Implementation of a national, nurse-led telephone health service in Scotland: assessing the consequences for remote and rural localities.

INTRODUCTION: Internationally, nurse-led models of telephone triage have become commonplace in unscheduled healthcare delivery. Various existing models have had a positive impact on the delivery of healthcare services, often reducing the demand on accident and emergency departments and staff workload 'out of hours'. Our objective was to assess whether a model of centralised nurse telephone triage (NHS 24, introduced in Scotland in 2001) was appropriate for remote and rural areas. In this qualitative study the views and perspectives of health professionals across Scotland are explored. METHODS: Thirty-five participants were purposively selected for interviews during 2005. Two types of interview were conducted: detailed, semi-structured, face-to-face interviews with key stakeholders of NHS 24; and briefer telephone interviews with partners from NHS Boards across Scotland. A constant comparative approach was taken to analysis. Ethical approval for the study was obtained from the Scottish Multi-site Research Ethics Committee. RESULTS: The findings are comparable with other research studies of new service developments in remote and rural health care. The rigidity of the centralised triage model introduced, the need to understand variation of health service delivery, and the importance of utilising local professional knowledge were all key issues affecting performance. CONCLUSION: Remote and rural complexities need to be considered when designing new healthcare services. It is suggested that new health service designs are 'proofed' for remote and rural complexities. This study highlights that a centralised nurse-led telephone triage model was inappropriate for remote and rural Scotland, and may not be appropriate for all geographies and circumstances.

Living and health conditions of Palestinian refugees in an unofficial camp in the Lebanon: a cross-sectional survey.

OBJECTIVE: To determine the living conditions and self-reported health of Palestinian refugees living in an unofficial camp in Lebanon. DESIGN: Cross-sectional survey. SETTING: Gaza displacement centre, Beirut, Lebanon. PARTICIPANTS: 97 Households and 437 residents. MAIN OUTCOME MEASURES: Household characteristics, including the number of rooms per household; access to outside air; the presence of mould and dampness. Resident characteristics, including age; educational attainment; and chronic conditions. RESULTS: Half of the households surveyed had only one room; 44% had three or more people per room; 11% had no external ventilation; 49% had no heating; 54% had mould and dampness. The use of wood or charcoal for heating was associated with an increase in mould and dampness (p = 0.015). 135 Members of the population (31%) were aged under 15 years; 130 (30%) had a chronic condition. Logistic regression results showed that overcrowding (odds ratio (OR) 3.26) and a member of the household living in Gaza buildings for more than 15 years (OR 0.48) were significantly associated with children under 15 years. Age over 45 years (OR 5.32), a member of the household in full-time employment (OR 0.58) and a member of the household living in Gaza buildings for more than 15 years (OR 1.71) were significantly associated with chronic disease. CONCLUSION: This study demonstrates the poor conditions under which Palestinian refugees in unofficial camps live, resembling the slum housing of the United Kingdom in the last century. In the absence of routine data collection, research may be the only way to obtain such data for future public and environmental health planning.

A cost comparison of photodynamic therapy and metallic stents in the palliation of oesophageal cancer.

BACKGROUND: There is currently little information on the cost effectiveness of photodynamic laser therapy (PDT) compared with other palliative treatments for oesophageal cancer. AIM: To compare the cost of oesophageal cancer palliation associated with PDT with those of another standard option, self-expanding metallic stents. METHODS: A cost comparison study using prospectively and retrospectively collected data was conducted. Data was collected from 25 patients who had received PDT between 1999 and 2003. Costs were compared with data from patients who received a metallic stent between 1998 and 2000. Costs were estimated using routine costs for the year 2002-2003. RESULTS: Patients receiving PDT or oesophageal stents were similar in terms of age, gender and tumour presentation. Patients receiving PDT had slightly shorter duration of symptoms, less metastatic spread but similar dysphagia scores to those in the oesophageal stent group. Costs of initial PDT treatment were significantly higher than those associated with stent placement (PDT mean costs £2068.48 versus stent mean costs £1086.76; cost difference £981.72 (95% CI: £844.47-1118.96)). This higher cost persisted throughout future re-interventions and hospital episodes. Patients receiving PDT survived longer however (132.5 (70.5-250 days) (medium IQR)) than those receiving a stent 105 (31-172.5 days), thus the mean cost per day's survival was equivalent between the two treatments. There was no impact of PDT on patients' quality of life at 6 weeks post-treatment. CONCLUSIONS: Although initially more expensive than metallic stents, a longer survival results in PDT being as cost effective as stenting in oesophageal palliation. A larger, randomised controlled trial is required combining both economic evaluation and quality of life measurement to fully establish the best palliative treatment in this disease.

What does GP out of hours care cost? An analysis of different models of out of hours care in Scotland.

