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B Hurwitz

Publications and source records attributed to B Hurwitz.

At least 19 recordsLinked to original sources
PubMed2001

House dust mite avoidance measures for perennial allergic rhinitis.

BACKGROUND: In developed countries, it is estimated that 15% of the general population suffer from one or more allergic disorders, of which allergic rhinitis is the most common. Perennial rhinitis is most often due to allergy to the house dust mite. In such patients, house dust mite avoidance is logical, but there is considerable uncertainty regarding the efficacy and effectiveness of interventions designed to reduce dust mite exposure. OBJECTIVES: To assess the benefit (and harm) of measures designed to reduce house dust mite exposure in the management of house dust mite sensitive allergic rhinitis. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register, Central, MEDLINE and EMBASE. No restrictions on the language of publication were employed. The bibliography of each paper and other published reviews were checked for further references. We wrote to first authors of all included trials in an attempt to identify further published and unpublished trials. SELECTION CRITERIA: Randomised controlled trial (with or without blinding), in which house dust mite control measures have been evaluated in comparison with placebo or other dust mite avoidance measures, in patients with clinician diagnosed allergic rhinitis and confirmed allergy to dust mite. DATA COLLECTION AND ANALYSIS: Two reviewers independently checked titles and abstracts identified by the searches and full text copies of all papers of potential relevance were considered. Trials were graded for methodological quality using the Cochrane approach. Data extraction was performed in a standardised manner. Meta-analysis was neither possible, nor considered appropriate, because of the heterogeneity of the patient groups studied; a narrative overview of the results is therefore presented. MAIN RESULTS: Four trials satisfied the inclusion criteria, all of which were small and of poor quality. Two trials investigated the efficacy of acaricides, a third investigated the role of high-efficiency particulate air (HEPA) filters, whilst a fourth investigated the efficacy of a bedroom environmental control program that comprised use of a barrier mattress cover, fortnightly washing of bed covers, removal of soft furnishings and daily cleaning. Each of the four trials showed the interventions to result in significant reductions in house dust mite load when compared with control. Trial results suggest that the interventions may be effective in reducing some rhinitis symptoms, though it is not possible to provide a reliable summary estimate about the magnitude of such symptom reduction. No serious adverse effects were reported from the interventions. REVIEWER'S CONCLUSIONS: Trials to date have been small and of poor methodological quality making it difficult to offer any definitive recommendations on the role, if any, of house dust mite avoidance measures in the management of house dust mite sensitive perennial allergic rhinitis. The results of these studies suggest that interventions designed to reduce house dust mite exposure in patients with house dust mite allergic perennial rhinitis may be of some benefit in reducing rhinitis symptoms. Data at present is only available for acaricides, HEPA filters and a bedroom-based environmental control program; therefore, if considered appropriate, these should be the interventions of choice.

Animals↗
PubMed2001

Ethical and research dilemmas arising from a questionnaire study of psychological morbidity among general practice managers.

A questionnaire-based research project enquiring into the psychological health of general practice managers found that 5% of managers admitted to suicidal ideas. This paper explores the moral issues raised when research conducted at a distance uncovers information about participants which indicates that they may be at increased risk of harm. It examines whether the authors of such studies have responsibilities towards their research participants beyond those of analysing and properly interpreting the data supplied to them. The paper is an exercise in self-reflection and self-criticism; not all the questions posed and explored by it can be answered definitively. Implications for planning studies of this kind are discussed.

Administrative Personnel↗
PubMed2001

Setting up a database of medical error in general practice: conceptual and methodological considerations.

Though common and the cause of much morbidity and health cost, medical error has until recently attracted little attention from primary care workers. A database that logs medical error, operating within the context of clinical governance initiatives at the level of Primary Care Groups, could provide an appropriate framework within which to scrutinise and identify systematic organisational features associated with risk of serious adverse events. This paper discusses some of the key conceptual and methodological issues that need to be resolved before such a database can be implemented in general practice and considers these deliberations in the light of the Chief Medical Officer for England's recent report, An organisation with a memory.

Clinical Competence↗
PubMed2001

Rationale for the new GP deprivation payment scheme in England: effects of moving from electoral ward to enumeration district underprivileged area scores.

