Is a separate clinical pathway for first seizures justified? Appraisal of the first seizure pathway at a tertiary neuroscience centre.

OBJECTIVES: To investigate the clinical characteristics, final diagnosis, investigation results, management, response to anti-seizure medications (ASMs) and clinical outcomes of individuals assessed in a First Seizure service over a 5-year period. METHODS: Retrospective analysis of 772 individuals who were clinically assessed in a dedicated First Seizure service at National Hospital for Neurology & Neurosurgery (NHNN), Queen Square over a 5-year period. RESULTS: 772 individuals were assessed following a suspected or reported first seizure (median age of 54, average age of 39.4, range 16-96). 393 (50.9 %) were ultimately diagnosed with a definite seizure of which 183 (46.5 %) had experienced seizures previously which had not been recognised or diagnosed. 250 (32 %) had vasovagal syncope and 69 (18.2 %) were diagnosed with psychogenic non-epileptic seizures. EEGs in 16.6 % of individuals who had a first unprovoked seizure demonstrated epileptiform discharges, whilst 33.6 % had abnormal MRI findings felt to be clinically relevant. CONCLUSIONS: Seizure mimics represent a significant proportion of attendees to a 'first seizure' service. Improved recognition and more education of this issue could facilitate earlier management of these other diagnostic entities and ensure that only appropriate cases are referred to the first seizure service. Almost half of 'first seizure' cases had previous seizures, highlighting the importance of obtaining this relevant history and in reviewing ASM-naive individuals in a timely manner with the primary aim of preventing further recurrences.

The quality, safety and content of telephone and face-to-face consultations: a comparative study.

INTRODUCTION: Telephone consulting is increasingly used to improve access to care and optimise resources for day-time work. However, there remains a debate about how such consultations differ from face-to-face consultations in terms of content quality and/or safety. To investigate this, a comparison of family doctors' telephone and face-to-face consultations was conducted. METHODS: 106 audio-recordings (from 19 doctors in nine practices) of telephone and face-to-face consultations, stratified at doctor level, were compared using the Roter Interaction Analysis Scale (RIAS) (content measure), the OPTION (observing patient involvement in decision making scale) and a modified scale based on the Royal College of General Practitioners (RCGP) consultation assessment instrument (measuring quality and safety). Patient satisfaction and enablement were measured using validated instruments. The Roter Interaction Analysis Scale scores were compared by multiple linear regression adjusting for covariates; other continuous measures by chi(2) and Student t tests and binary measures as odds ratios. RESULTS: Telephone consultations were shorter (4.6 vs 9.7 min, p<0.001), presented fewer problems (1.2 vs 1.8, p<0.001) and included less data gathering, counselling/advice and rapport building (all p<0.001) than face-to-face consultations. These differences remained significant when consultation length and number of problems were taken into account. Telephone consultations were judged less likely to include sufficient information to exclude important serious illnesses. Patient involvement and satisfaction outcomes were similar in both consultation types. CONCLUSION: Although telephone consultations are convenient and judged satisfactory by patients and doctors, they may compromise patient safety more than face-to-face consultations and further research is required to elucidate this. Telephone consultations may be more suited to follow-up and management of long-term conditions than for in-hours acute management.

Implementation of a national, nurse-led telephone health service in Scotland: assessing the consequences for remote and rural localities.

INTRODUCTION: Internationally, nurse-led models of telephone triage have become commonplace in unscheduled healthcare delivery. Various existing models have had a positive impact on the delivery of healthcare services, often reducing the demand on accident and emergency departments and staff workload 'out of hours'. Our objective was to assess whether a model of centralised nurse telephone triage (NHS 24, introduced in Scotland in 2001) was appropriate for remote and rural areas. In this qualitative study the views and perspectives of health professionals across Scotland are explored. METHODS: Thirty-five participants were purposively selected for interviews during 2005. Two types of interview were conducted: detailed, semi-structured, face-to-face interviews with key stakeholders of NHS 24; and briefer telephone interviews with partners from NHS Boards across Scotland. A constant comparative approach was taken to analysis. Ethical approval for the study was obtained from the Scottish Multi-site Research Ethics Committee. RESULTS: The findings are comparable with other research studies of new service developments in remote and rural health care. The rigidity of the centralised triage model introduced, the need to understand variation of health service delivery, and the importance of utilising local professional knowledge were all key issues affecting performance. CONCLUSION: Remote and rural complexities need to be considered when designing new healthcare services. It is suggested that new health service designs are 'proofed' for remote and rural complexities. This study highlights that a centralised nurse-led telephone triage model was inappropriate for remote and rural Scotland, and may not be appropriate for all geographies and circumstances.

