Vessel diameter and close surveillance helps predict early patency in native arteriovenous fistulas.

INTRODUCTION: Arteriovenous fistulas are the preferred method of vascular access for haemodialysis. Data suggests patency rates can be low and may be related to vessel diameters prior to creation. We use specific size criteria for fistula selection. We aimed to establish patency rates in relation to vessel size and whether other factors affect fistula patency. METHODS: Consecutive patients undergoing radiocephalic (RCF) or brachiocephalic (BCF) creation between 2016 and 2018 were analysed. Preoperative arterial and venous diameters were collected. Six-week and six-month primary and secondary patency rates were analysed to establish any impact of vessel size on patency and re-intervention rates between groups. A univariate analysis was performed. RESULTS: Ninety four RCFs and 101 BCFs were created. Median artery and vein size for RCF were 2.7 and 3.0 mm respectively. For BCF, they were 4.6 and 4.3 mm respectively. At 6-weeks, overall satisfactory patency for RCF and BCF combined was 91.8%. 89.7% demonstrated primary patency; 2.1% secondary patency. At 6-months, overall patency was 78.7%; 58.5% demonstrated primary patency, 20.2% secondary patency. A univariate analysis, for both groups, revealed vein size was a significant predictor of overall satisfactory patency at 6-weeks, with larger veins more likely to remain patent (p = 0.025 RCF, p = 0.007 BCF). However, artery size was not predictive (p = 0.1 RCF, p = 0.5 BCF). At 6-months, neither artery nor vein diameter were predictive in either group. When comparing size of vessel based on fistula type, vessels used to create RCFs were smaller than those for BCFs (p < 0.001). RCFs were more likely to receive endovascular intervention or occlude when compared to BCFs (p = 0.014). DISCUSSION: Excellent patency and maturation rates can be achieved using fairly strict vessel size criteria. Vein size might be the more important predictor of early success. RCFs can be challenging due to smaller vessels, but maturation rates can be optimised by close surveillance and aggressive re-intervention.

What is the optimum rehabilitation for patients who have undergone release procedures for frozen shoulder? A UK survey.

OBJECTIVE: Despite usually being considered necessary, the rehabilitation regime that optimises outcomes for patients following release procedures for frozen shoulder has not been established and no accepted best practice guidelines currently exist. The purpose of this study was to gain insight into what physiotherapists considered best practice and factors they considered likely to affect patient outcome. METHODS: A cross-sectional, self-administered online questionnaire was developed and distributed to UK based Physiotherapists, undergraduate students and support workers via email, social media and professional networks. RESULTS: 260 eligible and fully completed surveys were received. Clear preference for early (within 72 h), frequent (2-3 times per week or weekly) and prolonged (greater than 6 weeks) treatment delivered in a 1:1 setting was expressed. 99% were highly likely/likely to advocate education and advice, range of movement exercises (99.6%), stretching (73.5%) and strengthening (61.9%). More passive modalities (manual therapy, massage, electrotherapy, acupuncture) were highly unlikely/unlikely to be used and lack of manual therapy and insufficient contact with a physiotherapist were the reasons deemed least likely to affect outcome. Most clinicians (89.2%) were likely to prescribe exercises that patients reported as painful but persistent pain and poor adherence by patients to exercises were the top reasons given for poor outcome along with psychological and psychosocial patient characteristics. CONCLUSION: Physiotherapists consistently advocate early, frequent, prolonged, 1:1 treatment following release procedures for frozen shoulder. Most patients are discharged whilst still experiencing symptoms, particularly pain. Further work is needed to establish high value pathways for this patient group.

Initial testing of an electronic application of the simplified modified Rankin Scale questionnaire (e-smRSq).

