Histopathological features of gastrointestinal mucosal biopsy specimens in children with epidermolysis bullosa.
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Adolescent↗
Biomedical subjects
E Freeman
Publications and source records attributed to E Freeman.
Clinical relevance of laboratory-reported antibiotic resistance in acute uncomplicated urinary tract infection in primary care.
OBJECTIVES: To determine whether patients with an uncomplicated community-acquired urinary tract infection (UTI) and an isolate resistant to trimethoprim had worse clinical outcomes following empirical treatment with trimethoprim 200 mg twice daily for 3 days than did those with a susceptible isolate. PATIENTS AND METHODS: This was a prospective cohort study of clinical outcome. We enrolled 497 women (>or=18-70 years) presenting to general practitioner surgeries in Norwich and Gloucester with at least two symptoms of acute (<7 days) uncomplicated UTI. Significant bacteriuria was defined as >or=10(4) cfu/mL from a mid-stream urine (MSU). RESULTS: Of enrolled patients 75% (334/448) had significant bacteriuria, and trimethoprim resistance was present in 13.9% (44/317) of isolates. Patients with resistant isolates had a longer median time to symptom resolution (7 versus 4 days, P=0.0002), greater reconsultation to the practice (39% versus 6% in first week, P<0.0001), more subsequent antibiotics (36% versus 4% in first week, P<0.0001) and higher rates of significant bacteriuria at 1 month (42% versus 20% with susceptible isolate, P=0.04). Half of patients reconsulting in the first week had a resistant organism. CONCLUSIONS: Patients with uncomplicated UTI caused by trimethoprim-resistant organisms had significantly worse clinical outcomes than those with trimethoprim-susceptible organisms. Nevertheless, trimethoprim resistance was rarer than predicted from routine laboratory submissions and we calculate that 23 women require microbiological investigation to prevent one reconsultation arising from resistance-based treatment failure. We therefore suggest empirical antibiotic treatment in acute, uncomplicated UTIs. If patients reconsult in the first week, we suggest a change of antibiotic treatment with urine culture and susceptibility testing then done. More generally, laboratory resources should concentrate on resistance surveillance to inform empirical antibiotic choice.
Acute Disease↗
Interactions between attention and perceptual grouping in human visual cortex.
Freeman et al. demonstrated that detection sensitivity for a low contrast Gabor stimulus improved in the presence of flanking, collinearly oriented grating stimuli, but only when observers attended to them. By recording visual event-related potentials (ERPs) elicited by a Gabor stimulus, we investigated whether this contextual cueing effect involves changes in the short-latency afferent visual signal from V1 that have a stimulus onset latency between 60 and 80 ms and/or longer-latency changes from visual cortex. Under dual-task conditions, the subjects performed contrast discrimination for a central Gabor and an orientation judgment for a pre-specified subset of the flanking Gabors. On random trials, the central Gabor could be collinearly or orthogonally oriented with respect to the attended flankers. Subjects showed improvements in discriminating the contrast of the central grating when it was oriented collinearly with the attended flankers. The ERP difference between attending to collinear versus orthogonal flankers manifested as a positive polarity response at occipital electrodes with a latency of 180-250 ms after stimulus onset. No shorter-latency contextual cueing differences were observed in the ERPs. The ERP latency profile of the contextual cueing effect argues against the hypothesis that short-latency afferent activity from V1 is the stage of processing at which attention can influence neuronal lateral interactions. However, the scalp voltage distribution of the longer-latency contextual cueing effect is similar to the one generated by the early phasic stimulus onset activity from V1. These findings leave open the possibility that V1 is involved in the attentional modulation of lateral interactions but that this has a longer time course, likely being mediated by re-afferent inputs from later stages of the visual pathway.
Adolescent↗
Urinary catheterization in care homes for older people: self-reported questionnaire audit of catheter management by care home staff.