Long term monitoring in refractory epilepsy: the Gowers Unit experience.

INTRODUCTION: Guidelines from the National Institute for Health and Clinical Excellence (NICE) and the International League Against Epilepsy recommend long term EEG monitoring (LTM) in patients for whom seizure or syndrome type is unclear, and in patients for whom it is proving difficult to differentiate between epilepsy and non-epileptic attack disorder (NEAD). The purpose of this study was to evaluate this recommended use of LTM in the setting of an epilepsy tertiary referral unit. METHODS: This study reviewed the case notes of all admissions to the Sir William Gowers Unit at the National Society for Epilepsy in the years 2004 and 2005. A record was made of the type, duration and result of all LTM performed both prior to and during the admission. Pre- and post-admission diagnoses were compared, and patients were divided according to whether LTM had resulted in a change in diagnosis, refinement in diagnosis or no change in diagnosis. The distinction between change and a refinement in the diagnosis was made on the basis of whether or not this alteration resulted in a change in management. RESULTS: 612 patients were admitted during 2004 and 2005, 230 of whom were referred for diagnostic clarification. Of these, LTM was primarily responsible for a change in diagnosis in 133 (58%) and a refinement of diagnosis in 29 (13%). In 65 (29%) patients the diagnosis remained the same after LTM. In those patients in whom there was a change in diagnosis, the most common change was in distinguishing epilepsy from NEAD in 73 (55%) and in distinguishing between focal and generalised epilepsy in 47 (35%). LTM was particularly helpful in differentiating frontal lobe seizures from generalised seizures and non-epileptic attacks. Inpatient ambulatory EEG proved as effective as video telemetry in helping to distinguish between NEAD, focal and generalised epilepsy. DISCUSSION: The study revealed that LTM led to an alteration in the diagnosis of 71% of patients referred to a tertiary centre for diagnostic clarification of possible epilepsy. Although LTM is relatively expensive, time consuming and of limited availability, this needs to be balanced against the considerable financial and social cost of misdiagnosed and uncontrolled seizures. This service evaluation supports the use of performing LTM (either video or ambulatory) in a specialist setting in patients who present diagnostic difficulty.

Rufinamide.

Rufinamide is a new antiepileptic drug that is effective in acute animal seizure models and also in the kindling model of epilepsy with a high protective index. Its mechanism of action is largely unknown; studies suggest an effect at voltage-gated sodium channels, but whether this is its main mode of action remains to be determined. Rufinamide can be administered twice daily and has minimal drug interactions (it does, however, interact with the contraceptive pill). Food markedly increases absorption, which may complicate clinical use. Trials indicate that rufinamide is effective as adjunctive therapy in partial epilepsy and the Lennox-Gastaut syndrome with minimal adverse effects including headache, dizziness and fatigue. In addition, rufinamide has a favorable cognitive side-effect profile. However, it remains uncertain whether rufinamide offers significant advantages over other current antiepileptic drugs, and the results of further clinical trials are awaited.

A comparison of reduction in CT dose through the use of gantry angulations or bismuth shields.

This study investigated the effect of gantry angulation and eye shielding on radiation dose to the eye lens during brain Computed Tomography (CT), and secondly the effectiveness of thyroid and breast bismuth shielding during routine neck and chest CT. An anthropomorphic 'Rando' phantom was scanned at three commonly used gantry angles using this centre's normal adult brain protocol, and for normal adult neck and chest protocols. Bismuth shields were placed over the appropriate organs and dose measured using thermoluminescent dosimeters (TLD). Angling the gantry along the supraorbital meatal plane could reduce the dose by approximately 88% relative to the hard palate and Reid's base line protocols. Bismuth eye shields reduce dose by up to 48% when using either of the first two angles but gave no significant reduction in the supra-orbital plane. Reduction in thyroid dose for neck and chest scans were 55% and 47% respectively, and dose reduction in breast was 23%. We thus conclude that angling the gantry to avoid the orbits is the more effective method of reducing radiation dose to the eyes, with single use bismuth shields to be used where this is not feasible. Thyroid and breast shields should be used where the resultant artefact is not detrimental to image quality.

Developing a standard short questionnaire for the assessment of patient satisfaction with out-of-hours primary care.