INTRODUCTION AND PURPOSE: To facilitate modified Rankin scale (mRS) assessments, we developed and tested a smartphone/web application of the simplified mRS questionnaire (e-smRSq). The e-smRSq guides raters towards a final score according to the smRSq algorithm, and offers hints for scoring based on the conventional mRS concepts. METHODS: Initially, three experienced mRS certified raters prepared 30 vignettes of unstructured stroke patient interviews, and determined consensus reference scores. Using the e-smRSq, 16 raters of varied professional backgrounds without mRS training scored the mRS for 24 randomly selected vignettes. Subsequently, 5 certified and 5 uncertified raters using the e-smRSq scored 23 mRS certification vignettes developed and used in the Strategies to Innovate Emergency Care Clinical Trials Network-Neurological Emergencies Treatment Trials (SIREN-NETT). Cohen's and Fleiss's kappa (κ), weighted kappa (κw), and intra-class correlation (ICC) compared rater scores with reference scores and assessed interrater reliability. RESULTS: For the 16 initial raters using the e-smRSq with 24 vignettes, the κ (Fleiss) was 0.62 and ICC 0.87 (CI 0.80-0.93). Comparing raters' scores with reference scores, Cohen's κ was 0.68 and κw 0.90. For the 10 subsequent raters using the e-smRSq on SIREN-NETT vignettes, κ (Fleiss) was 0.8 and ICC 0.95 (CI 0.91-0.97). Comparing all 10 raters scores with SIREN-NETT reference scores, Cohen's κ was 0.88 and κw 0.97. There was no significant difference between certified and uncertified raters. CONCLUSIONS: The e-smRSq appears to have good reproducibility and validity metrics among both certified and non-certified mRS raters, possibly owing to its simplicity. Further testing in stroke patients in warranted.

Prostaglandin F2-Alpha Eye Drops (Bimatoprost) in Graves' Orbitopathy: A Randomized Controlled Double-Masked Crossover Trial (BIMA Trial).

BACKGROUND: Previous in vitro experiments have demonstrated that prostaglandin F2-alpha (PF2α) reduced proliferation and adipogenesis in a murine cell line and human orbital fibroblasts derived from subjects with inactive Graves' orbitopathy (GO). The objective of this study was to determine if the PGF2α analogue bimatoprost is effective at reducing proptosis in this population. METHODS: A randomized controlled double-masked crossover trial was conducted in a single tertiary care academic medical center. Patients with long-standing, inactive GO but persistent proptosis (>20 mm in at least one eye) were recruited. Allowing for a 15% dropout rate, 31 patients (26 females) were randomized in order to identify a treatment effect of 2.0 mm (p = 0.05; power 0.88). Following informed consent, participants were randomized to receive bimatoprost or placebo for three months, after which they underwent a two-month washout before switching to the opposite treatment. The primary outcome was the change in exophthalmometry readings over the two three-month treatment periods. RESULTS: The mean exophthalmometer at baseline was 23.6 mm (range 20.0-30.5 mm), and the mean age of the patients was 55 years (range 28-74 years). The median duration of GO was 7.6 years (interquartile range 3.6-12.3 years). The majority were still suffering from diplopia (61.3%) with bilateral involvement (61.3%). Using multi-level modeling adjusted for baseline, period, and carry-over, bimatoprost resulted in a -0.17 mm (reduction) exophthalmometry change ([confidence interval -0.67 to +0.32]; p = 0.490). There was a mean change in intraocular pressure of -2.7 mmHg ([confidence interval -4.0 to -1.4]; p = 0.0070). One patient showed periorbital fat atrophy on treatment, which resolved on stopping treatment. Independent analysis of proptosis by photographic images (all subjects) and subgroup analysis on monocular disease (n = 12) did not show any apparent benefit. CONCLUSIONS: In inactive GO, bimatoprost treatment over a three-month period does not result in an improvement in proptosis.

The SILKIE (Skin graftIng Low friKtIon Environment) study: a non-randomised proof-of-concept and feasibility study on the impact of low-friction nursing environment on skin grafting success rates in adult and paediatric burns.

OBJECTIVES: To evaluate the impact of low-friction (LF) bedding on graft loss in an acute burn care setting, and to examine the feasibility and costs of using LF bedding compared with standard care. DESIGN: Proof of concept before and after study with feasibility of delivering the intervention. SETTING: Three burns services within two UK hospital trusts. PARTICIPANTS: Inclusion criteria were patients older than 4 weeks, who received a skin graft after burn injury and were admitted overnight. The comparator cohort were eligible patients admitted in a 12-month period before the intervention. INTERVENTION: Introduction of LF sheets and pillowcases during a 15-month period. OUTCOME MEASURES: For proof of concept, the LF and comparator cohorts were compared in terms of number of regrafting operations (primary), percentage graft loss, hospital length of stay (LoS) and LoS cost (secondary). Feasibility outcomes were practicality and safety of using LF bedding. RESULTS: 131 patients were eligible for the LF cohort and 90 patients for the comparator cohort. Although the primary outcome of the proportion needing regrafting was halved in the LF cohort, the confidence interval (CI) crossed 1 (OR (95% CI): 0.56 (0.16 to 1.88)). Partial graft loss (any loss) was significantly reduced in the LF cohort (OR (95% CI): 0.27 (0.14, 0.51)). Inpatient LoS was no different between the two cohorts (difference in median days (95% CI): 0 (-2 to 1)), and the estimated difference in LoS cost was £-1139 (-4829 to 2551). Practical issues were easily resolved, and no safety incidents occurred while patients were nursed on LF bedding. CONCLUSIONS: LF bedding is safe to use in burned patients with skin grafts and we have shown proof of concept for the intervention. Further economic modelling is required to see if an appropriately powered randomised control trial would be worthwhile or if roll out across the National Health Service is justified. TRIAL REGISTRATION NUMBER: ISRCTN82599687.