A self-administered questionnaire was used to determine care home staff's reported knowledge of the urinary catheter care standards published by the National Institute for Clinical Excellence (NICE) and the Association of Continence Care, and to see whether this differed in homes with higher catheterization rates. Seven hundred and fifty out of 1438 (52%) nursing and care staff from 37 randomly selected care homes with high, medium and low catheterization rates responded. There was no difference in reported practice in care homes in the three health districts sampled or those with differing catheterization rates. Eighty-three percent of the nursing staff and 40% of the other care staff received formal catheter care training. However, at least 10% of all staff reported not washing their hands before handling a catheter, and delaying emptying a urine bag until it was full, rather than three-quarters full. Only 45% of nursing staff and 40% of other care staff encouraged residents to empty their own catheter bags. Routine use of catheter maintenance solutions or bladder washouts was reported by 50% of all staff. Nursing staff (29%) and other care staff (54%) took urine specimens from the catheter bag tap. Compliance with standards has improved greatly since an audit in 1998. However, some non-compliance remains. There is a need for ongoing local audit and formal training in urinary catheter care, particularly for non-qualified care staff. Education is needed to ensure local implementation of NICE guidance.
Aged↗
Variation in the use of H. pylori tests in UK general practice--a qualitative study.
BACKGROUND: Although serology is the main Helicobacter pylori test used by general practitioners in the UK, there is no information available on variation in requesting rates. AIM: To explore the reasons for any variation in H. pylori serology testing by general practices in the UK using qualitative methods. METHODS: Serology requesting rates were determined using laboratory and population data. Staff from randomly selected practices in the lowest and highest quintiles of testing attended focus groups to discuss the management of H. pylori and dyspepsia. Transcribed data were analysed using an interpretative phenomenological approach. RESULTS: Serology submission varied 600-fold (0.1-59/1000 population/year) and H. pylori positivity rate 17-100%. Low-testing practices were less aware of the benefits of H. pylori testing and had shorter endoscopy waiting times. They preferred endoscopy diagnosis over serology test. Three high-testing practices had a high non-white population with high H. pylori positivity. Most staff knew little about the predictive value of serology, the availability of urea breath test on prescription or the existence of a stool test. CONCLUSIONS: Seroprevalence of H. pylori is still high in dyspeptics, especially in non-white populations. Laboratories and primary care trusts should audit H. pylori requests and endoscopy referrals, target education at high endoscopy referrers and low H. pylori testers and inform clinicians of the more accurate H. pylori tests and NICE dyspepsia guidance.
Clinical Competence↗
Electrophysiological correlates of lateral interactions in human visual cortex.
Detection thresholds for visually presented targets can be influenced by the nature of information in adjacent regions of the visual field. For example, detection thresholds for low-contrast Gabor patches decrease when flanked by patches that are oriented collinearly rather than orthogonally with the target. Such results are consistent with the known microanatomy of primary visual cortex, where long-range horizontal connections link cortical columns with common orientation preferences. To investigate the neural bases of collinearity effects, we recorded event-related brain potentials (ERPs) together with psychophysical measures for targets flanked by collinear vs. orthogonal gratings. Human volunteers performed a contrast discrimination task on a target grating presented at a perifoveal location. For targets flanked by collinear stimuli, we observed an increased positive polarity voltage deflection in the occipital scalp-recorded ERPs between 80 to 140 ms after stimulus onset. Such a midline occipital scalp voltage distribution of this ERP collinearity effect is consistent with a generator in primary visual cortex. Two later negative voltage ERP deflections (latencies of 245-295 and 300-350 ms) were focused at lateral occipital scalp sites, a pattern consistent with activity in extrastriate visual cortex. These ERP effects were correlated with improved contrast discrimination for central targets presented with collinear flanks. These results demonstrate that the integration of local flanking elements with a central stimulus can occur as early as 80 ms in human visual cortex, but this includes processes occurring at longer latencies and appears to involve both striate and extrastriate visual areas.
Adolescent↗
Diagnosis of genital chlamydia in primary care: an explanation of reasons for variation in chlamydia testing.
OBJECTIVES: To explore the reasons for the 40-fold variation in diagnostic testing for genital Chlamydia trachomatis by general practices. METHODS: A qualitative study with focus groups. We randomly selected urban and rural high and low testing practices served by Bristol, Hereford, and Gloucester microbiology laboratories. Open questions were asked about the investigation of C trachomatis in men and women in different clinical contexts. RESULTS: The high and low testing practices did not differ in their age/sex make-up or by deprivation indices. There were major differences between high and low chlamydia testing practices. Low testing practices knew very little about the epidemiology and presentation of genital chlamydia infection and did not consider it in their differential diagnosis of genitourinary symptoms until patients had consulted several times. Low testers were less aware that chlamydia was usually asymptomatic, thought it was an inner city problem, and had poor knowledge of how to take diagnostic specimens. High testing practices either had a general practitioner with an interest in sexual health or a practice nurse who had completed specialist training in family planning. High testing practices were more cognizant of the symptoms and signs of chlamydia and always considered it in their differential diagnosis of genitourinary symptoms, including patients attending family planning clinics. CONCLUSIONS: Any programme to increase chlamydia testing in primary care must be accompanied by an education and awareness programme especially targeted at low testing practices. This will need to include information about the benefits of testing and who, when, and how to test.