BACKGROUND: The changes to out of hours care provided by General Practitioners have led to wide variation in the types and costs of out of hours care across the country. AIM: To examine the costs of different models of service delivery for GP out of hours organisations. METHODS: This was a prospective cross-sectional survey of eight GP out of hours organisations and samples of their patients. A deputising service, rotas, and various types of GP co-operative across Scotland were surveyed. Information on the quantities of resources used by each organisation was combined with unit costs. Costs incurred by patients and other NHS costs subsequent to the out of hours contact were also calculated. RESULTS: Annual costs incurred by the GP out of hours organisation per 1,000 population ranged from pounds sterling 2,916 to pounds sterling 12,120. There was no relationship between costs and type and size of organisation. There was a three-fold variation in total costs per out of hours contact (pounds sterling 15 to pounds sterling 51). Costs per phone contact were lowest (pounds sterling 6 to pounds sterling 11), followed by cost per centre contact (pounds sterling 10 to pounds sterling 16) and cost per home contact (pounds sterling 21 to pounds sterling 60). Total costs per episode ranged from pounds sterling 78 to pounds sterling 136 for centre contacts, from pounds sterling 130 to pounds sterling 303 for home contacts, and from pounds sterling 70 to pounds sterling 553 for telephone contacts. Home contacts had the highest average cost per episode (pounds sterling 212), followed by telephone contacts (pounds sterling 117) and centre contacts (pounds sterling 85). CONCLUSIONS: There are wide variations in the costs of operating GP out of hours services, It is likely that the context in which organisations were set up and local geography infuence variations in costs, as well as the level of GP cover.

Randomized clinical trial comparing self-expanding metallic stents with plastic endoprostheses in the palliation of oesophageal cancer.

BACKGROUND: There is little evidence of the clinical and cost effectiveness of self-expanding metallic stents in the palliation of oesophageal cancer. The aims of this randomized trial were to evaluate the immediate and medium-term clinical outcomes following palliative intubation, examine patient quality of life, and evaluate costs and benefits from the perspective of the health service. METHODS: Fifty patients with inoperable oesophageal cancer were randomly allocated a metallic stent (n = 25) or plastic endoprosthesis (n = 25). Patients were followed up monthly until death. RESULTS: There was no significant difference in procedure-related complications or mortality rate between the two groups. There was a trend towards significance in favour of metallic stents with respect to quality of life and survival (median survival 62 versus 107 days for plastic prosthesis and metallic stent respectively). The cost of the initial placement of metallic stents was significantly higher than that of plastic endoprostheses ( pound 983 versus pound 296). After 4 weeks, cost differences were no longer significant. CONCLUSION: Metallic stents may contribute to improved survival and quality of life in patients with oesophageal cancer. Although initially more expensive, this cost difference does not last beyond 4 weeks. A larger trial involving approximately 300 patients would be required to detect a quality of life benefit of the magnitude observed in this trial.

Assessing dissatisfaction with an out of hours service: reasons and remedies.

OBJECTIVE: To identify characteristics associated with dissatisfaction following contact with an out of hours co-operative in Glasgow, and to identify reasons for this dissatisfaction. To make recommendations for good practice in the light of these findings. DESIGN: Survey of attenders during one week of operation of an out of hours co-operative. Analysis of factors associated with dissatisfaction. SETTING: The Glasgow Emergency Medical Service, October 1996. SUBJECTS: Questionnaires were received from 1115 patients or their carers, representing a 69.3% response rate. RESULTS: Dissatisfaction was associated with unmet expectations, particularly among those expecting home visits. Parents of young children, more affluent patients, and those experiencing problems with daytime services also tended to be dissatisfied. Seventy four (7%) respondents indicated that they were very dissatisfied with aspects of the service. A high proportion of this dissatisfaction was related to telephone contact. Transport to out of hours centres caused problems for some patients, particularly for those with young children. Perceptions of dismissive attitudes by medical staff, and of incorrect diagnoses and treatment were causes of strong dissatisfaction. Patients with adverse medical outcomes were also likely to be very dissatisfied. CONCLUSION: Clear reasons for dissatisfaction were found among our sample. In most cases, remedial management action could be taken to reduce the likelihood of major dissatisfaction with the service.

Variation in GP referral rates: what can we learn from the literature?

BACKGROUND: Variations in referral rates exist, at GP and practice level. Although the National Institute for Clinical Excellence is to produce referral guidelines, it is unclear if this variation requires regulation. A critical review of the literature on variation in referral rates was undertaken to see if existing evidence could inform the debate. OBJECTIVES: The aim of this study was to describe the variation in referral rates; to identify likely explanatory variables; and to describe the effect of GPs' decision making on the referral process. METHODS: Six bibliographic databases, the Cochrane Library, the NHS Centre for Reviews and Dissemination, and the National Research Register were searched. RESULTS: Patient characteristics explain <40% of the observed variation; practice and GP characteristics <10%. The availability of specialist care does affect referral rates, but its influence on the observed variation of referral rates is not known. Intrinsic psychological variables are important. GPs who are less tolerant of uncertainty or who perceive serious disease to be a more frequent event may refer more patients. There is a lack of consensus about what constitutes an appropriate referral, and the use of guidelines has had only limited success in altering referral behaviour. CONCLUSIONS: Variation in referral rates remains largely unexplained. Targeting high or low referrers through clinical guidelines may not be the issue. Rather, activity should concentrate on increasing the number of appropriate referrals, regardless of the referral rate. Pressure on GPs to review their referral behaviour through the use of guidelines may reduce their willingness to tolerate uncertainty and manage problems in primary care, resulting in an increase in referrals to secondary care. The use of referral rates to stimulate dialogue and joint working between primary and secondary care may be more appropriate.

