Biomedical subjects
Publications and source records attributed to M Ashworth.
We report a case presenting with persistent pyrexia that led to the diagnosis of peripheral T-cell lymphoma, a rare malignancy in childhood. The case illustrates diagnostic conundrums in a patient who is not responding as expected to treatment.
A highly unusual case of a pregnancy complicated by diffuse placental chorioangiomatosis that resulted in a live-birth and short-term fetal survival is reported. The potential for antenatal diagnosis and intrauterine treatment to optimise fetal outcome is discussed.
We aimed to study the relationship between the prescribing of lipid-lowering medication, social deprivation and other general practice characteristics. We conducted a cross-sectional survey of all general practices in England, 2004-05. For each practice, the following variables were obtained: standardized cost and volume data for lipid-lowering medication, descriptors of general practices, Index of Multiple Deprivation, 2004, ethnicity data from the 2001 Census and Quality and Outcomes Framework data. A regression model was constructed which explained 34.5% of the variation in statin prescribing by general practitioners. The most powerful predictors were higher social deprivation, higher prevalence of coronary heart disease and achievement of cholesterol targets for diabetics. Negative regression coefficients were demonstrated for the proportion of elderly patients in the practice and, to a lesser extent, for the proportion of south Asian and Afro-Caribbean patients. In conclusion, contrary to previous local studies, we found that statin prescribing was higher in more deprived communities, even after adjustment for increased disease prevalence and practice variables associated with deprivation. Statin prescribing was also independently associated with success at achieving cholesterol targets in established disease (secondary prevention). However, our findings suggest under-prescribing of statins to the elderly and possibly also to ethnic minorities.
BACKGROUND: The terminology applied to vascular anomalies has been variable in previously published literature making interpretation suboptimal. The International Society for the Study of Vascular Anomalies (ISSVA) has proposed a revised classification based on clinical features and histopathological findings. This classification is increasingly being accepted as clinically useful and a platform for future studies. AIMS: To examine the extent to which the ISSVA classification can be practically applied to diagnostic histopathological specimens. METHODS: Cutaneous vascular lesions received in a single paediatric pathology unit during a 2-year period (2004-5) were reviewed, including glucose transporter protein 1 (GLUT1) immunostaining where required, and lesions were reclassified according to the ISSVA classification. RESULTS: 144 specimens were identified. Appropriate full clinical information was provided in only 17% of cases at submission. Infantile haemangiomas comprised 46% of cases, 18% of which were regressive type, initially inaccurately identified as vascular malformations before GLUT1 immunostaining. 30% of lymphatic malformations and all lymphovenous malformations were previously classified as vascular malformations, not otherwise specified. CONCLUSIONS: The ISSVA classification of vascular anomalies provides a useful framework for histopathologists to classify vascular anomalies. However, meaningful and appropriate use of such a system is dependent on the adequacy of clinical information provided and routine use of immunohistochemical markers.
BACKGROUND: International studies using data aggregated for all ages have shown decreasing rates of general practice consultations for acute respiratory infections with fewer antibiotic prescriptions issued per consultation. The occurrence of different respiratory infections varies widely at different ages but we do not know whether prescribing has reduced equally in all age groups. OBJECTIVE: We aimed to determine how reductions in consultation rates and antibiotic prescribing varied with age for different respiratory infections. METHODS: Data were abstracted from the General Practice Research Database for 108 general practices in the UK (mean registered population 642 685). We estimated age-specific changes between 1995 and 2000 in consultation rates, and the proportion of consultations resulting in an antibiotic prescription for 'all respiratory infections' and for 'sore throat', 'ear infection', 'bronchitis' and 'chest infection'. RESULTS: Consultation rates for 'all respiratory infections' declined in all age groups with the greatest decreases in children aged 1-4 years (41%), 5-10 year olds (53%) and 11-16 year olds (54%), whereas at 75-84 years the reduction was 28%. The pattern of greater reductions in children held for each separate condition even though the age of peak incidence varied. The relative reduction in antibiotic prescribing was greatest at 1-4 years (18%), 5-10 years (17%) and 11-16 years (17%), compared with 5% at 75-84 years. Antibiotic prescribing decreased most for sore throat and this was observed at all ages particularly in 5-10 year olds (relative reduction, 32%). CONCLUSIONS: School age children account for the greatest reduction in consultations for acute respiratory infection. School age and preschool children account for the greatest reductions in antibiotic prescribing during the consultation. The rapid changes in consultation rates are unexplained.
