostic markers or outcome.

The flow cytometric analysis of total p53 protein content and proliferation indices in colorectal cancer, in relation to clinical outcome.

This study was undertaken to assess the value of flow cytometric measurements of total p53 protein content and proliferation indices derived from in vivo halogenated pyrimidine labelling. Two series of colorectal cancer specimens were studied for which clinical outcome data were recorded. A series of 84 archival, ethanol-fixed, bromodeoxyuridine (BrdUrd) labelled colorectal tumours were analysed by flow cytometry for their total and cell cycle phase p53 protein content using the pAb1801 monoclonal antibody. A second series of 33 freshly obtained tumours was used for assay evaluation and for comparison with the archival material. In the archival series (n=84), the median p53-pAb1801 LI was 81.9% (range: 11.1-99.8%). In only three tumours could significant amounts of p53 protein not be detected. The median phase specific p53-pAb1801 LI in G0/G1 was 71.6%, in S was 95.5%, and in G2/M was 98.5%. In the series of fresh tumours (n=33), the median p53-pAb1801 labelling index (LI) was 94.6% (range: 17.9-99.9%). Only two tumours failed to express significant amounts of p53 protein. There was no significant difference in the generally high levels of p53 protein content between the fresh and archival series. Life-table analysis of the patients in the archival series failed to demonstrate a statistical difference in life expectancy in relation to Dukes' stage when tumours were stratified by the median total p53 labelling index. In this study, p53 content and proliferative indices measured by flow cytometry do not have independent predictive value over Dukes' grading in determining the outcome of colorectal cancer. Flow cytometry is confirmed as a practical tool for multi-parametric and cell cycle analysis of oncoprotein expression in human tumour biopsies.

Clinical outcome and bromodeoxyuridine-derived proliferation indices in 75 invasive breast carcinomas.

INTRODUCTION: In vivo labelling of human breast tumours with bromodeoxyuridine (BrdUrd) and analysis by flow cytometry (FCM) allows the labelling index (LI), S phase duration (t(s)) and the potential doubling time (t(pot)) of the tumour to be estimated. METHODS: The data for a series of tumour specimens from 75 patients with invasive breast carcinoma were reported in 1991, correlated with their lymph-node status, tumour size and grade. RESULTS AND CONCLUSIONS: This study reports the follow-up data over 10 years in respect of time to recurrence and death from the disease. There were no significant correlations between proliferation data and outcome measures. No adverse events were identified which could be attributed to the use of the halogenated pyrimidine label in vivo.

The Poole Diabetes Study: how many cases of Type 2 diabetes are diagnosed each year during normal health care in a defined community?

UNLABELLED: We have investigated the incidence of newly diagnosed Type 2 diabetes in the Poole area and extrapolated it to the rest of the UK. METHODS: this prospective observational study used a surveillance programme in primary and secondary care. We identified all cases of newly diagnosed Type 2 diabetes mellitus occurring from 1st May 1996 to 30th June 1998 through the normal health care process without any active screening in 186889 people registered with 24 primary care practices in the Poole area. RESULTS: the 1996 prevalence of diagnosed Type 2 diabetes in this population was 1.59 (95% CI 1.53-1.65%)%. During the first 24 months of the study, 706 new cases of Type 2 diabetes mellitus, 382 men and 324 women, were identified. The crude annual incidence of newly diagnosed Type 2 diabetes, thus was 1.93/1000 (95% CI 1.73-2.13%) and age/sex adjusted incidence was 1.67/1000 (95% CI 1.49-1.84%). The age-adjusted incidence was higher in men, 1.86/1000 (95% CI 1.60-2.13), than in women, 1.48/1000 (95% CI 1.25-1.71%), relative risk 1.26 (95% CI 0.997-1.527%), but this difference did not reach statistical significance. Mean HbA1c at diagnosis was 10.8 (S.D. 2.9%)%. Men were younger at diagnosis than women (mean age, 62.9 vs. 65.9%, P<0.01). CONCLUSION: in UK, prior to the change in the WHO diagnostic criteria for diabetes, we estimate that over 98000 new cases of Type 2 diabetes were diagnosed each year.

