Electronic personal assessment questionnaire for vascular conditions (ePAQ-VAS): development and validity.

BACKGROUND: This paper describes the development and validation of an electronic personal assessment questionnaire for vascular conditions (ePAQ-VAS) that captures the symptomatology, quality of life and clinically relevant data of patients presenting to vascular services. METHODS: A two-stage survey was conducted in patients attending a tertiary vascular department. Patients completed the ePAQ-VAS remotely online, or on site using an electronic tablet. In the first stage of the survey, the responses were used to perform confirmatory factor analysis to assess the construct validity and remove redundant items. The internal reliability of disease-specific scales was investigated. In the second stage of the survey, the acceptability, known-group validity, test-retest reliability, and responsiveness of ePAQ-VAS was assessed. RESULTS: In total, 721 patients completed ePAQ-VAS. Their mean(s.d.) age was 63·5(15·7) years and 468 (64·9 per cent) were men. Some 553 patients (76·7 per cent) completed the questionnaire in clinic and the remainder completed the questionnaire online. The results of the confirmatory factor analysis confirmed the conceptual model for ePAQ-VAS structure and eliminated six items. Internal reliability was acceptable for all the scales (Cronbach's α greater than 0·7). The test-retest reliability measured by the intraclass correlation coefficient ranged from 0·65 to 0·99. The results showed that the instrument was responsive over time with the standardized response mean ranging from 0·69 to 1·60. CONCLUSION: ePAQ-VAS is a holistic data-collection process that is relevant to vascular service users and has potential to contribute to patient-focused care and the collection of aggregate data for service evaluation. A demonstration version of the final version of ePAQ can be viewed at http://demo-questionnaire.epaq.co.uk/home/project?id=VASC_1.7&page=1.

ANTECEDENTES: Este artículo describe el desarrollo y la validación de un cuestionario electrónico de evaluación personal para enfermedades vasculares (ePAQ-VAS) que incluye la sintomatología, la calidad de vida y los datos clínicamente relevantes para los pacientes que son atendidos en los servicios de patología vascular. MÉTODOS: Se llevó a cabo una encuesta en dos fases entre los pacientes atendidos en un servicio de patología vascular de tercer nivel. Los pacientes completaron el cuestionario ePAQ-VAS a distancia en línea o bien en el centro hospitalario mediante una tableta electrónica. En la primera fase de la encuesta, las respuestas se utilizaron para realizar un análisis factorial de confirmación para evaluar la validez del diseño y eliminar los elementos redundantes. Se investigó la fiabilidad interna de las escalas específicas de la enfermedad. En la segunda fase de la encuesta, se evaluó la aceptabilidad, la validez de grupo conocida, la fiabilidad test-retest y la capacidad de respuesta del ePAQ-VAS. RESULTADOS: En total, 721 pacientes completaron el ePAQ-VAS, la edad media fue de 63,5 años (DE 15,7); el 64,9% eran varones (468); el 76% de los pacientes (553) completaron el cuestionario en la clínica y los pacientes restantes lo hicieron electrónicamente a distancia. Los resultados del análisis factorial de confirmación confirmaron el modelo conceptual para la estructura ePAQ-VAS y eliminaron seis ítems. La fiabilidad interna fue aceptable para todas las escalas (alfa de Cronbach > 0,7). La fiabilidad test-retest medida por el coeficiente de correlación intraclase osciló entre 0,65-0,99. Los resultados mostraron que el instrumento responde con el tiempo con una media de respuesta estandarizada que varía de 0,69 a 1,60. CONCLUSIÓN: El ePAQ-VAS es un proceso holístico de recopilación de datos que es relevante para los usuarios de servicios de patología vascular y tiene el potencial de contribuir a la atención centrada en el paciente y a la recopilación de datos agregados para la evaluación del servicio.

Strength of public preferences for endovascular or open aortic aneurysm repair.

BACKGROUND: This study evaluated public preferences for the treatment processes for abdominal aortic aneurysm repair in order to allow them to be incorporated into a cost-effectiveness analysis. METHODS: This was a telephone survey using a trade-off method in UK resident adults (aged at least 18 years) with no previous diagnosis of a vascular condition. RESULTS: Some 167 of 209 participants (79·9 per cent) stated that they would prefer endovascular aneurysm repair (EVAR), 40 (19·1 per cent) preferred open surgery and two (1·0 per cent) stated no preference. Participants preferred EVAR because of the less invasive nature of the intervention and quicker recovery. Participants preferring open surgery cited reasons such as having a single follow-up appointment, and a procedure that felt more permanent. When participants were asked to make a sacrifice in order to have their preferred treatment, 122 (58·4 per cent) favoured EVAR, 18 (8·6 per cent) favoured open surgery and 69 (33·0 per cent) had no preference. Those preferring EVAR were willing to give up a mean of 0·135 expected quality-adjusted life-years (QALYs) to have EVAR, compared with a willingness to give up 0·033 expected QALYs among those preferring open repair. CONCLUSION: These results indicate a clear preference for EVAR over open surgery for aortic aneurysm.

