Guiding hands of our teachers.
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Attitude of Health Personnel↗
Biomedical subjects
P Bradley
Publications and source records attributed to P Bradley.
Specialist epilepsy nurses for treating epilepsy.
BACKGROUND: Epilepsy is the most common serious neurological condition after stroke, with a 0.5 per cent prevalence, and a two to three per cent life time risk of being given a diagnosis of epilepsy in the developed world. As a result of the perceived deficiencies and suggestions to improve the quality of care offered to people with epilepsy, two models of service provision have been suggested by researchers: specialist epilepsy out-patient clinics (as opposed to the management of patients in general neurology clinics or general medical clinics) and nurse-based liaison services between primary (GP) and secondary/tertiary (hospital based) care. OBJECTIVES: The aim of this review is to overview the evidence from controlled trials investigating the effectiveness of specialist epilepsy nurses compared to routine care. SEARCH STRATEGY: The following databases were searched: The Cochrane Controlled Trials Register (The Cochrane Library, Issue 4, 1999), MEDLINE, GEARS, BIDS (EMBASE=Excepta Medica), ECRI, Effectiveness Healthcare Bulletin, Effectiveness Matters, Bandolier, Evidence Based Purchasing, National Research Register, Vignettes and expert panels from Standing Group on Health Technology Assessment, PsycLit database, World Wide Web sites and reference lists of articles. SELECTION CRITERIA: All randomized controlled and quasi-randomized trials which considered specialist epilepsy nurse interventions with standard or alternative care were included in this review. DATA COLLECTION AND ANALYSIS: Two reviewers independently selected trials for inclusion and extracted the relevant data. The following outcomes were assessed: (a) seizure frequency (b) appropriateness of medication prescribed (c) social or psychological functioning scores (d) knowledge about epilepsy scores (e) objective measures of general health status/quality of life (f) patients' reports of information received (g) number of days spent on sick leave/missing school and employment status (h) costs of care (i) adverse effects. MAIN RESULTS: Three trials were included, two based in general practice and one in a neurology centre. The population of patients differed between trials, for example one study excluded patients with learning disabilities, and one only recruited patients with a new diagnosis. In view of this heterogeneity we decided not to pool results in a meta-analysis. As yet, there is no convincing evidence that specialist epilepsy nurses improve outcomes for people with epilepsy overall. Important outcomes (e.g. seizure frequency, psychosocial functioning, knowledge of epilepsy, general health status, work days lost, depression and anxiety scores) show no significant improvement. There is some evidence that those patients who have not had an epileptic seizure in the last six months are less at risk for depression. There is also evidence that newly diagnosed patients whose knowledge about epilepsy is poor may improve their epilepsy knowledge scores after nurse intervention. REVIEWER'S CONCLUSIONS: It is clearly plausible that specialist epilepsy nurses could improve quality in epilepsy care. However, there is as yet little evidence to support this assumption as the present research base is small. Further research is needed to investigate the effectiveness of specialist epilepsy nurses before such recommendations can be made.
Epilepsy↗
Epilepsy clinics versus general neurology or medical clinics.
BACKGROUND: Epilepsy is the most common serious neurological condition after stroke, with a 0.5 per cent prevalence, and a two to three per cent life time risk of being given a diagnosis of epilepsy in the developed world. As a result of perceived deficiencies of the quality of care offered to people with epilepsy, two models of service provision have been suggested by researchers: specialist epilepsy out-patient clinics (as opposed to the management of patients in general neurology clinics or general medical clinics) and nurse-based liaison services between primary (GP) and secondary/tertiary (hospital based) care. OBJECTIVES: The aim of this review was to overview the evidence from controlled trials investigating the effectiveness of specialist epilepsy clinics compared to routine care. A second similar review investigating the effectiveness of specialist epilepsy nurses is also underway. SEARCH STRATEGY: We searched the Cochrane Epilepsy Group trials register, the Cochrane Controlled Trials Register (Cochrane Library Issue 4, 1999), MEDLINE (January 1966 to December 1999), GEARS, BIDS (EMBASE=Excepta Medica(1998-99)), ECRI, Effectiveness Healthcare Bulletin, Effectiveness Matters, Bandolier, Evidence Based Purchasing, National Research Register, Vignettes and expert panels from Standing Group on Health Technology Assessment, PsycLit database, World Wide Web sites and reference lists of articles. In addition, we contacted experts in the field. SELECTION CRITERIA: All randomized controlled and quasi-randomized trials which considered specialist epilepsy clinic interventions with standard or alternative care were included in this review. DATA COLLECTION AND ANALYSIS: No controlled trials of suitable quality were identified for inclusion in the review. MAIN RESULTS: No controlled trials of suitable quality were identified for inclusion in the review. REVIEWER'S CONCLUSIONS: It is not known whether specialist epilepsy clinics improve outcomes for people with epilepsy. As yet, there is no high quality evidence which describes their effectiveness in improving care for people with epilepsy.