BACKGROUND: Governmental reviews of out-of-hours services in England and Scotland have recommended that a standard questionnaire should be used to assess patient satisfaction. This is important because of the rapid introduction of new forms of care. OBJECTIVE: To produce a brief, reliable and valid measure of patient satisfaction for use by a wide variety of providers of out-of-hours primary care. METHODS: The Short Questionnaire for Out-of-Hours care was designed and compared with a longer questionnaire which had been validated and used in earlier research. Questionnaires were sent to 1906 people contacting an out-of-hours GP co-operative. Three versions of the short questionnaire were used with different formats. Analysis compared the response rates, measurement properties, concurrent and construct validity of the short and long questionnaires, and of different versions of the short questionnaire. RESULTS AND CONCLUSIONS: There was no significant difference in the overall response rates obtained from the short or long questionnaires (45.7% versus 41.9%; P = 0.17). The effective response rate of questionnaires from which all satisfaction scales could be calculated was higher for the short questionnaire (43.0% versus 36.4%; P = 0.01). There were no significant differences in response rates or distribution of responses between different versions of the short questionnaire. There was moderate agreement between items on the short questionnaire and corresponding scales on the long questionnaire. Scores using the short questionnaire showed anticipated relationships with the age and sex of patients and with characteristics of how the service was delivered. The SQOC is valid and reliable for routine service use.

Minor illness and injury: factors influencing attendance at a paediatric accident and emergency department.

AIMS: To gather information on children with minor illness or injury presenting to a paediatric accident and emergency (A&E) department and the decision making process leading to their attendance. METHODS: Prospective questionnaire based survey of 465 children selected by systematic sampling from A&E attenders allocated to the lowest triage category. RESULTS: The study population was statistically representative of the total population of A&E attenders. The lower deprivation categories were over represented. Educational attainment, childcare experience, and parental coping skills were important in relation to A&E attendance. More children attended with injury as opposed to illness. There were no significant demographic differences between those children who presented directly to A&E and those who made prior contact with a GP. Just under half the study population had made contact with a general practitioner (GP) before attending A&E. The majority of those children were directly referred to A&E at that point. GPs referred equivalent numbers of children with illness and injury. CONCLUSIONS: Parents and GPs view paediatric A&E departments as an appropriate place to seek treatment for children with minor illness or injury.

A comparative study on attitudes, mental health and job stress amongst GPs participating, or not, in a rural out-of-hours co-operative.

OBJECTIVES: To test the study hypothesis that GPs participating in co-operatives will have more positive attitudes towards co-operatives, better mental health and less stress than GPs using traditional out-of-hours arrangements. METHODS: A comparative questionnaire study was conducted amongst GPs, participating, or not, in an out-of-hours, largely rural, co-operative ('NoWDOC') which had been established one year previously. The general attitudes of GPs towards out-of-hours work were obtained together with responses to the General Health Questionnaire-12 (mental health) and Stress Arousal Checklist (job stress). RESULTS: Eighty-nine of 120 eligible practitioners responded (74%). The mean GHQ scores for GPs in NoWDOC was 10.2 [standard deviation (SD) 3.9] compared to a score of 11.3 (SD 4.5) for those not participating (t = -1.18; P = 0.24). The overall mean stress score for members of NoWDOC was 3.8 (SD 2.6) compared to 3.4 (SD 2.7) for non-NoWDOC (t = 0.59; P = 0.55). The overall mean arousal score for NoWDOC GPs was 5.2 (SD 2.0) compared to 5.5 (SD 2.9) for non-NoWDOC GPs (t = -0.68; P = 0.50). Multiple regression analyses suggested that the independent variables (partnership arrangements, age, working hours and membership of NoWDOC) did not account for any of the variability in the GHQ score but a significant amount of variability in stress and arousal scores. CONCLUSIONS: The anticipated differences in mental health and job stress among participating GPs were not shown. As the new generation of GPs resemble the NoWDOC participants in their preferences for multi-partner practices with limited out-of-hours care provision, clarification of these findings is important.

What does GP out of hours care cost? An analysis of different models of out of hours care in Scotland.

