Does post-caesarean dyspareunia reflect sexual malfunction, pelvic floor and perineal dysfunction?

The aim was to define post-caesarean dyspareunia as a sexual and pelvic-perineal symptom. Post-caesarean (80 elective, 104 emergency) and 100 vaginally delivered primiparae had domiciliary interviews at 10 months postpartum. A total of 50 (28% and 27%) post-caesarean and 46 (46%) vaginally delivered, reported dyspareunia. Severely impaired general sexual health occurred in 82 (24% elective, 25% emergency, 35% vaginally delivered) as category 3 (dyspareunia with sexual symptoms) and 27 (10% elective, 7% emergency, 12% vaginally delivered) as category 4 (reduced frequency < 6). The risk of dyspareunia (RR 1.14, CI 0.73, 1.77) or impaired general sexual health (RR 0.93, CI 0.32, 2.74) was similar among those with or without perineal trauma. Both caesarean and perineal scars were associated with sexual malfunction. Primiparae with new incontinence had a lower risk of dyspareunia than impaired general sexual health. Awareness of the associations of post-caesarean dyspareunia and impaired general sexual health with incontinence would facilitate appropriate obstetric decision-making. Further research is indicated.

Screening versus routine practice in detection of atrial fibrillation in patients aged 65 or over: cluster randomised controlled trial.

OBJECTIVES: To assess whether screening improves the detection of atrial fibrillation (cluster randomisation) and to compare systematic and opportunistic screening. DESIGN: Multicentred cluster randomised controlled trial, with subsidiary trial embedded within the intervention arm. SETTING: 50 primary care centres in England, with further individual randomisation of patients in the intervention practices. PARTICIPANTS: 14,802 patients aged 65 or over in 25 intervention and 25 control practices. INTERVENTIONS: Patients in intervention practices were randomly allocated to systematic screening (invitation for electrocardiography) or opportunistic screening (pulse taking and invitation for electrocardiography if the pulse was irregular). Screening took place over 12 months in each practice from October 2001 to February 2003. No active screening took place in control practices. MAIN OUTCOME MEASURE: Newly identified atrial fibrillation. RESULTS: The detection rate of new cases of atrial fibrillation was 1.63% a year in the intervention practices and 1.04% in control practices (difference 0.59%, 95% confidence interval 0.20% to 0.98%). Systematic and opportunistic screening detected similar numbers of new cases (1.62% v 1.64%, difference 0.02%, -0.5% to 0.5%). CONCLUSION: Active screening for atrial fibrillation detects additional cases over current practice. The preferred method of screening in patients aged 65 or over in primary care is opportunistic pulse taking with follow-up electrocardiography. TRIAL REGISTRATION: Current Controlled Trials ISRCTN19633732 [controlled-trials.com].

Evaluation by dental students of a communication skills course using professional role-players in a UK school of dentistry.

This paper reports student (n = 180) feedback on the role-play teaching methodology used in behavioural sciences teaching at The School of Dentistry in Birmingham (UK). The feedback received on this well-established (since 1995) educational programme was collected via questionnaire (100% response rate), requiring Likert scale and free text responses. Generally students reported that they had enjoyed and valued the session. Over two-thirds (69.7%) of students rated the role-players as 'very real' and over three-quarters (78.9%) rated their feedback as 'very fair'. The data collected from this study will inform future curriculum development. Student feedback was very positive and demonstrated that the cohort (86% of all students studying in years 1, 2 and 3) found the use of professional role-players involved in behavioural sciences teaching to be both acceptable and valuable.

Patterns of child-bearing behaviour amongst female hospital doctors and GPs.

BACKGROUND: The number of females entering and graduating from medical school is currently increasing and, as a result, the problems they face if they wish to work as doctors and have a family are becoming more apparent. METHODS: A questionnaire study of 105 female GPs and 98 female hospital doctors was carried out in Birmingham, UK, to determine doctors' experiences and views of child-bearing whilst working as a doctor. RESULTS: Of the GP responders, 81% had children compared with 49% of hospital doctors. GPs were shown to work fewer hours than hospital doctors. Problems were identified relating to the everyday difficulties faced whilst working and raising a family. CONCLUSIONS: The results highlight the need to address the difficulties faced by females pursuing this demanding career.