Epilepsy↗
A basic protocol for functional assessment of voice pathology, especially for investigating the efficacy of (phonosurgical) treatments and evaluating new assessment techniques. Guideline elaborated by the Committee on Phoniatrics of the European Laryngological Society (ELS).
The proposal of this basic protocol is an attempt to reach better agreement and uniformity concerning the methodology for functional assessment of pathologic voices. The purpose is to allow relevant comparisons with the literature when presenting/publishing the results of voice treatment, e.g. a phonosurgical technique, or a new/improved instrument or procedure for investigating the pathological voice. Meta-analyses of the results of voice treatments are generally limited and may even be impossible owing to the major diversity in the ways functional outcomes are assessed. A multidimensional set of minimal basic measurements suitable for all "common" dysphonias is proposed. It includes five different approaches: perception (grade, roughness, breathiness), videostroboscopy (closure, regularity, mucosal wave and symmetry), acoustics (jitter, shimmer, Fo-range and softest intensity), aerodynamics (phonation quotient), and subjective rating by the patient. The protocol is elaborated on the basis of an exhaustive review of the literature, of the experience of the Committee members, and of plenary discussions within the European Laryngological Society. Instrumentation is kept to a minimum, but it is considered essential for professionals performing phonosurgery.
Clinical Protocols↗
Serendipity -- yet another nail in the coffin.
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Clinical Competence↗
Double-blind, placebo-controlled comparison of intramuscular olanzapine and intramuscular haloperidol in the treatment of acute agitation in schizophrenia.
OBJECTIVE: The authors evaluated the comparative efficacy and safety of intramuscular olanzapine, intramuscular haloperidol, and intramuscular placebo for the treatment of acute agitation in schizophrenia. METHOD: Hospitalized patients with schizophrenia received one to three injections of intramuscular olanzapine, 10 mg, intramuscular haloperidol, 7.5 mg, or intramuscular placebo over a 24-hour period. Agitation was measured with the excited component of the Positive and Negative Syndrome Scale and two additional scales. RESULTS: According to scores on the excited component of the Positive and Negative Syndrome Scale, both intramuscular olanzapine and intramuscular haloperidol reduced agitation significantly more than intramuscular placebo 2 and 24 hours following the first injection. Intramuscular olanzapine reduced agitation significantly more than intramuscular haloperidol 15, 30, and 45 minutes following the first injection. No patients treated with intramuscular olanzapine experienced acute dystonia, compared with 7% of those who were treated with intramuscular haloperidol. No significant QT(c) interval changes were observed in any patients. CONCLUSIONS: Intramuscular olanzapine represents a rapid, effective, and safe treatment for acute agitation in schizophrenia.
Acute Disease↗
Weekly polyethylene glycol conjugated L-asparaginase compared with biweekly dosing produces superior induction remission rates in childhood relapsed acute lymphoblastic leukemia: a Pediatric Oncology Group Study.