Adolescent↗
Prevalence of urinary catheterization in UK nursing homes.
A postal questionnaire survey was undertaken in registered nursing homes in three different health districts in England: Gloucestershire, North Staffordshire and Leeds. Nursing homes may be registered as general nursing or mental health homes. If homes also have provision for residential beds these are defined as dual registered homes. Overall, 9% (438/4900) of residents, with an equal male:female split, had urinary catheters. There was no significant difference in the overall urinary catheterization rate in the three districts (P=0.9). There was a wide range of urinary catheterization prevalence between homes, with some homes of all three categories having no catheterized residents and several with a prevalence of over 40%. The wide range of prevalence may be due to differences in residents' underlying medical conditions or to differences in attitudes towards urinary catheterization by nursing home staff. Almost all homes (114/124, 92%) stated they had an infection control policy, but 31% (38/124) did not have a written policy on urinary catheter care. In view of the potential for morbidity, infection control policies should include a section on the care of urinary catheters and this should form part of the continuing training of nursing home staff.
Aged↗
Breathing retraining for dysfunctional breathing in asthma: a randomised controlled trial.
BACKGROUND: Functional breathing disorders may complicate asthma and impair quality of life. This study aimed to determine the effectiveness of physiotherapy based breathing retraining for patients treated for asthma in the community who have symptoms suggestive of dysfunctional breathing. METHODS: 33 adult patients aged 17-65 with diagnosed and currently treated asthma and Nijmegen questionnaire scores > or =23 were recruited to a randomised controlled trial comparing short physiotherapy breathing retraining and an asthma nurse education control. The main outcome measures were asthma specific health status (Asthma Quality of Life questionnaire) and Nijmegen questionnaire scores RESULTS: Of the 33 who entered the study, data were available on 31 after 1 month and 28 at 6 months. The median (interquartile range) changes in overall asthma quality of life score at 1 month were 0.6 (0.05-1.12) and 0.09 (-0.25-0.26) for the breathing retraining and education groups, respectively (p=0.018), 0.42 (0.11-1.17) and 0.09 (-0.58-0.5) for the symptoms domain (p=0.042), 0.52 (0.09-1.25) and 0 (-0.45-0.45) for the activities domain (p=0.007), and 0.50 (0-1.50) and -0.25 (-0.75-0.75) for the environment domain (p=0.018). Only the change in the activities domain remained significant at 6 months (0.83 (-0.10-1.71) and -0.05 (-0.74-0.34), p=0.018), although trends to improvement were seen in the overall score (p=0.065), the symptoms domain (p=0.059), and the environment domain (p=0.065). There was a correlation between changes in quality of life scores and Nijmegen questionnaire scores at 1 month and at 6 months. The number needed to treat to produce a clinically important improvement in health status was 1.96 and 3.57 at 1 and 6 months. CONCLUSION: Over half the patients treated for asthma in the community who have symptoms suggestive of dysfunctional breathing show a clinically relevant improvement in quality of life following a brief physiotherapy intervention. This improvement is maintained in over 25% 6 months after the intervention.
Administration, Inhalation↗
Laboratory diagnosis of urinary symptoms in primary care--a qualitative study.
The use of the microbiology laboratory for the investigation of urinary symptoms and the test positivity rate for the urine specimens varies considerably. We used qualitative methods to explore how and why primary care staff make diagnostic and management decisions in patients presenting with urinary symptoms. Stratified random sampling was used to include general practitioner (GP) practices that were heavy and light users of the microbiology service. The data were analysed using a modified grounded theory approach utilising the constant comparative method. Frequent users of the laboratory, with low specimen positivity, did not use near patient tests (NPTs) and sent urines from most patients with urinary symptoms to confirm their clinical diagnosis. Frequent users with high positivity advise patients with negative NPTs and send all specimens with positive NPTs for antibiotic susceptibility testing. Infrequent users did not value the laboratory for diagnosis, made great use of NPTs, and tended to prescribe empirical antibiotic treatment even in patients with minimal symptoms. Guidance on the management of urinary symptoms, the use of near patient tests and laboratory culture should form part of the ongoing education of primary care staff.