High complete resection rate for pre-lift and cold biopsy of diminutive colorectal polyps.

BACKGROUND AND STUDY AIMS: The majority of polyps removed at colonoscopy are diminutive (≤ 5 mm) to small (< 10 mm) and there are few guidelines for the best way for these polyps to be removed. We aimed to assess the feasibility and effectiveness of cold biopsy forceps polypectomy with pre-lift (CBPP) for polyps ≤ 7 mm. Our aims were to assess completeness of histological resection of this technique, to identify factors contributing to this and assess secondary considerations such as timing, retrieval and complication rates. PATIENTS AND METHODS: We conducted a prospective cohort study on consecutive patients receiving a colonoscopy at Cheltenham General Hospital, as part of the National Bowel Cancer Screening Program (BCSP) in England. The study included only polyps that were judged as ≤ 7 mm by the colonoscopist. A small sub-mucosal pre-lift injection was administered prior to removal of the polyp using cold biopsy forceps. One or more biopsies were taken until the polyp was confidently assessed visually as being completely removed by the colonoscopist. The entire polypectomy site was then removed en bloc by endomucosal resection (EMR) with a margin of at least 1 to 2 mm around defect. This was sent for histopathological analysis to assess completeness of resection. Polypectomy timing, tissue retrieval, number of bites required for visual resection and complications were recorded at the time of the procedure. RESULTS: Sixty-four patients were recruited and consented. Of them, 42 patients had a total of 60 polyps resected. Three patients had inflammatory polyps and were excluded from the study, leaving 57/60 polyps for final analysis. Seventeen were hyperplastic and 40 adenomatous polyps. Retrieval was complete for all 57 polyps and there were no complications both during or post- polypectomy. The complete resection rate (CRR) was 86 %. The technique was more effective in smaller polyps with 91.7 % of diminutive polyps (≤ 5 mm) completely excised. CONCLUSIONS: CBPP is a safe and highly effective technique for polyps < 5 mm with a high complete resection and retrieval rate. The time taken for the procedure is significantly greater than cold forceps alone, or cold snare as seen in other studies.

A service evaluation of outcomes in two in-patient recovery units.

Aims and method To evaluate outcomes for patients during their admission or in the first year of treatment in two in-patient recovery units. Changes in health and social functioning, service use and need (rated by patients and staff) were evaluated. Results In 43 patients treated, there was a large (30%) increase in patients discharged to their own tenancies, rather than supported accommodation. There was minimal change in Health of the Nation Outcome Scales (HoNOS) scores in the course of the admission but staff- and patient-rated unmet needs reduced and met needs increased. Needs changed mainly in domains relating to social functioning. Reductions in risk to self and others were rated by staff but not patients. There were no cases of patients being readmitted to acute hospital during the study period. Clinical implications Although these results offer some support to the treatment approach described in these in-patient recovery units, further research in larger samples is needed to identify how these services can best be deployed to help individuals with severe mental illness and complex needs.

Searching for prohibited items in mental-health hospitals: A randomised controlled trial of two metal-detecting technologies.

Weapons and other items with potential to cause harm are usually prohibited in mental-health hospitals and other psychiatric facilities. Detecting such prohibited items (PIs) can be problematic, particularly if concealed, and metal detectors are commonly used to search for such items. Our study compared two types of metal detection: continuous wave detection (CWD) by hand-held metal detector (HHMD) and magnetic anomaly detection (MAD) by a static pole device. In the study, real and dummy PIs were hidden on test subjects and in a simulated body cavity. The results showed MAD to be significantly superior to CWD in detecting small concealed PIs containing ferrous metal. The MAD pole found 100% of the real PIs on the test subjects and in the simulated body cavity. The CWD HHMD found only 5.2% of the real PIs, and these were limited to those on the test subjects, as it detected none in the simulated body cavity. In addition, the time taken to search by MAD pole was shorter than time taken to search by CWD HHMD.