BACKGROUND: The Department of Health introduced a new deprivation payments system for general practitioners (GPs) on 1 April 1999. Following a three-year phasing-in process, registered patients will attract deprivation payments based on the underprivileged area (UPA) score of their enumeration district (ED) of residence, rather than their electoral ward, changing the pattern and distribution of payments throughout England. AIM: To assess the rationale behind the changed deprivation payments system for GPs in England and to examine its impact on GP and practice payments. DESIGN OF STUDY: A quantitative study modelling practice-based deprivation payments. SETTING: A total of 25,450 unrestricted principal GPs in 8919 practices in England. METHOD: The effect of three new components in the system were examined: changes in the ED score ranges attracting payment, the percentage increase in the size of successive payment bands, and the total budget. The relationship between consultation rates (used as a proxy for workload) and UPA score was examined, together with changes in GP payments calculated nationally and by geographical area. RESULTS: A total of 11.6% of the population of England live in wards with a UPA score of 30 or more, qualifying for deprivation payments, and a similar proportion (11.4%) live in EDs with a UPA score of 20 or more. The larger percentage increases in the size of payments in successive ED UPA bands is supported by the modelled relationship between consultation rate and UPA score. Financially, under the new deprivations payment system, entitlement widens with 88% of practices receiving a payment. Overall, 74% of GPs gain and 13% lose (3% losing more than 1500 Pounds), with 13% receiving no payment. CONCLUSION: The new ED system maps onto the previous system well. Moreover, it more finely discriminates between smaller areas of different relative deprivation and, thereby, targets payments more accurately.

Capitation Fee↗
PubMed2001

Topical antibiotics for acute bacterial conjunctivitis: a systematic review.

There has been uncertainty about whether antibiotic therapy confers significant benefit in the treatment of acute bacterial conjunctivitis. This study aimed to assess the efficacy of antibiotic therapy in the management of acute bacterial conjunctivitis. Using standard Cochrane search methods, we identified double-blind randomised controlled trials in which any form of antibiotic treatment (topical, systemic or combination) had been compared with placebo in the management of acute bacterial conjunctivitis. Data extraction and analysis followed a pre-defined protocol. Meta-analysis was performed to obtain summary measures of relative risk. Six published trials were identified, of which three fulfilled the eligibility criteria for inclusion in this review. The trials were heterogeneous in terms of their inclusion and exclusion criteria, the nature of the intervention, and the outcome measures assessed. Meta-analysis indicates that acute bacterial conjunctivitis is frequently a self-limiting condition, as clinical remission occurred by days 2 to 5 in 64% (95% confidence interval (CI) = 57-71) of those treated with placebo. Treatment with antibiotics was, however, associated with significantly better rates of clinical remission (days 2 to 5: relative risk (RR) = 1.31, 95% CI = 1.11-1.55), with a suggestion that this benefit was maintained for late clinical remission (days 6 to 10: RR = 1.27, 95% CI = 1.00-1.61). Acute bacterial conjunctivitis is frequently a self-limiting condition but the use of antibiotics is associated with significantly improved rates of early clinical remission, and early and late microbiological remission. Since trials to date have been conducted in selected specialist care patient populations, generalisation of these results to a primary care-based population should be undertaken with a degree of caution.

Acute Disease↗
PubMed2000

Antibiotics for acute bacterial conjunctivitis.