First year medical students' perceptions and use of complementary and alternative medicine.

OBJECTIVES: To explore First Year medical students' rating of CAM therapies following a core teaching session. To determine the influence of student gender and previous experience of CAM and therapist/teacher gender and professional background on ratings. DESIGN: Survey; self-administered questionnaire following a teaching session. SETTING: First Year medical students Behavioural Science module CAM teaching session, University of Birmingham Medical School, UK. RESULTS: One hundred and fifty (71.0%) students completed a questionnaire. 56 (37.3%) students had previous experience of CAM, particularly where a family member already used it (P = < 0.001). Aromatherapy (29/56, 51.7%) and homoeopathy (17/56, 30.3%) were the most common therapies listed. Females were more likely than males to have used aromatherapy (P = 0.038) or reflexology (P = 0.007). Students using aromatherapy were more likely to have self treated (P = 0.01). Of 82 episodes of CAM use, most (67/82,81.7%) were stated to have been helpful. Hypnotherapy (P = 0.003) and aromatherapy (P = 0.015) were most helpful. Following the teaching session students rated therapies observed on a 10 point scale, 1 (extremely sceptical) to 10 (totally convinced). All were rated above the mid-point; highest rated was chiropractic (median score = 8), lowest, reflexology (median score = 5.06). Students who had previously used hypnotherapy gave it higher scores (P = 0.018). Students whose family used CAM were more likely to rate aromatherapy highly (P = .027) and to give homoeopathy a low score (P = 0.003). CONCLUSIONS: A short CAM teaching session early in the curriculum can inform students about the relationship of CAM with current medical practice. It can be used as a 'taster' prior to selection of Special Study Module choices in later years.

A randomised controlled trial of patient self management of oral anticoagulation treatment compared with primary care management.

BACKGROUND: The increase in numbers of patients receiving warfarin treatment has led to the development of alternative models of service delivery for oral anticoagulant monitoring. Patient self management for oral anticoagulation is a model new to the UK. This randomised trial was the first to compare routine primary care management of oral anticoagulation with patient self management. AIM: To test whether patient self management is as safe, in terms of clinical effectiveness, as primary care management within the UK, as assessed by therapeutic international normalised ratio (INR) control. METHOD: Patients receiving warfarin from six general practices who satisfied study entry criteria were eligible to enter the study. Eligible patients were randomised to either intervention (patient self management) or control (routine primary care management) for six months. The intervention comprised two training sessions of one to two hours duration. Patients were allowed to undertake patient self management on successful completion of training. INR testing was undertaken using a Coaguchek device and regular internal/external quality control tests were performed. Patients were advised to perform INR tests every two weeks, or weekly if a dose adjustment was made. Dosage adjustment was undertaken using a simple dosing algorithm. RESULTS: Seventy eight of 206 (38%) patients were eligible for inclusion and, of these, 35 (45%) declined involvement or withdrew from the study. Altogether, 23 intervention and 26 control patients entered the study. There were no significant differences in INR control (per cent time in range: intervention, 74%; control, 77%). There were no serious adverse events in the intervention group, with one fatal retroperitoneal haemorrhage in the control group. Costs of patient self management were significantly greater than for routine care (pound 90 v pound 425/patient/year). CONCLUSION: These are the first UK data to demonstrate that patient self management is as safe as primary care management for a selected population. Further studies are needed to elucidate whether this model of care is suitable for a larger population.

Degrees of aversion shown by rats and mice to different concentrations of inhalational anaesthetics.