Can an ethics officer role reduce delays in research ethics approval? A mixed-method evaluation of an improvement project.

OBJECTIVE: Frustration continues to be directed at delays in gaining approvals for undertaking health research in the UK. We aimed to evaluate the impact of an ethics officer intervention on rates of favourable opinions (approval) and provisional opinions (requiring revision and resubmission) and on the time taken to reach a final opinion by research ethics committees (RECs), to characterise how the role operated in practice, and to investigate applicants' views. DESIGN: Mixed-method study involving (i) a 2-group, non-randomised before-and-after intervention study of RECs assigned an ethics officer and a matched comparator group; (ii) a process evaluation involving a survey of applicants and documentary analysis. PARTICIPANTS: 6 RECs and 3 associated ethics officers; 18 comparator RECs; REC applicants. RESULTS: Rates of provisional and favourable opinions between ethics officer and comparator RECs did not show a statistically significant effect of the intervention (logistic regression, p=0.26 for favourable opinions and p=0.31 for provisional opinions). Mean time to reach a decision showed a non-significant reduction (ANOVA, p=0.22) from 33.3 to 32.0 days in the ethics officer RECs compared with the comparator RECs (32.6 to 32.9 days). The survey (30% response rate) indicated applicant satisfaction and also suggested that ethics officer support might be more useful before submission. Ethics officers were successful in identifying many issues with applications, but the intervention did not function exactly as designed: in 31% of applicants, no contact between the applicants and the ethics officer took place before REC review. LIMITATIONS: This study was a non-randomised comparison cohort study. Some data were missing. CONCLUSIONS: An ethics officer intervention, as designed and implemented in this study, did not increase the proportion of applications to RECs that were approved on first review and did not reduce the time to a committee decision.

Barrett's Oesophagus Surveillance versus endoscopy at need Study (BOSS): protocol and analysis plan for a multicentre randomized controlled trial.

OBJECTIVES: The absolute annual risk of patients with Barrett's oesophagus (BO) developing oesophageal adenocarcinoma (OAC) is ≤ 0.5%. Screening BO patients for malignant progression using endoscopic surveillance is widely practised. To assess the efficacy and cost-effectiveness of this, we developed a protocol for a randomized controlled trial of surveillance versus 'at need' endoscopy. METHODS: In a multicentre trial, 3400 BO patients randomized to either 2-yearly endoscopic surveillance or 'at need' endoscopy will be followed up for 10 years. Urgent endoscopy will be offered to all patients who develop symptoms of dysphagia, unexplained weight loss > 7lb (3.2 kg), iron deficiency anaemia, recurrent vomiting, or worsening upper gastrointestinal symptoms. Participants must have endoscopically and histologically confirmed BO, with circumferential BO ≥ 1 cm or maximal tongue/island length ≥ 2 cm. Candidates with existing oesophageal high-grade dysplasia or cancer, or previous upper gastrointestinal cancer will be excluded. Primary outcome will be overall survival. Secondary outcomes will be cost effectiveness (cost per life year saved and quality adjusted life years); cancer-specific survival; time to OAC diagnosis and stage at diagnosis; morbidity and mortality related to any interventions; and frequency of endoscopy. CONCLUSIONS: This randomized trial will provide data to evaluate the efficacy and cost-effectiveness of screening BO patients for OAC.

Four-year follow-up of transient ischemic attacks, strokes, and mimics: a retrospective transient ischemic attack clinic cohort study.