BACKGROUND: There are concerns regarding whether antibiotic therapy confers significant benefit in the treatment of acute bacterial conjunctivitis. OBJECTIVES: The aim of this review is to assess the benefit and harm of antibiotic therapy in the management of acute bacterial conjunctivitis. SEARCH STRATEGY: We searched the Cochrane Eyes and Vision Group specialised register, the Cochrane Controlled Trials Register - Central, MEDLINE and the reference lists of identified trial reports. We used the Science Citation Index to look for articles that cited the relevant studies, and we contacted investigators and pharmaceutical companies for information about additional trials. The most recent searches were carried out in September 1998. SELECTION CRITERIA: We included double masked randomised controlled trials in which any form of antibiotic treatment had been compared with placebo in the management of acute bacterial conjunctivitis. This included topical, systemic and combination (for example, antibiotics and steroids) antibiotic usage. DATA COLLECTION AND ANALYSIS: One reviewer extracted data and the accuracy was checked by a second reviewer. Relative risks were summarised. We tested for heterogeneity between studies. MAIN RESULTS: Six published trials were identified of which three fulfilled the eligibility criteria for inclusion in this review. One trial was single masked and therefore excluded. A second report, when translated, was found to have no placebo group and was therefore excluded. One trial is currently 'awaiting assessment'. This has been published in abstract form and has yet to be fully reported. All the trials thus far identified appear to have been conducted on a selected specialist care patient population. The trials were heterogeneous in terms of their inclusion and exclusion criteria, the nature of the intervention, and the outcome measures assessed. Meta-analysis indicates that acute bacterial conjunctivitis is frequently a self-limiting condition, as clinical remission (cure or significant improvement) occurred by days two to five in 64% (95% confidence interval (CI) 57% to 71%) of those treated with placebo. Treatment with antibiotics was, however, associated with significantly better rates of clinical remission (days two to five: relative risk (RR) 1.31 95% CI 1.11 to 1.55, NNT=5) with a suggestion that this benefit was maintained for late clinical remission (days six to 10: RR 1.27 95% CI 1.00 to 1.61, NNT=5). Antibiotic treatment was associated with rates of microbiological remission (pathogen eradication or reduction). No serious outcomes were reported in either the active or placebo arms of these trials, indicating that important sight-threatening complications are an infrequent occurrence. REVIEWER'S CONCLUSIONS: Acute bacterial conjunctivitis is frequently a self-limiting condition but the use of antibiotics is associated with significantly improved rates of early clinical remission and early and late microbiological remission. Since trials to-date have been conducted in selected specialist care patient populations these results may not necessarily be generalisable to a primary care based population. A trial based in primary care designed to assess the cost-effectiveness of commonly prescribed antibiotic(s) versus placebo in acute bacterial conjunctivitis is warranted.

Acute Disease↗
PubMed2000

Psychological morbidity in general practice managers: a descriptive and explanatory study.

BACKGROUND: Proposals to establish an occupational health service for primary care should be informed by knowledge of the health needs of general practice employees. AIM: To determine the prevalence and occupational correlates of stress, anxiety, and depression among practice managers in two contrasting health authorities in England. METHOD: A postal questionnaire, soliciting information about stress induced by work-related activities, which contained the General Health Questionnaire (GHQ) and Hospital Anxiety and Depression Scale (HADS), was sent to all 149 practice managers in two health authorities areas of south-east England. RESULTS: Completed questionnaires were returned by 111 (75%) managers; 41/111 (37%) achieved GHQ case status with scores on HADS indicating that 49/111 (44%) classified themselves as anxious and 19/111 (17%) as depressed. The likelihood of being a case was found to be higher in managers from practices with larger numbers of GP partners (P = 0.02) and in managers from practices not in receipt of deprivation payments (P = 0.03). Multiple logistic regression showed that managers' perceived difficulties with general practice administration duties (relative ratio [RR] = 3.27, 95% confidence interval [CI] = 1.22-8.75) and dealings with GPs (RR = 1.86, 95% CI = 1.03-3.34) were the most powerful predictors of case status. CONCLUSION: The questionnaire uncovered high prevalences of self-reported stress, anxiety, and depression in general practice managers. Although the vast majority of National Health Service (NHS) employees have access to an occupational health service, no such source of support exists for those working in general practice. The NHS needs to establish an occupational health service that caters to the needs of clinical and non-clinical members of primary health care teams.

Administrative Personnel↗
PubMed1999

Explaining differences in English hospital death rates using routinely collected data.

OBJECTIVES: To ascertain hospital inpatient mortality in England and to determine which factors best explain variation in standardised hospital death ratios. DESIGN: Weighted linear regression analysis of routinely collected data over four years, with hospital standardised mortality ratios as the dependent variable. SETTING: England. SUBJECTS: Eight million discharges from NHS hospitals when the primary diagnosis was one of the diagnoses accounting for 80% of inpatient deaths. MAIN OUTCOME MEASURES: Hospital standardised mortality ratios and predictors of variations in these ratios. RESULTS: The four year crude death rates varied across hospitals from 3.4% to 13.6% (average for England 8.5%), and standardised hospital mortality ratios ranged from 53 to 137 (average for England 100). The percentage of cases that were emergency admissions (60% of total hospital admissions) was the best predictor of this variation in mortality, with the ratio of hospital doctors to beds and general practitioners to head of population the next best predictors. When analyses were restricted to emergency admissions (which covered 93% of all patient deaths analysed) number of doctors per bed was the best predictor. CONCLUSION: Analysis of hospital episode statistics reveals wide variation in standardised hospital mortality ratios in England. The percentage of total admissions classified as emergencies is the most powerful predictor of variation in mortality. The ratios of doctors to head of population served, both in hospital and in general practice, seem to be critical determinants of standardised hospital death rates; the higher these ratios, the lower the death rates in both cases.

