Evaluation of physician assistants in National Health Service Scotland.

Physician assistants (PAs) have medical training and work supervised by a doctor. In 2006-2008 the Scottish Government piloted use of USA-trained PAs. The aim of the paper is to evaluate the impact and contribution made by PAs to delivering effective health care in National Health Service (NHS) Scotland. Mixed methods, longitudinally, including interviews, feedback forms and activity data collection. Data analysis used nVivo, SPSS and Excel. Participants were 15 USA-trained PAs, medical supervisors and team members, 20 patients, four NHS senior managers and three trade union representatives. Settings were four Scottish NHS Boards where PAs worked in primary care, out of hours clinics, emergency medicine, intermediate care and orthopaedics. Two minor patient safety issues arose. Patients were satisfied with PAs. Scope of practice did not replicate US working. Inability to prescribe was a hindrance. PAs tended to have longer consultations, but provided continuity and an educational resource. They were assessed to be mid-level practitioners approximating to nurse practitioner or generalist doctor. Valued features were generalism, medical background, confidence differential diagnosis and communication. Interviewees suggested PAs could fulfil roles currently filled by medical staff, potentially saving resources. In conclusion, there is potential for PAs to fulfil distinctive mid-level roles in the Scottish NHS adding value in continuity, communication and medical approach.

How useful is uterine artery Doppler flow velocimetry in the prediction of pre-eclampsia, intrauterine growth retardation and perinatal death? An overview.

OBJECTIVE: To evaluate the clinical usefulness of Doppler analysis of the uterine artery velocity waveform in the prediction of pre-eclampsia and its associated complications of intrauterine growth retardation and perinatal death. DESIGN: Quantitative systematic review of observational diagnostic studies using online searching of the MEDLINE database coupled with scanning of the bibliographies of primary and review articles including known unpublished studies. MATERIAL: Twenty-seven studies involving 12,994 subjects stratified into population subgroups at low and high risk of developing pre-eclampsia and its complications. OUTCOME MEASURES: The outcome measures studied were: 1. the development of pre-eclampsia; 2. intrauterine growth retardation; and 3. perinatal death. The main meta-analyses were the flow velocity waveform ratio +/- diastolic notch derived by transabdominal Doppler ultrasound as the measurement parameter. The analyses were conducted using likelihood ratio as a measure of diagnostic accuracy. A likelihood ratio of 1 indicates that the test has no predictive value for the outcome. Prediction for the outcome event is considered conclusive with likelihood ratios of > 10 or < 0 x 1 for a positive and negative test result, respectively. Moderate prediction can be achieved with likelihood ratios of 5-10 and 0 x 1-0 x 2 whereas likelihood ratios values of 1-5 and 0 x 2-1 would generate only minimal prediction. RESULTS: In the low risk population a positive test result, predicted pre-eclampsia with a pooled likelihood ratio of 6 x 4 (95% CI 5 x 7-7 x 1), while a negative test result had a pooled likelihood ratio of 0 x 7 (95% CI 0 x 6-0 x 8). For intrauterine growth retardation the pooled likelihood ratio was 3 x 6 (95% CI 3 x 2-4 x 0) for a positive test result and 0 x 8 (95% CI 0 x 8-0 x 9) for a negative test result. Using perinatal death as outcome measure, the pooled likelihood ratio was 1 x 8 (95% CI 1 x 2-2 x 9) for a positive test result and 0 x 9 (95% CI 0 x 8-1 x 1) for a negative test result. In the high risk population a positive test result predicted pre-eclampsia with a pooled likelihood ratio of 2 x 8 (95% CI 2 x 3-3 x 4), while a negative test had a likelihood ratio of 0 x 8 (95% CI 0 x 7-0 x 9). For intrauterine growth retardation the pooled likelihood ratio was 2 x 7 (95% CI 2 x 1-3 x 4) for a positive test result and 0 x 7 (95% CI 0 x 6-0 x 9) for a negative result. For perinatal death the pooled likelihood ratio was 4 x 0 (95% CI 2 x 4-6 x 6) for a positive test result and 0 x 6 (95% CI 0 x 4-0 x 9) for a negative result. CONCLUSION: Uterine artery Doppler flow velocity has limited diagnostic accuracy in predicting pre-eclampsia, intrauterine growth retardation and perinatal death.

Variations in oxytocin regimes in Scottish labour wards in 1998.

Oxytocin (Syntocinon, Sandoz Pharmaceuticals) is a commonly used drug in the modern management of labour. A recently published British survey found that 38% of low risk primigravid labours were augmented, most commonly by intravenous syntocinon. Unfortunately the misuse of syntocinon can lead to potentially serious problems for the fetus and mother. Despite the frequency of usage there appears to be no consensus as to the optimal dose and mode of administration. This paper explores the extent of this variation among Scottish obstetric units, the reasons for any variation in its use and makes some suggestions as to the way forward based on the current literature.

Misleading authors' inferences in obstetric diagnostic test literature.