ANTECEDENTES: Este estudio evaluó las preferencias de la opinion pública en relación a las opciones de tratamiento para la reparación del aneurisma de aorta abdominal, con el objetivo de que dichas preferencias se puedan incorporar en un análisis de coste-efectividad. MÉTODOS: Se realizó una encuesta telefónica utilizando el método trade-off (solución de intercambio) en adultos residentes en el Reino Unido (mayores de 18 años) sin diagnóstico previo de enfermedad vascular. RESULTADOS: Un total de 167 (79,9%) de 209 participantes declararon que preferirían la reparación endovascular del aneurisma (endovascular aneurysm repair, EVAR), 40 (19,1%) prefirieron cirugía abierta y dos (1,0%) no tenían preferencia. Los participantes prefirieron el EVAR debido a la naturaleza menos invasiva de la intervención y a tiempos de recuperación más rápidos. Los participantes que preferían la cirugía abierta mencionaron como razones tener una única visita de seguimiento y consideraron que se trataba de un procedimiento más permanente. Cuando se pidió a los participantes que para recibir su tratamiento preferido hicieran un intercambio, 122 (58,4%) se decantaron por la EVAR, 18 (8,6%) por la cirugía abierta y 69 (33%) no tuvieron preferencia. Los que prefirieron EVAR estaban dispuestos a renunciar a una media de 0,135 años de vida ajustados por calidad (QALYs) esperados con tal de recibir una EVAR en comparación con la renuncia de 0,033 QALYs esperada entre quienes preferían la reparación abierta. CONCLUSIÓN: Estos resultados indican una clara preferencia por la EVAR sobre la cirugía abierta, lo que está en desacuerdo con la reciente recomendación de NICE de que la EVAR no debe recomendarse como una opción de tratamiento. Los hallazgos sugieren que se debe prestar mayor atención a las características del proceso de tratamiento. Al no incorporar explícitamente tales preferencias en el proceso de toma de decisiones, NICE corre el riesgo de recomendar opciones de tratamiento que son contrarias a las preferencias de la población del Reino Unido.

HLAMatchmaker is effective for selecting appropriate platelet units for alloimmunised thrombocytopaenic patients who are refractory to random donor platelets.

BACKGROUND: HLAMatchmaker has been used in the Irish Blood Transfusion Service (IBTS) to select platelets for HLA-alloimmunised, platelet refractory thrombocytopaenic patients since 2006. Although available since 2002, only three studies have been published supporting the programme's effectiveness for this indication. OBJECTIVES: We sought to examine increments to HLA-matched platelets (HMPs) at various matchmaker scores and to examine the impact of transfusing older platelets and ABO-mismatched platelets to this patient group. METHODS/MATERIALS: A total of 20 consecutive HLA-alloimmunised thrombocytopaenic patients were retrospectively studied. Data collected included: pre- and post-transfusion platelet count, indication for transfusion, HLAMatchmaker score, age of unit and degree of ABO mismatch. Data were also collected on the last 3 U of (RDPs). The Mann-Whitney U-test was used to compare increments between transfusion episodes of random donor platelets (RDPs) vs HMPs with matchmaker scores <3, 4-7 or >8. RESULTS: Increments at <2 h were available for 63 transfusion episodes. Increments at 2-24 h were available for 93 transfusion episodes. Increments were higher when transfusing HMPs than when transfusing RDPs. Increments for HMPs that were ABO mismatched were no different than for ABO-identical units, with the exception of late increments post-transfusing HMPs with a major ABO mismatch. Age of platelets did not influence increments. CONCLUSION: The use of HLAMatchmaker to select platelet units for thrombocytopaenic HLA-alloimmunised patients produced satisfactory platelet increments. When providing HLAMatchmaker-selected HMPs, ABO mismatch and the use of platelet units that are up to 7 days old should be permissible.

Quality of HIV care in the United Kingdom: key indicators for the first 12 months from HIV diagnosis.