The significance of involved tumour bed biopsy following wide local excision of breast cancer.

AIM: Following wide local excision of breast cancer approximately 25% of patients have residual disease in the tumour bed. The aim of this study was to determine whether positive bed biopsy correlated with either local recurrence or overall survival. METHOD: Following wide excision bed biopsies were taken at four separate sites from the tumour bed. Histopathological assessment of the bed biopsies was made and compared to features within the primary tumour. Patients were followed-up over a median period of 6.17 years and local recurrence and survival data documented. RESULTS: Two hundred and sixty-eight patients were included in the study and 63 had positive bed biopsies. In all, 85 patients had a recurrence of breast cancer and 69 died. Kaplan-Meier plots showed no evidence of a difference in survival between bed biopsy positive and negative patients. Bed biopsy positive patients were at greater risk of local recurrence. CONCLUSIONS: These findings suggest that positive bed biopsy is associated with an increase in local recurrence rates but has no effect on overall survival following wide excision of breast cancer.

Lung function measurement in general practice: a comparison of the Escort spirometer with the Micromed turbine spirometer and the mini-Wright peak flow meter.

It is important that new types of spirometer for widespread clinical use are pragmatically evaluated in primary care. This study compared measurements taken by a new portable Fleisch pneumotachograph spirometer (known as the Escort) with those of the commonly used mini-Wright peak flow meter and the Micromed Pocket turbine spirometer. A pragmatic study was conducted in two phases during routine surgeries at Aldermoor Health Centre, Southampton. Phase I compared the new spirometer with the mini-Wright peak flow meter and Phase 2 compared the new spirometer and the turbine spirometer. One hundred patients aged 5-88 years (56 patients with a history of chronic respiratory complaints and 44 patients without) entered Phase 1, and 100 patients aged 6-82 years (62 patients with a history of chronic respiratory complaints and 38 patients without) entered Phase 2. Each patient contributed only once to each phase, but some entered both phases on separate occasions. Ninety-five percent limits of agreement (mean +/- SD) were wide for all comparisons. Graphical plots revealed trends towards higher Escort values as mean values rose compared with both mini-Wright and turbine readings for peak expiratory flow rate and forced expiratory volume in one second. Possible over-reading of peak expiratory flow rate with the mini-Wright meter at low mean values was also seen. Readings taken with these different types of meter cannot be interchanged with confidence in clinical practice. The clinical significance of the theoretically more accurate measures of lung function produced with the new meter, and indeed of spirometry itself, needs further investigation.

A bibliography of the statistical analysis of vaginal bleeding patterns.

An annotated bibliography of 123 references and review papers on graphical description and statistical analysis of vaginal bleeding patterns is presented.

Proactive, nurse-run asthma care in general practice reduces asthma morbidity: scientific fact or medical assumption?

Nurse-run asthma care in general practice in the United Kingdom has become extremely common, particularly since the introduction of the 1990 contract for general practitioners, but there have been few controlled trials of the clinical effectiveness of this approach to asthma care. A study attempted to compare the outcome of asthma care over three years in two similar practices when one practice provided proactive, nurse-run care and the second continued with a traditional (reactive) approach, and to examine the process of care when such changes were introduced. Despite the investment of considerable resources, statistically significant differences could not be shown between the two practices using a comprehensive variety of outcome measures. This could be interpreted as meaning that nurse-run asthma care may be ineffective, but the negative outcome is much more likely to reflect difficulties in the manner in which the intervention practice sought to develop its service and in the research process. There were extensive methodological problems leading to a potential type 2 error. A randomized controlled trial of nurse-run asthma care would now be difficult to conduct, and so it may be necessary to accept nurse-run asthma care without definitive proof of its clinical effectiveness.