BACKGROUND: The changes to out of hours care provided by General Practitioners have led to wide variation in the types and costs of out of hours care across the country. AIM: To examine the costs of different models of service delivery for GP out of hours organisations. METHODS: This was a prospective cross-sectional survey of eight GP out of hours organisations and samples of their patients. A deputising service, rotas, and various types of GP co-operative across Scotland were surveyed. Information on the quantities of resources used by each organisation was combined with unit costs. Costs incurred by patients and other NHS costs subsequent to the out of hours contact were also calculated. RESULTS: Annual costs incurred by the GP out of hours organisation per 1,000 population ranged from pounds sterling 2,916 to pounds sterling 12,120. There was no relationship between costs and type and size of organisation. There was a three-fold variation in total costs per out of hours contact (pounds sterling 15 to pounds sterling 51). Costs per phone contact were lowest (pounds sterling 6 to pounds sterling 11), followed by cost per centre contact (pounds sterling 10 to pounds sterling 16) and cost per home contact (pounds sterling 21 to pounds sterling 60). Total costs per episode ranged from pounds sterling 78 to pounds sterling 136 for centre contacts, from pounds sterling 130 to pounds sterling 303 for home contacts, and from pounds sterling 70 to pounds sterling 553 for telephone contacts. Home contacts had the highest average cost per episode (pounds sterling 212), followed by telephone contacts (pounds sterling 117) and centre contacts (pounds sterling 85). CONCLUSIONS: There are wide variations in the costs of operating GP out of hours services, It is likely that the context in which organisations were set up and local geography infuence variations in costs, as well as the level of GP cover.

Mathematical modeling of phosphorus losses from land application of hog and cattle manure.

Mathematical models may provide a means to estimate phosphorus (P) losses from land application of manure. Phosphorus losses typically occur during brief episodes of runoff and erosion. Models must be able to simulate P losses during these episodes by representing the basic chemical, physical, and biological processes by which these losses occur. The mathematical model ecosys combines dynamic distributed flow of solutes and nonsolutes through runoff and erosion with convective-dispersive transport of solutes, and both biologically and thermodynamically driven transformations between solutes and nonsolutes. This model was tested against P lost in runoff, erosion, and leachate measured during 90 min of controlled rainfall at 65 mm h(-1) on soils from six sites at which different rates of manure had been applied over the previous 3 to 6 yr. Transport and transformation kinetics in the model enabled it to simulate changes of dissolved inorganic phosphorus (DIP) in runoff from >1.0 to <0.05 mg L(-1) and changes of total phosphorus (TP) in sediment from 15 to 3 mg L(-1) measured during controlled rainfall on soils with diverse P contents. Results from 60-yr model runs using these kinetics with different application rates of cattle manure indicated that (i) a positive interaction exists between annual rainfall and application rate on P losses and (ii) rates greater than 30 Mg ha(-1) yr(-1) would cause TP concentrations in water leaving the site to rise above acceptable limits. The interaction between rainfall and rate suggests that P losses from manure application at any site should be assessed under the upper range of likely rainfall intensities.

Assessment of impact of information booklets on use of healthcare services: randomised controlled trial.

OBJECTIVES: To investigate the effect of patient information booklets on overall use of health services, on particular types of use, and on possible interactions between use, deprivation category of the area in which respondents live, and age. To investigate the possibility of a differential effect on health service use between two information booklets. DESIGN: Randomised controlled trial of two patient information booklets (covering the management and treatment of minor illness). SETTING: 20 general practices in Lothian, Scotland. PARTICIPANTS: Random sample of patients from the community health index (n=4878) and of those contacting out of hours services (n=4530) in the previous 12 months in each of the study general practices. INTERVENTION: Booklets were posted to participants in intervention groups (3288 were sent What Should I Do?; 3127 were sent Health Care Manual). Patients randomised to control group (2993) did not receive a booklet. MAIN OUTCOME MEASURES: Use of health services audited from patients' general practice notes in 12 months after receipt of booklet. RESULTS: Receipt of either booklet had no significant effect on health service use compared with a control group. However, nine out of ten matched practices allocated to receive Health Care Manual had reduced consultation rates compared with matched practices allocated to What Should I Do? CONCLUSION: Widespread distribution of information booklets about the management of minor illness is unlikely to reduce demand for health services.

Comparing the cost of epilepsy across eight European countries.

To observe the degree to which prices for medical services and anti-epileptic drugs (AEDs) vary between eight European Union (EU) countries, to identify the factors that are likely to contribute to these variations and to consider the validity of international cost-of-illness comparisons. Cost-of-illness study methodology has been used to estimate the national cost of epilepsy in several developed countries. The validity of comparing these studies is unknown. Eight EU member countries were selected. Charges and prices were obtained for important aspects of medical care of patients with epilepsy including AEDs. The perspective taken was that of the major health care payer within each country. Prices were validated by a local panel of doctors expert in treating epilepsy. Prices for similar services were compared between countries. Charges and prices levied to health service payer vary widely between the eight countries considered. The cheapest and most expensive medical services vary by as much as 24 times, whereas the price of AED varies up to 4.4 times. These wide variations suggest that prices do not reflect the true cost of providing these important aspects of epilepsy treatment. International comparisons between national cost-of-illness estimates relying on such prices should be interpreted with caution.