OBJECTIVES: Prompt HIV diagnosis and treatment are associated with increased longevity and reduced transmission. The aim of the study was to examine late diagnoses and to assess the quality of care following diagnosis. METHODS: National surveillance and cohort data were used to examine late HIV diagnoses and to assess the quality of care received in the 12 months following HIV diagnosis. RESULTS: In 2011, 79% (4910/6219) of persons (15 years and over) diagnosed with HIV infection had CD4 counts reported within 3 months; of these, 49% were diagnosed late (CD4 count < 350 cells/µL). Adults aged 50 years and over were more likely to be diagnosed late (67%) compared with those aged 15-24 years (31%). Sixty-four per cent of heterosexual men were diagnosed late compared with 46% of women and 36% of men who have sex with men (MSM) (P < 0.01). The percentage of late diagnoses was highest among black African adults (66%) compared with other ethnicities; 96% of black African adults diagnosed late were born abroad. Overall, 88% and 97% of patients were linked to care within 1 and 3 months of diagnosis, respectively, with little variation by demographics and exposure category. The crude 1-year mortality rate was 31.6 per 1000 persons diagnosed in 2010. It was highest among adults diagnosed late (40.3/1000 versus 5.2/1000 for prompt diagnoses) and particularly among those aged 50 years and over. Excluding deaths, 85% of the 5833 diagnosed in 2010 were retained in care in 2011; 92% of the 2264 adults diagnosed late in 2010 received antiretroviral therapy by the end of 2011. CONCLUSIONS: The National Health Service provides high-quality care to persons newly diagnosed with HIV infection in the UK, with no evidence of health inequalities. Despite excellent care, half of adults are diagnosed late according to the threshold at which national guidelines recommend treatment should begin. Such patients have an 8-fold increased risk of 1-year mortality compared with those diagnosed promptly. Reducing late diagnosis of HIV infection remains a public health priority in the UK.

Strong absorption and selective emission from engineered metals with dielectric coatings.

We demonstrate strong-to-perfect absorption across a wide range of mid-infrared wavelengths (5-12µm) using a two-layer system consisting of heavily-doped silicon and a thin high-index germanium dielectric layer. We demonstrate spectral control of the absorption resonance by varying the thickness of the dielectric layer. The absorption resonance is shown to be largely polarization-independent and angle-invariant. Upon heating, we observe selective thermal emission from our materials. Experimental data is compared to an analytical model of our structures with strong agreement.

Rising rates of hospital-onset Klebsiella spp. and Pseudomonas aeruginosa bacteraemia in NHS acute trusts in England: a review of national surveillance data, August 2020-February 2021.

Increases in hospital-onset Klebsiella spp. and Pseudomonas aeruginosa bacteraemia rates in England were observed between August 2020 and February 2021 to the highest levels recorded since the start of mandatory surveillance in April 2017. Cases were extracted from England's mandatory surveillance database for key Gram-negative bloodstream infections. Incidence rates for hospital-onset bacteraemia cases increased from 8.9 (N=255) to 14.9 (N=394) per 100,000 bed-days for Klebsiella spp. [incidence rate ratio (IRR) 1.7, P<0.001], and from 4.9 (N=139) to 6.2 (N=164) per 100,000 bed-days for P. aeruginosa (IRR 1.3, P<0.001) (August 2020-February 2021). These incidence rates were higher than the average rates observed during the same period in the previous 3 years. These trends coincided with an increase in the percentage of hospital-onset bacteraemia cases that were also positive for severe acute respiratory syndrome coronavirus-2.

Do all patients attending genitourinary medicine services want to be seen within 48 hours?

At a time of high capacity almost 40% of patients declined an appointment within 48 hours. Data were collected prospectively on the reasons why, and the impact of demand exceeding capacity.

HLA-A, B, Cw, DRB1, DQB1 and DPB1 alleles and haplotypes in the genetically homogenous Irish population.

The frequencies of human leucocyte antigen (HLA) class I and II alleles and haplotypes of 250 Irish unrelated bone marrow donors were determined by high resolution polymerase chain reaction (PCR), using a combination of reverse line blot hybridization and PCR with sequence-specific primers. Phylogenetic analyses indicate that this Irish population is closely related to British, North-western European, American and Australian Caucasian populations. These observations are consistent with recognized historical, geographical, cultural, ethnic and linguistic relationships between these populations and suggest that Irish haematopoietic stem cell transplant recipients have a greater likelihood of finding a phenotypically matched donor within registries based on these populations. HLA-A, B, Cw, DRB1, DQB1 and DPB1 analysis confirms that this young homogenous population is characterized by features of a North-western European anthropological type with limited influence of additional ethnic haplotypes.

Source tracking using microbial community fingerprints: Method comparison with hydrodynamic modelling.