Audit of the effect of a nurse run asthma clinic on workload and patient morbidity in a general practice.

The aim of this study was to assess the effect of a nurse run asthma clinic on practice workload and the morbidity of patients in a four partner general practice. One hundred and fifteen asthmatic patients were studied and comparisons were made between the 12 months prior to the introduction of the clinic and the first 12 months after the clinic started. Morbidity was measured in terms of: the number of courses of oral steroids, the number of emergency salbutamol nebulizations, and the number of days lost from work or school. The number of consultations with the general practitioners were recorded. The repeat prescribing register was also monitored throughout the study to examine the effect of the clinic on prescribing in the practice. Consultations with general practitioners fell from a total of 818 to 414 during the study period (P less than 0.001). This was offset by 496 consultations with the nurse in the first 12 months of the clinic. As a result of attending the nurse clinic significant reductions (P less than 0.01) were found in the patients' requirements for courses of oral steroids, acute nebulizations and days lost from work or school. The results for the 46 children were similar to those for the 69 adults, confirming that the asthma clinic was effective for all ages. The clinic coincided with an increase in the number of patients receiving regular bronchodilator therapy and prophylactic medication. Eighty per cent of patients had their medication modified as a result of attending the clinic. The cost of prescribing remained remarkably stable.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison between primary care physiotherapy education/advice clinics and traditional hospital based physiotherapy treatment: a randomized trial.

BACKGROUND: Studies have shown that patients prefer to received physiotherapy services in the primary care setting, but none has made direct comparisons between hospital and primary care based physiotherapy. AIM: This pragmatic randomized trial set out to compare general-practice-based physiotherapy education and advice clinics with traditional physiotherapy treatment in an acute hospital setting. METHOD: The study involved 130 patients referred to physiotherapy services by 43 general practitioners over a one-year period. Patients were included in the study if they were at work, independent in all activities of daily living and would have routinely been referred to the hospital physiotherapy department for treatment. Patients were randomly allocated to one of two intervention groups: general practice education/advice, or treatment and education/advice at the local hospital. Patients completed a questionnaire prior to their first physiotherapy appointment and again 6 weeks later. RESULTS: A disappointing number of patients failed to attend either the first or subsequent appointments. The post-intervention scores revealed improvements in patients' problems, with the advice group exhibiting a slightly better outcome than the hospital group, as measured by the Nottingham health profile, the anxiety component of the hospital anxiety and depression rating scale, pain and problem size visual analogue scales, and measures of patient satisfaction. Advice group patients also had less attendances than the hospital treatment group. The general practitioners surveyed commented favourably on the advice clinics. CONCLUSIONS: The findings of this study justify the concept of general-practice-based physiotherapy education and advice clinics.

To what extent are the needs of severely disabled people met by community rehabilitation services? A follow-up study.

PURPOSE: To evaluate which needs of disabled people would be met over a one year follow-up period and to examine which factors would be predictive of identifying those people who had more needs met from those who had fewer needs met. METHOD: A follow-up study of a cohort of community dwelling disabled people (aged 16-65) from two NHS Health Districts in Southern England with contrasting patterns of rehabilitation provision, who had participated in a cross-sectional interview study one year previously which had assessed their met and unmet needs. The Southampton Needs Assessment Questionnaire was used to examine needs. Disability was evaluated with the OPCS Disability and Severity Scales and perceived health status with the SF-36. RESULTS: Participation rate at follow-up was 92 %. Of the 300 baseline unmet needs reported by 69 of the 77 participants 33% had been met at follow-up. People whose disability had increased more and/or whose mental health status had improved more had greater percentages of their baseline needs met. There was a non-significant trend for smaller percentages of baseline needs to be met in Basingstoke than in Southampton. CONCLUSIONS: At ground level, disabled people's views were taken into account, to some extent, in the provision of rehabilitation services. This input should be made at a higher level, in the overall shaping of services.