BACKGROUND AND PURPOSE: There is limited information on outcomes from rapid access transient ischemic attack (TIA) clinics. We present 4-year outcomes of TIAs, strokes, and mimics from a UK TIA clinic database. METHODS: All patients referred between April 2010 and May 2012 were retrospectively identified and outcomes determined. End points were stroke, myocardial infarction, any vascular event (TIA, stroke, or myocardial infarction), and all-cause death. Data were analyzed by survival analysis. RESULTS: Of 1067 patients, 31.6% were TIAs, 18% strokes, and 50.4% mimics. Median assessment time was 4.5 days from onset and follow-up was for 34.9 months. Subsequent strokes occurred in 7.1% of patients with TIA, 10.9% of patients with stroke, and 2.0% of mimics at the end of follow-up. Stroke risk at 90 days was 1.3% for patients diagnosed as TIA or stroke. Compared with mimics, hazard ratios for subsequent stroke were 3.88 (1.90-7.91) for TIA and 5.84 (2.81-12.11) for stroke. Hazard ratio for any subsequent vascular event was 2.91 (1.97-4.30) for TIA and 2.83 (1.81-4.41) for stroke. Hazard ratio for death was 1.68 (1.10-2.56) for TIA and 2.19 (1.38-3.46) for stroke. CONCLUSIONS: Our results show a lower 90-day stroke incidence after TIA or minor stroke than in earlier studies, suggesting that rapid access daily TIA clinics may be having a significant effect on reducing strokes.

Aromatherapy and massage intrapartum service impact on use of analgesia and anesthesia in women in labor: a retrospective case note analysis.

BACKGROUND: Over the past decade, interest in complementary therapies and alternative medicine has escalated among midwives and the general public in response to increased demand from expectant mothers for more choice, control, and continuity in labor. OBJECTIVE: The aim of this study was to explore if an aromatherapy and massage intrapartum service (AMIS) reduced the need for analgesia during labor. This article reports results related to the effects of an AMIS on type of analgesia chosen by women in labor, and on rates of anesthesia--one aspect of the full study. SETTING/LOCATION: The study was conducted in a general maternity unit in southwest England, UK. DESIGN: A quantitative research approach was taken, whereby contemporaneously completed service evaluation forms of 1079 women (601 nulliparous women and 478 multiparous women; AMIS group) were retrospectively analyzed in comparison with the birth records of an equal number of similar women (comparison group). Data analysis was achieved by entering data from the forms and comparison sample into an SPSS package and running statistical tests. RESULTS: In the AMIS group, overall analgesia usage was higher for transcutaneous electrical stimulation at 34%, compared with 15.9% (p<0.001 allowing for parity), and for nitrous oxide and oxygen at 87.6%, compared with 80.8% (p<0.001). Pethidine use did not differ after adjustment for parity at 30.1%, compared with 24.2% (p=0.27) in the AMIS and comparison groups, respectively. Rates were lower in the AMIS group for epidural anesthesia at 29.7%, compared with 33.8% (p=0.004 allowing for parity) in the comparison group; spinal anesthesia at 6%; compared with 12.1% (p<0.001) in the comparison group; and general anesthesia at 0.8%, compared with 2.3% (p=0.033) in the comparison group. CONCLUSIONS: Having an AMIS appears to have a positive impact on reducing rates of all types of intrapartum anesthesia. The Service is a beneficial addition to conventional midwifery practice that may influence mode of delivery and reduce general anesthesia rates.

Focal active colitis: a prospective study of clinicopathological correlations in 90 patients.

AIMS: Considerable controversy exists about the clinical implication of a diagnosis of focal active colitis (FAC). The aim of this study was to assess clinicopathological correlations of FAC in 90 adults, representing the largest and only prospective series of FAC. METHODS AND RESULTS: Patients were assessed by comprehensive clinical follow-up and questionnaires. Fifteen histopathological features were scored and correlated with clinical outcome. In 24% of patients drugs, especially NSAIDs, were implicated. Infection was a probable cause in 19%. In 14 patients (15.6%), predominantly women, a diagnosis of chronic inflammatory bowel disease was ultimately made. Most were Crohn's disease, but this is the first study in which FAC has presaged an ultimate diagnosis of ulcerative colitis in adults (in two patients). A specific subtype of FAC, termed basal FAC, was significantly associated with drugs. These excepted, this study has found no histopathological parameters of FAC, such as amount, location and/or distribution, to correlate with clinical outcome or allowed selection of those patients more likely to show subsequent evidence of chronic inflammatory bowel disease. CONCLUSION: This study has provided powerful information on the implication of a diagnosis of FAC. In a small but not inconsiderable case number, the ultimate diagnosis will be chronic inflammatory bowel disease.

Trends in disability prevalence over 10 years in older people living in Gloucestershire.