A series of 100 consecutive osteoarthritic patients was randomised to undergo total knee replacement using a Miller-Galante II prosthesis, with or without a cemented polyethylene patellar component. Knee function was evaluated using the American Knee Society score, Western Ontario and McMaster University Osteoarthritis index, specific patellofemoral-related questions and radiographic evaluation until the fourth post-operative year, then via questionnaire until ten years post-operatively. A ten-point difference in the American Knee Society score between the two groups was considered a significant change in knee performance, with alpha and beta levels of 0.05. The mean age of the patients in the resurfaced group was 71 years (53 to 88) and in the non-resurfaced group was 73 years (54 to 86). After ten years 22 patients had died, seven were suffering from dementia, three declined further participation and ten were lost to follow-up. Two patients in the non-resurfaced group subsequently had their patellae resurfaced. In the resurfaced group one patient had an arthroscopic lateral release. There was no significant difference between the two treatment groups: both had a similar deterioration of scores with time, and no further patellofemoral complications were observed in either group. We are unable to recommend routine patellar resurfacing in osteoarthritic patients undergoing total knee replacement on the basis of our findings.
Wilms' tumour commonly presents with an abdominal mass and gross haematuria. Here, we present the novel application of paediatric renal arterial embolisation to control life-threatening haematuria in Wilms' tumour.
OBJECTIVE: To explore the relationship between the income of general practitioners (GPs) and the performance characteristics of their practices. DESIGN: Cross-sectional survey. SETTING: All practices (n = 166) in an inner city health authority, two years before the introduction of the new GP contract in April 2004 were studied. MAIN OUTCOME MEASURES: True income per GP was unavailable to us. Instead, the proxy measure - superannuable pay - was calculated (gross eligible income per GP minus the national average sum for GP expenses). Practice staff funding figures were also obtained. These two financial indicators were compared with practice characteristics and performance indicators. RESULTS: Data were available from 151 out of 166 practices. Based on regression analysis, larger list sizes and higher practice staff budgets predicted 31% of the variation in GP income (standardized beta = 0.66, P < 0.001; beta = 0.19, P = 0.02; respectively). Higher staff budgets were independently associated with better cervical smear and two-year-old vaccination rates (standardized beta = 0.24, P < 0.01; beta = 0.18, P = 0.03; respectively). No association was demonstrated between performance indicators and income. CONCLUSION: Under the previous contract, GPs were able to maximize their income by taking on more patients, whereas achievement of performance targets had very little impact on overall income. The opportunity costs of pursuing higher-quality care might have outweighed the modest financial rewards attached to performance targets. Provided rewards for good-quality care are sufficiently high, the new GP contract is likely to tip the balance in favour of generating earnings by improving the quality of clinical care. To deliver this care, as measured by available performance indicators, our findings imply that a greater investment in practice staff will be needed.
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OBJECTIVE: To evaluate a scheme offering pharmacy referrals for minor ailments in a refugee community. To determine if minor ailments could be managed by pharmacists offering over-the-counter (OTC) medication, free of charge, to refugees exempt from prescription charges. DESIGN: Refugees presenting with minor illnesses were offered a voucher. This voucher could be taken to the pharmacist, who, after a consultation, could exchange the voucher for appropriate OTC medication. SETTING: A refugee community in south London. OUTCOME MEASURES: The presenting minor ailment and corresponding medication as recorded by the pharmacist. RESULTS: A total of 200 vouchers were distributed to 184 refugees over a 5-month period resulting in the dispensing of 264 items. The five most frequent minor ailments were: upper respiratory tract infections (37%), headache (14%), musculo-skeletal pains (7%), allergy including hay fever (6%), indigestion (6%). The five most frequently dispensed items were: paracetamol (28%), sudafed (16%), ibuprofen (11%), aspirin (10%) and simple linctus (8%). Only two clients were referred directly to the GP and two advised to attend if symptoms persisted. CONCLUSIONS: Minor ailment schemes elsewhere have demonstrated the potential to divert about one-third of patients with minor illnesses out of general practice and to care in the pharmacy. Such a scheme is being widely adopted in Scotland this year. Our results are the first to demonstrate the feasibility and acceptability of such a scheme in the refugee community.