Met and unmet needs reported by severely disabled people in southern England.

PURPOSE: To examine the met and unmet needs for rehabilitation of disabled people living in the community in Southern England. METHOD: A cross sectional interview study of people with a primary physical disability, aged 1665. Disabled people were randomly selected from two existing disability registers, which comprised disabled people who had been identified by community rehabilitation services as being in need of regular surveillance by formal assessment of their care needs. A new semi-structured needs assessment questionnaire was developed and validated for the study (the Southampton Needs Assessment Questionnaire, SNAQ). Level of disability was examined with the OPCS Disability and Severity Scales. RESULTS: Ninety three disabled people participated. Their median (IQR) OPCS score was 8 (6-10). Participants reported a median (IQR) of three unmet needs (2-7). The most prevalent unmet needs were for adaptations, equipment, physiotherapy and wheelchairs, rather than unmet needs for intellectual and social fulfilment. CONCLUSIONS: Disabled people who were already in touch with community rehabilitation services continued to express unmet needs for further services. Meeting the more basic needs relating to people's housing, equipment, physiotherapy and wheelchairs may enable them to be more independent and fulfilled in other areas of their lives.

Breast size and prognosis in early breast cancer.

The influence of breast size on the prognosis of 196 patients with early breast cancer diagnosed in the period 1984-1985 was studied. Breast size was based on the volume from mammography. This method was validated against the volume of the mastectomy specimen determined by water displacement in 18 patients and found to be accurate (r = 0.93, P < 0.01). The median breast volume was 833.5 cm3 (interquartile range 522.8-1153.3 cm3). Breast size was significantly associated independently with age (Spearman's rank r = 0.24. P = 0.001), menstrual status (z = -4.81, P < 0.001), body weight (Spearman's rank r = 0.61, P < 0.001), T stage (z = -1.91, P = 0.05) but not N stage (z = -1.64, P = 0.10) or hormone receptor status (z = -0.80, P = 0.42). In an analysis of breast size and other known prognostic factors, based upon Cox's proportional hazards regression, N stage was the only significant factor for both breast cancer survival and disease-free survival. Even though women with larger tumours at presentation had larger breasts, breast size was not a significant prognostic factor in early breast cancer.

Double-blind, placebo-controlled, randomized clinical trial of homoeopathic arnica C30 for pain and infection after total abdominal hysterectomy.

Homoeopathic potencies of arnica have been used for many years to aid postoperative recovery. The effects of arnica C30 on pain and postoperative recovery after total abdominal hysterectomy were evaluated in a double-blind, randomized, controlled study. Of 93 women entered into the study, 20 did not complete protocol treatment: nine were excluded because they failed to comply with the protocol, nine had their operations cancelled or changed within 24 h and two had to be withdrawn because of the recurrence of previously chronic painful conditions. Those who did not complete protocol treatment were equally divided between the arnica (nine patients) and placebo groups (11 patients). 73 patients completed the study, of whom 35 received placebo and 38 received arnica C30. The placebo group had a greater median age and the arnica group had slightly longer operations; nevertheless, no significant difference between the two groups could be demonstrated. We conclude that arnica in homoeopathic potency had no effect on postoperative recovery in the context of our study.

The impact of the first 3 years of breast cancer screening on the overall presentation of breast cancer.