The distress associated with the induction of anaesthesia with halothane, isoflurane, enflurane and carbon dioxide was investigated in rats and mice by measuring the level of aversion they displayed on exposure to low, medium and high concentrations of these agents. The animals were exposed to each agent in a test chamber containing air or gas mixtures, which they were able to enter and leave at will, and the level of aversion was assessed in terms of the initial withdrawal and total dwelling times in the chamber. Comparisons between the anaesthetic and air-control treatments indicated that concentrations of the agents recommended for the rapid and efficient induction of anaesthesia were associated with some degree of aversion. Carbon dioxide was by far the most aversive gas for both rats and mice, with the least aversive being halothane for rats, and halothane and enflurane for mice. With all the anaesthetics, the level of aversion increased as the concentration increased.

Does the Birmingham model of oral anticoagulation management in primary care work outside trial conditions?

The effectiveness of the Birmingham model of primary care oral anticoagulation management has previously been demonstrated within a randomised controlled trial. The aim of this study was to assess the effectiveness of the Birmingham model in routine care. All patients from 12 primary care centres attending either practice-based or hospital-based anticoagulation clinics were retrospectively followed up from October 1996 to March 1998. Outcome measures were therapeutic International Normalised Ratio (INR) control, haemorrhagic and thrombotic episodes, and recall frequency; 452 patients who had two or more INR results during the follow-up period were investigated. There were no significant differences between practice-based and hospital-based populations in terms of the percentage time in range, (69% and 64% respectively). The proportion of tests in range was significantly higher in the practice-based group (61% practice-based, 57% hospital-based; P = 0.015). There was no difference between the two populations in terms of mean follow-up time (36 days in each group). There were no significant differences between groups for the number of clinical outcomes per patient. This study confirmed that, within these practices, oral anticoagulation management is safe and effective using the Birmingham model.

European survey of primary care physician perceptions on heart failure diagnosis and management (Euro-HF).

AIMS: To survey a random sample of primary care physicians across six European countries regarding their perceptions of diagnostic and prescribing issues in heart failure, and to consider factors that might be associated with physician under-performance. METHODS AND RESULTS: Qualitative, postal questionnaire-based, validated survey in the native tongue of a random sample of 200 primary care physicians in each of five European countries (France, Germany, Italy, The Netherlands and Spain) and of 250 U.K. primary care physicians. Respondents provided: details of practice characteristics; the usual way a diagnosis of heart failure was established; access to investigations; names of drugs prescribed in heart failure, with estimates of the proportion of patients supplied with particular classes; and physician attitudes regarding the evidence base (in terms of benefits and risks) for treatments used. Outcomes were physician perceptions and attitudes about heart failure diagnosis and treatment. Adjusted response rates varied from 17% (France) to 56% (Britain). Primary care physicians underestimate the prevalence of heart failure. Most patients are diagnosed on symptoms and signs alone, with only 32% having further investigations or referral. Although most primary care physicians stated they prescribe ACE inhibitors in heart failure, this was for only 47-62% of patients, and at doses below those identified as effective in trials. Most prescribing doctors (91%) believe there is strong evidence of reduced mortality in heart failure patients using ACE inhibitors, but 51% also consider ACE inhibitors have substantial risks with their use. CONCLUSION: Limitations of the data include the general problem of questionnaires, whether responses accord with actual clinical practice, and, specific to these data, the low response rate in some countries (although the study does provide information from nearly 300 randomly selected primary care physicians across Europe). New preliminary insights include exposition of the 'low tech' approach to heart failure diagnosis across Europe: doctors report the use of symptoms and signs alone; the lack of direct (open) access to objective investigations, such as echocardiography, which almost guarantees that misdiagnoses will occur; and the under-utilization and under-dosing with ACE inhibitors. The main factor influencing under-use would appear to be the exaggerated perceptions of treatment risk amongst primary care physicians that dominate the widespread and accurate knowledge of treatment benefits.

Oral anticoagulation management in primary care with the use of computerized decision support and near-patient testing: a randomized, controlled trial.