Anti-Bacterial Agents↗
Prevalence of dysfunctional breathing in patients treated for asthma in primary care: cross sectional survey.
OBJECTIVES: To estimate the prevalence of dysfunctional breathing in adults with asthma treated in the community. DESIGN: Postal questionnaire survey using Nijmegen questionnaire. SETTING: One general practice with 7033 patients. PARTICIPANTS: All adult patients aged 17-65 with diagnosed asthma who were receiving treatment. MAIN OUTCOME MEASURE: Score >/=23 on Nijmegen questionnaire. RESULTS: 227/307 patients returned completed questionnaires; 219 (71.3%) questionnaires were suitable for analysis. 63 participants scored >/=23. Those scoring >/=23 were more likely to be female than male (46/132 (35%) v 17/87 (20%), P=0.016) and were younger (mean (SD) age 44.8 (14.7) v 49.0 (13.8, (P=0.05). Patients at different treatment steps of the British Thoracic Society asthma guidelines were affected equally. CONCLUSIONS: About a third of women and a fifth of men had scores suggestive of dysfunctional breathing. Although further studies are needed to confirm the validity of this screening tool and these findings, these prevalences suggest scope for therapeutic intervention and may explain the anecdotal success of the Buteyko method of treating asthma.
Adolescent↗
Segmentation, attention and phenomenal visual objects.
Issues concerning selective attention provoke new questions about visual segmentation, and vice-versa. We illustrate this by describing our recent work on grouping under conditions of inattention, on change blindness for background events and the residual processing of undetected background changes, on modal versus amodal completion in visual search, and the differential effects of these two forms of completion on attentional processes, and on attentional modulation of lateral interactions thought to arise in early visual cortex. Many of these results indicate that segmentation processes substantially constrain attentional processes, but the reverse influence is also apparent, suggesting an interactive architecture. We discuss how the 'proto-objects' revealed by studies of segmentation and attention (i.e. the segmented perceptual units which constrain selectivity) may relate to other object-based notions in cognitive science, and we wrestle with their relation to phenomenal visual awareness.
Attention↗
Lateral interactions between targets and flankers in low-level vision depend on attention to the flankers.
Detection of an oriented visual target can be facilitated by collinear visual flankers. Such lateral interactions are thought to reflect integrative processes in low-level vision. In past studies, the flankers were task-irrelevant, and were typically assumed to be unattended. Here we manipulated attention to the flankers directly, by requiring observers to judge the relative alignment of two flankers while ignoring a second flanker-pair. Under identical stimulus conditions, attended flankers produced typical lateral interactions, but ignored flankers did not. These data show that lateral interactions can depend on attention to the flanking context, revealing the functional consequences of attentional modulation in low-level vision.
Humans↗
Inter-rater reliability of stroke sub-type classification by neurologists and nurses within a community-based stroke incidence study.
The stroke classification developed for use in the Oxfordshire Community Stroke Project (OCSP) is simple, clinically meaningful and requires no investigations. However, its inter-rater reliability in a community setting is unknown. We aimed to assess the inter-rater reliability of this classification among neurologists and nurses within a community-based stroke incidence study. Fifty-four stroke patients with cerebral infarction who were registered in the North East Melbourne Stroke Incidence Study (NEMESIS) were assigned OCSP classifications by two neurologists and one of seven research nurses. There was moderate agreement between neurologists (kappa = 0.53), fair agreement between neurologist 1 and nurse (kappa = 0.31) and moderate agreement between neurologist 2 and nurse (kappa = 0.45). Disagreement about the neurological signs was an important reason for classification differences. The OCSP classification can be easily applied in a community setting with moderate inter-rater reliability and is thus a useful instrument for commun ity-based epidemiological studies.
Australia↗
Combined homicide-suicide in Galveston County.
Combined homicide-suicides have been classified based on the psychopathology of the perpetrator and the nature of the relationship between perpetrator and victim(s). To further understand the nature of this tragic phenomenon and to test the validity and practicality of a previously suggested classification system, investigators systematically collected data on all combined homicide-suicide events that occurred in Galveston County, Texas over a continuous 18-year period (n = 20). The most common psychopathological finding for perpetrators was high serum alcohol levels that suggested intoxication. Most combined homicide-suicides fell into one of the relational categories and most of these, as predicted, were of the consortial type, possessive subtype. As expected, due to the small sample size, the less common types of combined homicide-suicide were not represented in this sample.