We have assessed the effect of the first round of the Breast Cancer Screening Programme on the presentation of breast cancer in the Southampton Health District with respect to number of cases and pathological characteristics. A retrospective comparative survey of the presentation of breast cancer in the 3 years prior to breast cancer screening (1985-1988) with the presentation of breast cancer during the prevalent round of breast cancer screening (1988-1991) was performed. During the period of study 1536 cases of breast cancer presented. Six hundred and sixty presented in the years prior to screening and 864 during the first round of screening. All patients lived within the Southampton Health District. The study was designed to assess the changes in breast cancer presentation with regard to age, pathological characteristics, and treatment. Even allowing for the increases in the local population there was a significant increase in the number of cases of breast cancer diagnosed (chi 2 = 23.7, df = 1, P < 0.001). The majority of this increase was in the 50-64 age group. There was also a significant shift towards an earlier stage at diagnosis and a significant reduction in tumour size when all cases were included (mean 26 mm versus 34 mm P < 0.001). Screening also created the opportunity for less invasive treatment. Consequently there was a rise in the number of excisions by localization biopsy from 1% to 13% during the screening period. In conclusion, the National Breast Cancer Screening Programme (NBCSP) has had a significant impact on the presentation of breast cancer.(ABSTRACT TRUNCATED AT 250 WORDS)

Needs of carers of severely disabled people: are they identified and met adequately?

OBJECTIVE: To examine the unmet needs of informal carers of community dwelling disabled people and to compare their perspectives to those of disabled people and nominated professionals. It was hypothesised that a poor recognition of carers' needs could have implications for carers' well- being and thus their ability to maintain their caring role. Need was defined as a service or a resource that would confer a health or rehabilitation gain. DESIGN: Face to face interviews with carers and disabled participants, telephone interviews with professionals (Southern England). Disabled participants had been selected randomly from two disability registers. MAIN OUTCOME MEASURES: The Southampton Needs Assessment Questionnaire (carers version), SF-36 (carers' health status). RESULTS: Carers experienced similar health status to people in the general population. The most frequently carer-reported unmet needs were for short breaks, domestic help and respite care. Carers who had reported unmet need for short breaks had significantly poorer levels of mental health and vitality (SF-36) than carers who had not reported this. Similar numbers of unmet carers' needs were reported by disabled participants, professionals and carers themselves. In terms of type of unmet needs, poor concordance between carers and disabled participants occurred in 52% of cases: carers reported more unmet needs than disabled participants for short breaks and domestic help. Poor concordance scores between carers and professionals occurred in 59% of cases: carers reported more unmet needs for short breaks than professionals and professionals reported more unmet needs for formal respite care. CONCLUSION: In line with recent legislation, carers' needs must be independently addressed and services, especially for flexible community support such as short break services, must be developed specifically to meet the needs of carers. Further research is warranted to evaluate whether recent legislation for carers has any effect on carers' well-being and ability to cope with their caring role.

Measuring peak expiratory flow in general practice: comparison of mini Wright peak flow meter and turbine spirometer.

OBJECTIVE: To compare measurements of the peak expiratory flow rate taken by the mini Wright peak flow meter and the turbine spirometer. DESIGN: Pragmatic study with randomised order of use of recording instruments. Phase 1 compared a peak expiratory flow type expiration recorded by the mini Wright peak flow meter with an expiration to forced vital capacity recorded by the turbine spirometer. Phase 2 compared peak expiratory flow type expirations recorded by both meters. Reproducibility was assessed separately. SETTING: Routine surgeries at Aldermoor Health Centre, Southampton. SUBJECTS: 212 Patients aged 4 to 78 presenting with asthma or obstructive airways disease. Each patient contributed only once to each phase (105 in phase 1, 107 in phase 2), but some entered both phases on separate occasions. Reproducibility was tested on a further 31 patients. MAIN OUTCOME MEASURE: 95% Limits of agreement between measurements on the two meters. RESULTS: 208 (98%) Of the readings taken by the mini Wright meter were higher than the corresponding readings taken by the turbine spirometer, but the 95% limits of agreement (mean difference (2 SD] were wide (1 to 173 l/min). Differences due to errors in reproducibility were not sufficient to predict this level of disagreement. Analysis by age, sex, order of use, and the type of expiration did not detect any significant differences. CONCLUSIONS: The two methods of measuring peak expiratory flow rate were not comparable. The mini Wright meter is likely to remain the preferred instrument in general practice.