Urban estuaries around the world are experiencing contamination from diffuse and point sources, which increases risks to public health. To mitigate and manage risks posed by elevated levels of contamination in urban waterways, it is critical to identify the primary water sources of contamination within catchments. Source tracking using microbial community fingerprints is one tool that can be used to identify sources. However, results derived from this approach have not yet been evaluated using independent datasets. As such, the key objectives of this investigation were: (1) to identify the major sources of water responsible for bacterial loadings within an urban estuary using microbial source tracking (MST) using microbial communities; and (2) to evaluate this method using a 3-dimensional hydrodynamic model. The Yarra River estuary, which flows through the city of Melbourne in South-East Australia was the focus of this study. We found that the water sources contributing to the bacterial community in the Yarra River estuary varied temporally depending on the estuary's hydrodynamic conditions. The water source apportionment determined using microbial community MST correlated to those determined using a 3-dimensional hydrodynamic model of the transport and mixing of a tracer in the estuary. While there were some discrepancies between the two methods, this investigation demonstrated that MST using bacterial community fingerprints can identify the primary water sources of microorganisms in an estuarine environment. As such, with further optimization and improvements, microbial community MST has the potential to become a powerful tool that could be practically applied in the mitigation of contaminated aquatic systems.

Computerised cognitive behaviour therapy for depression and anxiety update: a systematic review and economic evaluation.

OBJECTIVES: To evaluate computerised cognitive behaviour therapy (CCBT) for the treatment of anxiety, depression, phobias, panic and obsessive-compulsive behaviour (OCD). The software packages to be considered include Beating the Blues (BtB), Overcoming Depression: a five areas approach, FearFighter (FF), Cope and BT Steps. Other packages or programmes incorporating CCBT were also considered. DATA SOURCES: Electronic databases from 1966 to March 2004. Evidence submitted by sponsors for CCBT products. REVIEW METHODS: A systematic review was a review of the literature and the evidence submitted by sponsors for each of the products. A series of cost-effectiveness models was developed and run by the project team for the five CCBT products across the three mental health conditions. RESULTS: Twenty studies were identified in the clinical effectiveness review. The analysis of these results showed some evidence that CCBT is as effective as therapist-led cognitive behaviour therapy (TCBT) for the treatment of depression/anxiety and phobia/panic and is more effective than treatment as usual (TAU) in the treatment of depression/anxiety. CCBT also appears to reduce therapist time compared with TCBT. When reviewing cost-effectiveness studies, only one published economic evaluation of CCBT was found. This was an economic evaluation of the depression software BtB alongside a randomised controlled trial (RCT), which found that BtB was cost-effective against TAU in terms of cost per quality-adjusted life-year (QALY) (less than 2000 pounds), however it contained weaknesses that were then addressed in the cost-effectiveness model developed for the study. The results of the model for the depression software packages in terms of incremental cost per QALY compared with TAU and the chance of being cost-effective at 30,000 pounds per QALY were for BtB 1801 pounds and 86.8%, for Cope 7139 pounds and 62.6% and for Overcoming Depression 5391 pounds and 54.4%. The strength of the BtB software being that it has been evaluated in the context of an RCT with a control group. The subgroup analysis found no differences across the severity groupings. For phobia/panic software, the model showed an incremental cost per QALY of FF over relaxation was 2380 pounds. Its position compared with TCBT is less clear. When modelling OCD packages, using the practice-level licence cost meant that BT Steps was dominated by TCBT, which had significantly better outcomes and was cheaper. However, the cheaper PCT licence resulted in the incremental cost-effectiveness of BT Steps over relaxation being 15,581 pounds and TCBT over BT Steps being 22,484 pounds. CONCLUSIONS: The study findings are subject to substantial uncertainties around the organisational level for purchasing these products and the likely throughput. This is in addition to concerns with the quality of evidence on response to therapy, longer term outcomes and quality of life. The position of CCBT within a stepped care programme needs to be identified, as well as its relationship to other efforts to increase access to CBT and psychological therapies. Research is needed to compare CCBT with other therapies that reduce therapist time, in particular bibliotherapy and to explore the use of CCBT via the Internet. Independent research is needed, particularly RCTs, that examine areas such as patient preference and therapist involvement within primary care.

Mentoring in genitourinary medicine.