Adolescent↗
Parents' perspectives on the MMR immunisation: a focus group study.
BACKGROUND: The uptake of the combined measles, mumps and rubella immunisation (MMR) in Britain has fallen since 1998, when a link was hypothesised with the development of bowel disorders and childhood autism. Despite reassurances about the safety of MMR, uptake levels remain lower than optimal. We need to understand what influences parents' decisions on whether to accept MMR or not so that health professionals can provide a service responsive to their needs. AIM: To investigate what influences parents' decisions on whether to accept or refuse the primary MMR immunisation and the impact of the recent controversy over its safety. DESIGN: Qualitative study using focus group discussions. SETTING: Forty-eight parents, whose youngest child was between 14 months and three years old, attended groups at community halls in six localities in Avon and Gloucestershire. METHODS: Purposive sampling strategy was used to include parents from a variety of socioeconomic backgrounds. Three groups comprised parents who had accepted MMR and three groups comprised parents who had refused MMR. Data analysis used modified grounded theory techniques incorporating the constant comparative method. RESULTS: All parents felt that the decision about MMR was difficult and stressful, and experienced unwelcome pressure from health professionals to comply. Parents were not convinced by Department of Health reassurances that MMR was the safest and best option for their children and many had accepted MMR unwillingly. Four key factors influenced parents' decisions: (a) beliefs about the risks and benefits of MMR compared with contracting the diseases, (b) information from the media and other sources about the safety of MMR, (c) confidence and trust in the advice of health professionals and attitudes towards compliance with this advice, and (d) views on the importance of individual choice within Government policy on immunisation. CONCLUSIONS: Parents wanted up-to-date information about the risks and benefits of MMR to be available in advance of their immunisation appointment. Many parents did not have confidence in the recommendations of health professionals because they were aware that GPs needed to reach immunisation targets. Most parents would, however, welcome more open discussion about immunisation with health professionals.
Adult↗
Changes in cerebral blood flow associated with premenstrual syndrome: a preliminary study.
The purpose of this study was to determine changes in regional cerebral blood flow (rCBF) associated with premenstrual syndrome (PMS). Regional CBF was examined using single photon emission computed tomography (SPECT) in seven women who sought treatment for PMS and seven control subjects. Confirmation of PMS was based on the Daily Symptom Report (DSR) of 17 common symptoms associated with PMS. A first SPECT scan was performed near the peak of premenstrual symptoms based on DSR reports from the two previous cycles. A second scan was performed in the postmenstrual period. Prior to scanning, each subject had a Hamilton Depression Rating Scale (Ham-D) obtained. Regions of interest were drawn on the images to generate mean counts per pixel, and normalized to the cerebellum. Activity in the frontal, temporal and parieto-occipital cortices, and the thalami and basal ganglia, were compared between the two scans. Correlations between activity in each region of interest and Ham-D values were also determined. There were marked decreases in rCBF in the temporal lobes on the premenstrual scan compared to the postmenstrual scan in PMS patients. Significant correlations were observed between the change in rCBF in the right and left temporal lobes and the changes in Ham-D scores (r = 0.91, p < 0.01 and r = 0.86, p = 0.01 respectively). No rCBF changes were observed in controls. We conclude that SPECT imaging demonstrates modest decreases in rCBF in the temporal lobes that correlate with the level of depression in subjects with PMS.
Adult↗
Rapid amperometric verification of PCR amplification of DNA.
Amplification of an 800-base template was verified in a 10-min test on a 2-microL sample of the PCR product solution. For verification, digoxigeninylated primers and biotinylated d-UTP-16-biotin were added to the amplification solution. The resulting amplified product was digoxigeninlabeled at its 3'-end and was also labeled with multiple biotin functions along its chain. The detecting electrode was coated with an electron-conducting redox hydrogel to which anti-digoxin monoclonal antibody was covalently bound. The amplified DNA was captured by the electrode through conjugation of its 3'-digoxigenin with the antibody. Exposure to a solution of horseradish peroxidase-labeled avidin led to capture of the enzyme and switched the redox hydrogel from a noncatalyst to catalyst for H2O2 electroreduction. The switching resulted in an H2O2 electroreduction current density of 2.1 +/- 0.9 microA cm-2 in 10-4 M H2O2 at Ag/AgCl potential and at 25 degrees C.
DNA↗