INTRODUCTION: life expectancy in the UK appears to be growing faster than healthy life expectancy, which may imply that there are increasing years of disability. There are few sequential studies examining changes in disability amongst older people within a defined locality. METHODS: the population aged 75 and over of 10 general practices in Gloucestershire was surveyed using a validated postal questionnaire for disability called the Elderly At Risk Rating Scale. Surveys were carried out in 1998 and 2008. Age-adjusted disability prevalences were measured. Care home residents were under-represented in the 1998 survey, and missing data was supplied from a countywide census of care home residents in 2000. RESULTS: response rates of 81 and 74% were achieved. Reductions in disability prevalence were found for mobility, vision and self-care, but there was no significant change in a measure of self-rated health. Higher rates of independence were found in both genders and across the age range in 2008. The improvements suggested that the latter sample was equivalent to subjects being 3.8 years 'younger' than 10 years before and entering dependency on care 2.1 years later. DISCUSSION: the prevalence of disability affecting activities of daily living appears to have reduced over 10 years in older people in Gloucestershire. If generalisable, these results provide some optimism for current trends in ageing in England.

Improving the appropriateness of laboratory submissions for urinalysis from general practice.

BACKGROUND: Urine is the most common microbiology laboratory specimen. Submissions increase annually by 5-10%, and many specimens may be unnecessary. OBJECTIVES: To assess the impact of guidance, implemented by interactive workshops and reinforced with modified request forms, on specimen submission. METHODS: This was a prospective randomized controlled study with modified Zelen design. The study population comprised five primary care trusts (PCTs) in Gloucestershire/County Durham/Darlington, containing 82 general practices in six geographical clusters. The six clusters were randomly assigned to urine workshop covering submission in the elderly, adults and children or a control workshop. Within these groups, half the practices were randomized to receive modified laboratory forms emphasizing the workshop messages. Practices were not aware of the study. RESULTS: Workshops lead to a 12% reduction in urine submissions from 16- to 64-year olds, which persisted for the 15 months but had no effect on bacteriuria rate. Workshops had no significant effect in the elderly or children. Modified forms were not associated with any reduction in submissions but were associated with an 11% reduction in detection of significant bacteriuria in 16- to 64-year olds. CONCLUSIONS: The 12% decrease in urine submissions from 16- to 64-year olds, attained with workshops, may help counter relentlessly rising test submissions. Modified forms are currently not worth pursuing. When educational workshops are used across PCTs to change practice, the change in test submission is smaller than attained in educational initiatives involving volunteers. Workshops may be more effective if they also discuss urine submissions from asymptomatic patients and are directed at high testing practices and care homes.

Interactive workshops increase chlamydia testing in primary care--a controlled study.

BACKGROUND: Primary care clinicians suggest that staff education is needed to increase chlamydia testing appropriately. OBJECTIVES: To determine if interactive workshops and modified laboratory request forms could increase testing and case detection. STUDY DESIGN: Prospective cluster randomized controlled study, using modified Zelen's design, examining the effect of workshops and modified request forms on primary care clinicians' chlamydia specimen submission and case positivity rate. STUDY POPULATION: 82 general practices in six geographical clusters within five primary care trusts (PCTs) in Gloucestershire and County Durham and Darlington. INTERVENTION: Practices within geographical clusters were randomly assigned to workshops on chlamydia or a control consisting of comparable workshops on the management of urinary symptoms, held in PCT-protected learning time. Half the practices were randomized to receive modified laboratory request forms. Staff were unaware that they were part of a study. RESULTS: Interactive workshops increased chlamydia testing in 16- to 24-year-old women by 33% in intervention practices compared to controls with effect persisting at 10 months (P = 0.003). No associated rise in the number of chlamydia infections was detected (P = 0.91), suggesting that increased testing may have occurred in a lower risk population. Modified forms did not change test submission (P = 0.75). CONCLUSIONS: Interactive workshops for general practices can be used to successfully increase chlamydia-testing rates. Chlamydia detection rates will need to be monitored as this type of educational programme may not increase absolute numbers of chlamydia infections detected, if patients at lower risk of infection are inappropriately tested. Other interventions may need to be combined with the workshops, to reach sufficiently high chlamydia screening rates to significantly reduce prevalence of chlamydial infection.

Factors associated with changing patient needs in an assertive outreach team.