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OBJECTIVE: To examine the prescribing incentive schemes used by primary care groups (PCGs); to determine the prescribing indicators used under these schemes; and to assess whether the schemes were seeking to improve the quality of prescribing as well as controlling prescribing costs. DESIGN: Cross-sectional survey. SETTING: A total of 145 PCGs in the London and South-East NHS regions. PARTICIPANTS: Prescribing advisers in each PCG. METHODS: Descriptions of the prescribing indicators monitored by each PCG were obtained from a questionnaire survey of PCGs at the end of the 1999-2000 financial year. Financial information on prescribing and details about the implementation of prescribing incentive schemes for this period became available 6 months later and were obtained by a further questionnaire, follow-up telephone and E-mail surveys. OUTCOME MEASURES: Prescribing indicators, prescribing budgets and spend. RESULTS: One hundred and twenty-one out of 145 (83%) PCGs replied to the questionnaires about prescribing indicators and 129 out of 145 (89%) replied with details about their prescribing costs. The most frequently monitored prescribing indicator was generic prescribing, used by 106 out of 121 (88%) PCGs. The most frequently used clinical areas for prescribing indicators were antibiotics (76% of PCGs), gastro-intestinal prescribing (68%), non-steroidal anti-inflammatories (37%) and cardiovascular prescribing (32%). Seventy-six (63%) schemes also used non-prescribing analysis & cost (PACT) based data for their incentive schemes such as information from prescribing audits and reviews of repeat prescribing protocols. Only 33 (23%) had reached agreement with their practices enabling all prescribing indicator information to be disseminated on a named basis to allow practices to examine each others' prescribing data. CONCLUSIONS: Prescribing incentive schemes usually include targets for improvements in prescribing quality as well as cost. PACT-based data were used for cost control and quality improvement but non-PACT data were almost entirely used to promote prescribing quality improvements. The validity of non-PACT data was questioned as was the choice of some indicators that appeared to have been selected without full consideration of current expert opinion. Further work is needed on which indicators are most likely to act as catalysts to prescribing change.
BACKGROUND: It is not known to what extent general practitioners (GP) can change their prescribing upon joining a commissioning group and what features of a commissioning group may promote prescribing change. The opportunity to study potential prescribing change arose with the formation of a limited number of Primary Care Commissioning Groups (PCCGs), a precursor of Primary Care Groups (PCGs) and Primary Care Trusts (PCTs). METHODS: This was a controlled study of general practice prescribing costs. All practices (n=24) within one inner city PCCG were compared with matched controls that were not part of a PCCG. Cross sectional survey data was collected from the PCCG practices to determine possible reasons for prescribing change. RESULTS: The total annual prescribing cost rose by 4.0% in the PCCG practices and by 6.9% in controls (P=0.01). Significant cost containment was found for gastrointestinal prescribing (P=0.03), attributable to differences in the cost of proton pump inhibitors (PPIs) which fell by 0.7% in the PCCG but rose by 7.3% in controls (P=0.03). Total relative savings in the PCCG practices amounted to around pound 220,000. General practitioners making the greater savings in PPI costs within the PCCG, were more likely to report being influenced by information from the prescribing adviser. CONCLUSION: General practice prescribing costs were contained to a greater degree in practices participating in the PCCG. The differences in gastrointestinal prescribing were most marked for PPIs which were specifically targeted by the prescribing adviser. The GPs themselves attributed their own prescribing change to information provided by the prescribing adviser. Other factors operating within the PCCG may also have influenced prescribing such as a more locally based management system, different financial incentives and a greater degree of co-operative working amongst GPs.
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Sphygmomanometers are the cornerstone of blood pressure management and yet there is no national standard for the regulation of this equipment in the UK. It is known that these machines may often be inaccurate, particularly those used in the community. We embarked upon a survey of all sphygmomanometers in current use in one inner city primary care group. Contrary to our initial hypothesis, inaccuracy rates were lower than in other reported community surveys with 2.3% of mercury and 14.8% of anaeroid sphygmomanometers failing the test. Surprisingly, inaccurate machines did not cluster in the less well developed practices. The implication is that all practices need to have procedures in place for the regular calibration of their sphygmomanometers.
UNLABELLED: Barth syndrome is a metabolic disease characterized by infantile cardiomyopathy, neutropenia and organic aciduria. We report disease evolution in one of the first affected boys to undergo successful cardiac transplantation. CONCLUSION: Although cardiac status stabilized, he developed disabling skeletal myopathy, protracted lymphopenia and--5 y after transplant--fatal Epstein Barr (EBV)-negative T-cell non-Hodgkin's lymphoma.
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