The relapse rate in childhood acute lymphoblastic leukemia (ALL) is approximately 30% but few reinduction regimens have investigated the intensive use of polyethylene glycol Escherichia coli asparaginase (PEG-Asp). Therefore, we assessed the pharmocokinetics and efficacy of PEG-Asp in this setting. Children with B-precursor ALL, in first marrow and/or extramedullary relapse were eligible. Reinduction included doxorubicin on day 1, prednisone for 28 days, vincristine weekly for 4 weeks, and PEG-Asp either weekly or biweekly by randomization. Asparaginase levels and antibody to both E coli asparaginase and PEG-asp were measured weekly just before each PEG-asp dose. Overall, 129 of 144 patients (pts) (90%) achieved a complete remission (CR). There was a highly significant difference in CR rates between weekly (69 of 71; 97%) and biweekly (60 of 73; 82%) PEG-Asp dosing (P =.003). Grade 3 or 4 infectious toxicity was common (50%), but only 4 pts died of sepsis during induction. Other toxicities were infrequent and hypersensitivity was rare (6 of 144; 4%). Low asparaginase levels were associated with high antibody titers to either native (P =.024) or PEG asp (P =.0013). The CR rate was significantly associated with higher levels of asparaginase (P =. 012). Patients with ALL in first relapse receiving weekly PEG-Asp had a higher rate of second remission compared with biweekly dosing. Low levels of asparaginase were associated with high antibody titers. Increased asparaginase levels may correlate with an improved CR rate. The use of intensive PEG-Asp should be explored further in the treatment of ALL. (Blood. 2000;96:1709-1715)
Adolescent↗
Learning gross anatomy in a clinical skills course.
Recent developments in undergraduate medical education in the United Kingdom have produced changes in the content and delivery of component courses, including human anatomy. Anatomy can retain its place in the medical course in the new world of problem-based learning and clinical skills teaching by gaining recognition as an integral part of the curriculum which underpins much of the practice of clinical medicine. In these new courses, anatomical information is clinically relevant and discussed in the context of medical problems and the acquisition of clinical skills. Students are encouraged to study in a manner in which information is retained (deep learning) and where understanding replaces rote learning of facts. Students take responsibility for their own learning, with appropriate support and resources. In clinical skills courses, anatomy underpins the development and retention of clinical knowledge and skills.
Anatomy↗
A survey of basic life support training in various undergraduate health care professions.
Basic life support (BLS) is a core skill in which all healthcare professionals should be proficient. It is logical to provide BLS training during undergraduate years ensuring basic competence in all graduating healthcare students. Previous surveys of medical and dental schools have highlighted deficiencies in BLS training. This survey sought to assess the level of BLS training provided for students across a broad range of disciplines in the North West region of the UK. This included courses leading to an entry qualification into medicine, dentistry, nursing, midwifery or a profession allied to medicine (PAM). Information was collected by self-administered postal questionnaire with a response rate of 87%. The survey highlighted major variations in BLS training provided at undergraduate level across disciplines.
Adult↗
The student from hell - a horror story for Christmas.
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Journal Article↗
Snap without crackle or pop: a rude awakening. A case history of penile fracture.
Penile fracture is a rare but worrying condition. The presentation to accident and emergency or primary care should not present difficulty in diagnosis but may cause concern with regard to initial treatment and definitive management. Emergency admission to a urologist is mandatory.
Adult↗
Issues of consent and the primary-school medical.
This article discusses what level of consent is needed from a child or parent before a primary-school medical can take place (i.e. where children are aged under 12). It also considers whether there are occasions when a doctor can see a child if the parents have failed to give consent or have explicitly refused consent. Primary-school children are considered incompetent to make decisions about their own medical treatment and so their consent does not need to be gained before a medical takes place, although it is highly desirable to obtain it. However, a doctor cannot justify a decision to see a child purely in terms of the benefit conferred on the child. Parents can be wronged if their wishes are ignored and usually those wishes should be considered overriding. Normally, general consent, which need not be fully informed, is needed before a school medical. However, if a child is considered to be in danger of being harmed significantly or suspected to have a major medical condition, a medical should go ahead regardless of the level of consent obtained from the parent, so that a reasonable standard of health is maintained for the child.
Child↗
Out-of-hospital cardiac arrests in an urban/rural area during 1991 and 1996: have emergency medical service changes improved outcome?