BACKGROUND, AIMS: Although clinical use of needs assessment tools is widespread, there is little evidence about their value in longitudinal use. This study aimed to identify the factors associated with changing needs in an assertive outreach (AO) team's caseload, over a 6-month rating period. METHODS: The Camberwell Assessment of Needs Short Appraisal Schedule (CANSAS) and the Engagement Measure (EM) were used to assess need and engagement with services respectively, in an AO team caseload. Care planning was based partly on awareness of current unmet needs. The patients were then reassessed at a 6-month follow-up, to determine to what extent identified unmet need had been successfully addressed, and whether levels of engagement had altered. RESULTS: Data were obtained for 79 of 82 patients on the AO team caseload. At 6-month follow-up patient-rated unmet need, but not staff-rated unmet need, was significantly reduced. Patient-, but not staff-rated met need was significantly increased. Measures of engagement were unchanged. Patients' needs changed across a variety of physical, social and psychological domains, rather than in one specific area. In regression analyses, only accommodation type was independently associated with patient-rated changing met need; only diagnosis was significantly related to changing patient-related unmet need. CONCLUSION: In this study, the CANSAS was used routinely in a standard AO team, and the finding that over a 6-month period patient-rated unmet need reduced significantly suggests that formal rating of needs assessment may have helped to target care planning effectively. The results suggest that accommodation type and diagnosis may play an important role in the ability of services to effectively meet patient needs, but further work in larger samples is needed to address these questions.

The Watcombe Housing Study: the short term effect of improving housing conditions on the health of residents.

OBJECTIVE: To assess the short term health effects of improving housing. DESIGN: Randomised to waiting list. SETTING: 119 council owned houses in south Devon, UK. PARTICIPANTS: About 480 residents of these houses. INTERVENTION: Upgrading houses (including central heating, ventilation, rewiring, insulation, and re-roofing) in two phases a year apart. MAIN OUTCOME MEASURES: All residents completed an annual health questionnaire: SF36 and GHQ12 (adults). Residents reporting respiratory illness or arthritis were interviewed using condition-specific questionnaires, the former also completing peak flow and symptom diaries (children) or spirometry (adults). Data on health service use and time lost from school were collected. RESULTS: Interventions improved energy efficiency. For those living in intervention houses, non-asthma-related chest problems (Mann-Whitney test, p = 0.005) and the combined asthma symptom score for adults (Mann-Whitney test, z = 2.7, p = 0.007) diminished significantly compared with control houses. No difference between intervention and control houses was seen for SF36 or GHQ12. CONCLUSIONS: Rigorous study designs for the evaluation of complex public health and community based interventions are possible. Quantitatively measured health benefits are small, but as health benefits were measured over a short time scale, there may have been insufficient time for measurable improvements in general and disease-specific health to become apparent.

Long term results of compression therapy alone versus compression plus surgery in chronic venous ulceration (ESCHAR): randomised controlled trial.

OBJECTIVE: To determine whether recurrence of leg ulcers may be prevented by surgical correction of superficial venous reflux in addition to compression. DESIGN: Randomised controlled trial. SETTING: Specialist nurse led leg ulcer clinics in three UK vascular centres. PARTICIPANTS: 500 patients (500 legs) with open or recently healed leg ulcers and superficial venous reflux. INTERVENTIONS: Compression alone or compression plus saphenous surgery. MAIN OUTCOME MEASURES: Primary outcomes were ulcer healing and ulcer recurrence. The secondary outcome was ulcer free time. RESULTS: Ulcer healing rates at three years were 89% for the compression group and 93% for the compression plus surgery group (P=0.73, log rank test). Rates of ulcer recurrence at four years were 56% for the compression group and 31% for the compression plus surgery group (P<0.01). For patients with isolated superficial reflux, recurrence rates at four years were 51% for the compression group and 27% for the compress plus surgery group (P<0.01). For patients who had superficial with segmental deep reflux, recurrence rates at three years were 52% for the compression group and 24% for the compression plus surgery group (P=0.04). For patients with superficial and total deep reflux, recurrence rates at three years were 46% for the compression group and 32% for the compression plus surgery group (P=0.33). Patients in the compression plus surgery group experienced a greater proportion of ulcer free time after three years compared with patients in the compression group (78% v 71%; P=0.007, Mann-Whitney U test). CONCLUSION: Surgical correction of superficial venous reflux in addition to compression bandaging does not improve ulcer healing but reduces the recurrence of ulcers at four years and results in a greater proportion of ulcer free time. TRIAL REGISTRATION: Current Controlled Trials ISRCTN07549334 [controlled-trials.com].