Mentoring is a process whereby one doctor (the mentor) facilitates and encourages another doctor (the mentee) to develop their career, in light of their own priorities. Mentees benefit from time dedicated to addressing their needs, challenging the status quo, and exploring ways to change. Mentoring schemes depend on the availability and enthusiasm of suitably trained mentors, as well as the voluntary participation of mentees. The specialty of genitourinary (GU) medicine is setting up such a scheme, which will initially be offered to new consultants. Workshops to train mentors are starting that are specifically tailored to our specialty. We discuss the principles and benefits of mentoring, different models that can be used, and potential difficulties. We also present the results of a survey that demonstrated widespread interest in mentoring within GU medicine.

Mycobacterium kansasii: its presentation, treatment and outcome in HIV infected patients.

AIM: To report the clinical significance and treatment of Mycobacterium kansasii infection in the context of HIV disease. DESIGN/METHODS: Retrospective case review of all isolates of M kansasii until June 1994. RESULTS: Ten cases of M kansasii were isolated. All but one patient with this infection had clinical symptoms compatible with generalised infection. The majority had chest infections with the organism isolated on induced sputum but not routine sputum. All isolates were sensitive to ethambutol and nine of 10 to rifampicin. All isolates were resistant to isoniazid and pyrazinamide. CONCLUSION: M kansasii is a pathogen in HIV infected patients and should be treated when isolated. Treatment should be with rifampicin and ethambutol but not isoniazid, as has been recommended previously.

'Get it on' in the millennium.

Over the Christmas and New Year period the Health Education Authority launched a sexual health promotion campaign aimed at increasing the awareness of and reducing the incidence of sexually transmitted infections (STIs) and unwanted pregnancy. We undertook a study to assess the effect of this campaign locally in 2 genitourinary medicine (GUM) clinics. From our study we concluded the following: (1) Although rarely performed, it is possible to assess the effectiveness of health promotion campaigns. (2) Genitourinary medicine clinics provide a good forum for the assessment of such campaigns. (3) The information obtained from such assessments can be valuable for effective targeting of future campaigns.

Interventions for treating genital chlamydia trachomatis infection in pregnancy.

BACKGROUND: Chlamydia trachomatis is a sexually transmitted infection. Mother-to-child transmission can occur at the time of birth and may result in ophthalmia neonatorum or pneumonitis in the newborn. OBJECTIVES: The objective of this review was to assess the effects of antibiotics in the treatment of genital infection with Chlamydia trachomatis during pregnancy with respect to neonatal and maternal morbidity. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group trials register and the Cochrane Controlled Trials Register (Cochrane Library issue 1, 1999). SELECTION CRITERIA: Randomised trials of any antibiotic regimen compared with placebo or no treatment or alternative antibiotic regimens in pregnant women with genital Chlamydia trachomatis infection. DATA COLLECTION AND ANALYSIS: Trial quality assessments and data extraction were done independently by two reviewers. Study authors were contacted for additional information. MAIN RESULTS: Eleven trials were included. Trial quality was generally good. Amoxycillin appeared to be as effective as erythromycin in achieving microbiological cure (odds ratio 0.54, 95% confidence interval 0.28 to 1.02). Amoxycillin was better tolerated than erythromycin (odds ratio 0.16, 95% confidence interval 0.09 to 0.30). Clindamycin and azithromycin also appear to be effective, although the numbers of women included in trials are small. REVIEWER'S CONCLUSIONS: Amoxycillin appears to be an acceptable alternative therapy for the treatment of genital chlamydial infections in pregnancy when compared with erythromycin. Clindamycin and azithromycin may be considered if erythromycin and amoxycillin are contra-indicated or not tolerated.

Successful use of a moderate analgesic (Fortagesic) in the symptomatic treatment of osteoarthritis.

In a between-patient single blind controlled trial, two groups of patients with osteoarthritis were treated for two weeks with either Fortagesic or naproxen tablets. Onset of analgesia was significantly more rapid with Fortagesic than with naproxen. Other assessments favoured Fortagesic but the differences were not statistically significant. It is concluded that Fortagesic can be successfully used to fill the gap between mild analgesics and the anti-inflammatory agents in the symptomatic treatment of osteoarthritis.

Asymptomatic expansion of the mandible.

Frequently, the first noticeable sign of an odontogenic myxoma is a slowly enlarging, painless expansion of the jaw. Spreading, loosening, and migration of teeth in the area commonly occur. In the early stages, the tumor is asymptomatic, and detection is made only by routine radiographs. Clinicians should be aware of the radiographic changes caused by this benign odontogenic tumor, and include it in their differential consideration of lesions presenting such changes in the jaws. A typical case of a fairly large odontogenic myxoma has been presented. The clinical, radiographic, and histological presentations have been discussed. The tumor was treated by en bloc resection with immediate bone and nerve reconstruction. The patient responded well to therapy and no tumors were found at the 1 year follow-up examination.