Data Collection↗
PubMed1998

Investigation by Parkinson's Disease Research Group of United Kingdom into excess mortality seen with combined levodopa and selegiline treatment in patients with early, mild Parkinson's disease: further results of randomised trial and confidential inquiry.

OBJECTIVE: To determine whether the excess mortality observed in patients who received both levodopa and selegiline in a randomised trial could be explained by revised diagnosis of Parkinson's disease, autonomic or cardiovascular effects, more rapid disease progression, or drug interactions. DESIGN: Open randomised trial and blind comparison and reclassification of the cause of death of patients who were recruited from 93 hospitals between 1985 and 1990 and who had died before December 1993 in arms 1 and 2. SETTING: United Kingdom. SUBJECTS: 624 patients with early Parkinson's disease who were not receiving dopaminergic treatment and a subgroup fo 120 patients who died during the trial. INTERVENTIONS: Levodopa and a dopa carboxylase inhibitor (arm 1), levodopa and a dopa decarboxylase inhibitor in combination with selegiline (arm 2), or bromocriptine alone (arm 3). MAIN OUTCOME MEASURES: All cause mortality for 520 subjects in arms 1 and 2 and for 104 subjects who were randomised into these arms from arm 3. Cause specific mortality for people who died in the original arms 1 and 2 on the basis of the opinion of a panel, revised diagnosis and disability ratings, evidence from clinical records of either autonomic or cardiovascular episodes, other clinical features before death, and drug interactions. RESULTS: After extended follow up (mean 6.8 years) until the end of September 1995, when arm 2 was terminated, the hazard ratio for arm 2 compared with arm 1 was 1.32 (95% confidence interval 0.98 to 1.79). For subjects who were randomised from arm 3 the hazard ratio for arm 2 was 1.54 (0.83 to 2.87). When all subjects were included the hazard ratio was 1.33 (1.02 to 1.74) and after adjustment for other baseline factors it was 1.30 (0.99 to 1.72). The excess mortality seemed to be greatest in the third and fourth year of follow up. Cause specific death rates showed an excess of deaths from Parkinson's disease only (hazard ratio 2.5 (1.3 to 4.7)). No significant differences were found for revised diagnosis, disability rating scores, autonomic or cardiovascular events, other clinical features, or drug interactions. Patients who died in arm 2 were more likely to have had possible dementia and a history of falls before death compared with those who died in arm 1. CONCLUSION: The results consistently show excess mortality in patients treated with combined levodopa and selegiline. Revised diagnosis, autonomic or cardiovascular events, or drug interactions could not explain this finding, but falls and possible dementia were more common in arm 2. The results do not support combined treatment in patients with newly diagnosed Parkinson's disease. In more advanced disease, combined treatment should perhaps be avoided in patients with postural hypotension, frequent falls, confusion, or dementia.

Antiparkinson Agents↗
PubMed1998

The implementation of prompted retinal screening for diabetic eye disease by accredited optometrists in an inner-city district of North London: a quality of care study.

Diabetic retinopathy remains the most common cause of blindness in people of working age but the provision of high quality eye screening for diabetic patients is still erratic in many health districts in the UK. National consensus guidelines recommend comprehensive population coverage, high sensitivity (>80%), high specificity (>95%), agreed clinical criteria, referral procedures and centralized data collection to facilitate audit. This study looks at the effectiveness of implementing a prompted recall programme for retinal screening in an inner-city district of North London. The scheme uses trained, accredited optometrists to screen patients with diabetes who are looked after in the community by their general practitioner. During the first 17 months of the scheme, 63 optometrists attended training and gained accreditation. Of the 666 patients recruited, 645 were scheduled for screening and 536 (83%) attended. Fourteen per cent of patients screened were found to have background retinopathy and 2.3% sight-threatening eye disease. In two audits, carried out 15 months apart in a random sample of GP practices, the incidence of recorded dilated fundoscopy increased from 48% at baseline to 56%, an increase of 8% (95% CIs 2%-14%). For referable eye disease, the sensitivity of this screening technique was 100%, the specificity 94% (95% CIs 90%-98%), the positive predictive value 79% (95% CIs 72%-86%) and the negative predictive value 100%. The administrative cost per case screened was Pound Sterling 12.60 (excluding clinical costs and any additional optometry payment).

Diabetic Retinopathy↗