BACKGROUND: There is increased pressure on primary care physicians to monitor oral anticoagulation. OBJECTIVE: To test the null hypothesis that oral anticoagulation care can be provided at least as well in primary care through a nurse-led clinic, involving near-patient testing and computerized decision support software, compared with routine hospital management based on a variety of clinical outcome measures. METHODS: A randomized, controlled trial in 12 primary care practices in Birmingham, England (9 intervention and 3 control). Two control populations were used: patients individually randomly allocated as controls in the intervention practices (intrapractice controls) and all patients in control practices (interpractice controls). Intervention practices' patients were randomized to the intervention (practice-based anticoagulation clinic) or control (hospital clinic) group. The main outcome measure was therapeutic control of the international normalized ratio. RESULTS: Three hundred sixty-seven patients were recruited (122 intervention patients, 102 intrapractice control patients, and 143 interpractice control patients). Standard measures of control of the international normalized ratio (point prevalence) showed no significant difference between the intervention and control groups. Data on proportion of time spent in the international normalized ratio range showed significant improvement for patients in the intervention group (paired t test, P =.008). CONCLUSIONS: Nurse-led anticoagulation clinics can be implemented in novice primary care settings by means of computerized decision support software and near-patient testing. Care given by this model is at least as good as routine hospital follow-up. The model is generalizable to primary health care centers operating in developed health care systems.

A major sporting event does not necessarily mean an increased workload for accident and emergency departments. Euro96 Group of Accident and Emergency Departments.

AIM: To determine whether there were any changes in attendance at accident and emergency departments that could be related to international football matches (Euro96 tournament). METHOD: Fourteen accident and emergency departments (seven adjacent to and seven distant from a Euro96 venue) provided their daily attendance figures for a nine week period: three weeks before, during, and after the tournament. The relation between daily attendance rates and Euro96 football matches was assessed using a generalised linear model and analysis of variance. The model took into account underlying trends in attendance rates including day of the week. RESULTS: The 14 hospitals contributed 172 366 attendances (mean number of daily attendances 195). No association was shown between the number of attendances at accident and emergency departments and the day of the football match, whether the departments were near to or distant from stadia or the occurrence of a home nation match. The only observed independent predictors of variation were day of the week and week of the year. Attendance rates were significantly higher on Sunday and/or Monday; Monday was about 9% busier than the daily average. Increasing attendance was observed over time for 86% of the hospitals. CONCLUSION: Large sports tournaments do not increase the number of patients attending accident and emergency departments. Special measures are not required for major sporting events over and above the capacity of an accident and emergency department to increase its throughput on other days.

A primary care evaluation of three near patient coagulometers.

AIM: To compare the reliability and relative costs of three international normalised ratio (INR) near patient tests. MATERIALS: Protime (ITC Technidyne), Coaguchek (Boehringer Mannheim), and TAS (Diagnostic Testing). METHODS: All patients attending one inner city general practice anticoagulation clinic were asked to participate, with two samples provided by patients not taking warfarin. A 5 ml sample of venous whole blood was taken from each patient and a drop immediately added to the prepared Coaguchek test strip followed by the Protime cuvette. The remainder was added to a citrated bottle. A drop of citrated blood was then placed on the TAS test card and the remainder sent to the reference laboratory for analysis. Parallel INR estimation was performed on the different near patient tests at each weekly anticoagulation clinic from July to December 1997. RESULTS: 19 patients receiving long term warfarin treatment provided 62 INR results. INR results ranged from 0.8-8.2 overall and 1.0-5.7 based on the laboratory method. Taking the laboratory method as the gold standard, 12/62 results were < 2.0 and 2/62 were > 4.5. There were no statistical or clinically significant differences between results from the three systems, although all near patient tests showed slightly higher mean readings than the laboratory, and 19-24% of tests would have resulted in different management decisions based on the machine used in comparison with the laboratory INR value. The cost of the near patient test systems varied substantially. CONCLUSIONS: All three near patient test systems are safe and efficient for producing acceptable and reproducible INR results within the therapeutic range in a primary care setting. All the systems were, however, subject to operator dependent variables at the time of blood letting. Adequate training in capillary blood sampling, specific use of the machines, and quality assurance procedures is therefore essential.