Survival after out-of-hospital cardiac arrest is influenced by pre-hospital emergency medical care. This study compares outcome of cardiac arrest victims presenting to an emergency department serving a mixed urban/rural area (Norfolk, UK) in 1991 with 1996. Between these years the regional emergency medical service (EMS) was extensively re-organized. We identified 113 such cases of out-of-hospital cardiac arrest in 1991 and 147 in 1996. The age distribution, proportion of witnessed arrests, and initial rhythms were similar for the 2 years. In 1996 EMS response time was significantly slower and the proportion of cases where the EMS arrived before arrest was significantly lower. Fewer patients who had a witnessed arrest received immediate bystander CPR in 1996. The number of patients discharged home decreased from 15 in 1991 to 11 in 1996, but this difference did not reach statistical significance. The majority of survivors had restoration of spontaneous circulation prior to arrival in the emergency department (14 in 1991 and ten in 1996). Survival was greatest in those arresting in the presence of the EMS (ten in 1991 and nine in 1996). In conclusion changes in EMS provision have resulted in an increase in the response time. This was associated with a decrease in the number of survivors although this was not statistically significant.
Aged↗
One year's experience with a clinical skills resource centre.
OBJECTIVES: To describe our experience of teaching clinical skills to first-year medical students in a new problem-based curriculum. DESIGN: Prospective evaluation of clinical skills acquisition using objective measures. SETTING: Students were taught in a purpose-designed clinical skills resource centre in weekly structured sessions. SUBJECTS: All 210 first year medical undergraduates in the first year of a new problem-based and clinically oriented course. RESULTS: Student performance in structured objective examinations improved over 1 year. In all but one of nine matched stations, involving history, examination and procedural skills, improvements were significant. Ninety-three per cent thought that the appropriateness of the skills training course to other course elements was 'good' or 'very good'. CONCLUSIONS: First-year medical students can learn a wide range of clinical skills. Integrated teaching of clinical skills improves satisfaction with undergraduate studies.
Clinical Competence↗
A simple eye model to objectively assess ophthalmoscopic skills of medical students.
OBJECTIVES: Ophthalmoscopy is an important clinical skill that is essential for medical students to master. Competency in the performance of this skill needs to be assessed objectively. DESIGN: The development of a simple, cheap eye model for objective assessment of ophthalmoscopic skills of medical students is described. SETTING: University of Liverpool. SUBJECTS: Undergraduate medical students. RESULTS: The model was used in 803 assessments and showed a high level of student performance, based on both checklist marking of the general approach to the examination and objective marking of the ability of students to manipulate the light beam, focus the lens and systematically examine the model's fundus. CONCLUSIONS: The method described provides a simple, cost-effective, objective assessment of the performance of ophthalmoscopy.
Audiovisual Aids↗
Assessing the ability of medical students to apply evidence in practice: the potential of the OSCE.
OBJECTIVES: Critical analysis and application of evidence-based practice are key skills for students to master. Assessment of these skills can be undertaken by written examination. Regardless of how knowledge of the appraisal process may be assessed, written examinations ignore assimilation of that evidence into everyday practice. DESIGN: A combined clinical and communication skills station was used in an objective structured clinical examination where the ability to appraise evidence critically was assessed along with the application of that evidence in managing a common clinical problem. SETTING: University of Liverpool. SUBJECTS: Undergraduate medical students. RESULTS: The results from 156 undergraduate medical students demonstrated that it is possible to assess the application of evidence in practice, both in terms of outcome and patient assessment of the encounter. CONCLUSIONS: Assessment is a powerful tool in promoting learning and adoption of such assessment strategies may help to address concerns surrounding apparent poor effect of critical appraisal training.
Adult↗
'Hello, my name is Gabriel, I am the house officer, may I examine you?' or the Objective Santa Christmas Examination (OSCE).
OBJECTIVE: To design a clinical examination of high content validity suitable for use as a formative assessment tool with pre-registration house officers (PRHO'S) towards the end of their first house officer post. DESIGN: A multicentre collaboration between four UK medical schools who offer undergraduate curricula which are problem-based, systems-based, patient-orientated, student-centred, jargon-laden and utterly staff-bewildering. MAIN OUTCOME: An objective structured clinical examination (OSCE) which is suitable for use with graduates of UK medical schools. It assesses the knowledge, skills and attitudes essential for future careers in a hierarchical system where protecting the senior staff from all forms of irritation is paramount. RESULTS: PRHO'S who excel in this examination get better references. CONCLUSION: The OSCE format can be used to provide 'real-life' scenarios appropriate to the season.
Career Choice↗