OBJECTIVE: Our goal was to determine the validity of authors' inferences about the value of the cervico-vaginal fetal fibronectin test in the prediction of preterm birth and the utility of uterine artery Doppler waveform analysis in the prediction of preeclampsia. STUDY DESIGN: We evaluated all 35 diagnostic test studies (14 on fetal fibronectin and 21 on uterine artery Doppler) included in 2 meta-analyses. The information on authors' conclusions regarding the value of a positive or negative test result was independently abstracted from each article by 2 reviewers, and it was classified as definitely useful, moderately useful, slightly useful, or not at all useful. For the "gold" standard, likelihood ratios of >10 and <0. 1 were regarded as definitely useful, 5 to 10 and 0.1 to 0.2 were regarded as moderately useful, 2 to 5 and 0.2 to 0.5 were regarded as slightly useful, and 1 to 2 and 0.5 to 1 were regarded as not at all useful. The agreement between the authors and the reference standard was computed by simple percentage agreement and weighted kappa statistic. RESULTS: Among articles assessing the diagnostic value of fetal fibronectin the simple agreement between the authors and the "gold" standard was 26% (7/26) with a kappa of 0.05 (P =.83), and authors overestimated the value of the test result in 66% (17/26) of instances. Similarly, among articles assessing uterine artery Doppler the simple agreement between the authors and the "gold" standard was 31% (13/42) with a kappa of 0.28 (P =.31), and authors overestimated the value of the test result in 48% (20/42) of instances. CONCLUSION: Authors claimed more positive conclusions than could be supported by their data. When studies are reported in a misleading manner, the chance of misinterpretation on the part of the clinical reader is increased. The use of explicit criteria that are based on likelihood ratios may reduce the risk of erroneous inferences.

Magnesium sulphate in the treatment of eclampsia and pre-eclampsia: an overview of the evidence from randomised trials.

OBJECTIVE: To evaluate the effectiveness of magnesium sulphate in the treatment of eclampsia and pre-eclampsia by a systematic quantitative overview of controlled clinical trials. DESIGN: Online searching of the MEDLINE database between 1966 and 1995, and scanning of the bibliography of known primary studies and review articles on the use of magnesium sulphate in eclampsia and pre-eclampsia. Study-selection, study quality assessment and data extraction were performed independently by two reviewers under masked conditions. Where possible outcome data from trials were pooled and summarised using the Mantel-Haenszel method. PARTICIPANTS: One thousand seven hundred and forty-three women with eclampsia and 2390 with pre-eclampsia included in nine randomised trials that evaluated the effects of magnesium sulphate. MAIN OUTCOME MEASURES: Seizure activity and maternal death. RESULTS: In eclampsia, recurrence of seizures was less common with magnesium sulphate therapy compared with phenytoin (odds ratio [OR] 0.27, 95% CI 0.17-0.45, P = 0.00) and diazepam (OR 0.41, 95% CI 0.30-0.57, P = 0.00). As indicated by the point estimate, there was a trend towards a reduction in maternal mortality with magnesium sulphate in eclampsia (OR 0.51, 95% CI 0.24-1.07, P = 0.10 versus phenytoin; OR 0.78, 95% CI 0.41-1.45, P = 0.52 versus diazepam). When used for seizure prophylaxis in pre-eclampsia, magnesium sulphate was found to be more effective than phenytoin (OR 0.15, 95% CI 0.03-0.72, P = 0.01). CONCLUSION: Magnesium sulphate is a superior drug in preventing the recurrence of seizures in eclampsia and in seizure prophylaxis in pre-eclampsia.

The expression of mRNA for insulin-like growth factors and their receptor in giant cell tumors of human bone.

Insulin-like growth factors I and II are among the most abundant growth factors found in bone, and their expression also has been reported in a variety of neoplastic tissues. Using the technique of in situ hybridization, the authors have studied the expression of the messenger ribonucleic acid (mRNA) for insulin-like growth factors I and II and the Type I insulin-like growth factor receptor in giant cell tumors of human bone (n = 8). The expression of the mRNA for insulin-like growth factors I and II and the Type 1 insulin-like growth factor receptor was observed in giant cells and in the mononuclear stromal cell component but not in cells of the fibrous connective tissue at the growing edge of the tumor. The multinucleated cells expressed tartrate resistant acid phosphatase and showed reactivity with osteoclast selective monoclonal antibodies, confirming the close relationship between these giant cells and osteoclasts. Thus, these results are consistent with the possibility that locally produced insulin-like growth factors have an important regulatory role in the growth and development of giant cell tumors of bone. In addition, they suggest that these growth factors may function as autocrine or paracrine regulators of the proliferation of differentiation of cells of the osteoclast lineage.

Osteoblasts and osteoclasts in adult human osteophyte tissue express the mRNAs for insulin-like growth factors I and II and the type 1 IGF receptor.

Insulin-like growth factors (IGFs) are among the most abundant growth factors present in bone. In vitro, bone-derived cells both produce and respond to IGFs I and II, suggesting that these growth factors play an autocrine role in the regulation of bone turnover. In vivo, however, particularly in adult bone, their sites of expression have not been well documented. We have used, therefore, the technique of in situ hybridization to study the expression of the mRNAs for IGFs I and II and the type 1 IGF receptor in adult human osteophyte tissue. Throughout the developing osteophyte there was a strong association between osteogenesis and the expression of all three mRNA transcripts. The highest levels of expression were observed in active osteoblasts. Hybridization signals were weak or absent in flat cells lining quiescent surfaces and in cells of the bone marrow, including those that expressed alkaline phosphatase activity. Osteocytes and cells of the periosteum were negative. At sites of endochondral bone formation newly differentiated and hypertrophic chondrocytes expressed the mRNAs for IGFs and IGF receptor whereas cells of the perichondrium were negative. A striking finding of this investigation was that osteoclasts at sites of bone and calcified cartilage resorption expressed high levels of all three mRNA transcripts. These results support the hypothesis that locally produced IGFs are important regulators of bone formation. The differential expression of all three transcripts among cells of the osteoblast lineage suggests that IGFs may be involved in the maintenance of the mature osteoblast phenotype rather than in inducing the differentiation of marrow precursors or controlling the osteoblast-osteocyte transition.(ABSTRACT TRUNCATED AT 250 WORDS)