Developing a 'consultation quality index' (CQI) for use in general practice.

BACKGROUND: The core values of general practice include holism and patient-centredness. None of the measures of quality of care in general practice presently capture the expression of these values at routine consultations. OBJECTIVES: The aim of the present study was to construct a 'consultation quality index' (CQI) which reflects the core values of general practice, using as proxies 'consultation length' and how well patients 'know the doctor' as process measures and 'patient enablement' as an outcome measure. METHODS: The CQI was constructed from data collected from 23 799 adult English-speaking patients consulting 221 doctors in four demographically contrasting areas of the UK during 2 weeks of March/April 1998. A total of 171 doctors who entered 50 qualifying consultations were allocated scores for the three component variables, and a total CQI was calculated. RESULTS: CQI scores were in the range 4-18. Validity was examined by looking at high and low scorers in greater detail and by searching for correlates with case mix, patient age and gender, and the deprivation scores of the practices concerned. Particular attention was paid to how registrars and doctors new to their practices scored. The scores of different doctors in the same practice were also noted. The results had strong face validity and were independent of case mix and deprivation. Reliability was gauged by examining similar work from a previous study which had collected information on consultation length and enablement over three time periods. High CQI scores were associated with smaller overall practice list sizes. CONCLUSIONS: We have outlined possible uses for the CQI as part of the packages assessing quality of care by doctors and practices. The measure may also have a part to play in recognizing poorly performing doctors. We suggest how CQI scores could contribute to an incentive scheme to reward good consulting practice. Further work is in hand to compare doctors' CQI scores with scores based on performance indicators constructed from routine NHS data on prescribing and preventive medicine.

[Analysis of cost minimization of monotherapy antiepileptic treatment in patients with recent diagnosed epilepsy : the situation in Spain]. / Análisis de coste-minimización del tratamiento antiepiléptico en monoterapia en pacientes con epilepsia de reciente diagnóstico: situación en España.

OBJECTIVE: To analyze the cost of monotherapeutic treatment of patients with newly diagnosed epilepsy. PATIENTS AND METHODS: We analysed the cost of treatment with lamotrigine (LTG), carbamazepine (CBZ), phenytoin (PHT) and valproic acid (VPA) using published data regarding the efficacy and tolerability of comparative clinical trials of monotherapy. We established a model of treatment for newly diagnosed patients during the first 12 months after diagnosis. A panel of doctors reached a consensus on the use of resources, costs and model of treatment in Spain. We made a cost minimization analysis for economic assessment of the data based on the fact that randomized trials indicated that CBZ, LTG, PHT and VPA ware of similar efficacy. Analysis was done as 'intention to treat'. Only direct medical costs were considered. RESULTS: In Spain treatment with LTG is twice or three times as expensive as treatment with the other drugs. Sensitivity analysis showed that variations in the interval of use of resources and of costs (defined by the panel of doctors) did not significantly alter the results. CONCLUSIONS: Treatment with LTG is more expensive than treatment with the classical drugs. In view of the methodological limitations of this study, further analysis is necessary, particularly of the methodology of cost-benefit, to evaluate the economic impact of the new antiepileptic drugs and determine whether their use is justified as drugs of first choice.

Cost minimization analysis of antiepileptic drugs in newly diagnosed epilepsy in 12 European countries.

A recent United Kingdom cost minimization analysis (CMA) of four antiepileptic drugs (AEDs) used to treat newly diagnosed adult epilepsy demonstrated that a new drug, lamotrigine (LTG), incurred higher costs than carbamazepine (CBZ), phenytoin (PHT), and valproate (VPA), whose costs were similar. This analysis took account of each drug's side-effect and tolerability profile. The present analysis investigated the costs of treatment with LTG, CBZ, PHT, and VPA in 12 European countries. Data were derived from published sources and from a panel of locally based experts. When no published data were available, estimates were obtained using expert opinion by a consensus method. These data were incorporated into a treatment pathway model, which considered the treatment of patients during the first 12 months after diagnosis. The primary outcome considered was seizure freedom. Randomized controlled trials demonstrate that the drugs considered are equally effective in terms of their ability to achieve seizure freedom, and thus the most appropriate form of economic evaluation is a CMA. These trials provided data on the incidence of side effects, dosages, and retention rates. The economic perspective taken was that of society as a whole and the analysis was calculated on an "intent-to-treat" basis. Only direct medical costs were considered. In each country considered, LTG was twofold to threefold more expensive than the other drugs considered. A sensitivity analysis demonstrated that varying each of the assumptions (range defined by expert panels) did not significantly alter the results obtained.