Social variation in reasons for contacting general practice out-of-hours: implications for daytime service provision?

BACKGROUND: Contact with general practice out-of-hours services increases with socioeconomic deprivation. The reasons for this association are unclear but may include variations in access to daytime services or differences in morbidity. AIM: To identify the reasons for contact with the Glasgow Emergency Medical Service (GEMS) in relation to patient sociodemographic characteristics and the nature of the presenting problem. METHOD: All contacts with GEMS over a one-week period (n = 3193) in October 1996 were identified and a random 1:2 sample were sent a postal questionnaire investigating their reasons for contacting the service. Sociodemographic data and presenting problems were extracted from the service contact sheet. Data were analysed using correspondence analysis. RESULTS: Correspondence analysis identified two factors characterised as 'perceived problems with daytime services' and 'perceived urgency'. Scores on the former dimension were significantly associated with age (P < 0.0001), gender (P < 0.0001), socioeconomic category (P < 0.0001), and presenting problem (P = 0.015) and scores were higher in adults, in males, among the non-affluent (particularly those resident in deprived areas), and in those presenting with a musculoskeletal problem. Scores on the latter dimension were significantly associated with age (P < 0.0001) and presenting problem (P < 0.0001). Scores tended to increase after childhood and for each of the five most frequent categories of presenting problem relative to other symptoms. CONCLUSIONS: Compared to those from affluent areas, patients from non-affluent areas appear to perceive difficulties accessing their general practitioner during surgery hours and may contact out-of-hours services as an alternative.

Out of hours primary care: a critical overview of current knowledge.

Out of hours care in the UK has undergone radical changes in the past five years, with a rapid increase in the number of general practitioner co-operatives operating from primary care centres. Patients wishing to see a general practitioner outwith normal surgery hours can now be asked to attend a centre, be given telephone advice or may still receive a home visit if required. This overview examines the current literature evaluating these changes. While there are now a number of studies examining general practitioner co-operatives and centres in both England and Scotland, there is little or no work on other forms of out of hours care. In particular, little is known about the continuing role of the single handed general practitioner or about out of hours care in small towns and in rural areas. The need for these issues to be addressed is discussed and the aims of the current Scottish study comparing different models of out of hours care outlined.

Does palpability of primary cutaneous melanoma predict dermal invasion?

BACKGROUND: Relatively few studies have addressed the question of whether clinical estimation of melanoma thickness by palpation can accurately predict its histologic thickness. If palpability was a reliable predictor of dermal invasion, it could be used to define the surgical margin. OBJECTIVE: We sought to determine whether clinical elevation of melanoma could be used to predict the presence or absence and the degree of dermal invasion in patients with stage 1 cutaneous melanoma. METHODS: Melanomas in 165 patients were categorized by one observer as flat, just palpable, palpable, or nodular. This was compared with histologic measurements of tumor thickness. RESULTS: Overall there was significant correlation between the degree of palpability of melanoma and the presence or absence of dermal invasion (p<0.001), Breslow thickness (p<0.0001), and Clark level (p<0.001). However, the relation between palpability and Breslow thickness for invasive melanomas less than 1 mm thick was weaker (n=62, p=0.053), and the correlation between elevation and Clark level was not significant for invasive melanomas less than 4 mm thick (n=111, p>0.999). CONCLUSION: We conclude that palpability of melanoma is an inadequate guide to the presence or absence and degree of dermal invasion in melanomas less than 1 mm thick and cannot be used to determine the surgical margin.

Glycoinositolphospholipids of Leishmania major inhibit nitric oxide synthesis and reduce leishmanicidal activity in murine macrophages.

Murine macrophages express high levels of inducible nitric oxide (NO) synthase and produce large amounts of nitric oxide when activated with interferon-gamma and lipopolysaccharide in vitro. Nitric oxide is a mediator of a variety of biological functions including microbicidal activity against the protozoan parasite Leishmania species. Glycoinositolphospholipids (GIPL) are the predominant surface glycolipids in both developmental stages of Leishmania major. We report here that GIPL can inhibit the synthesis of NO in a time- and dose-dependent manner. In contrast, lipophosphoglycan, which is present in the promastigote stage did not inhibit NO synthesis. GIPL-treated macrophages also showed markedly reduced leishmanicidal activity. The majority of the inhibitory activity of GIPL was found within the alkylacylglycerol moiety of the GIPL molecule. These data, therefore, suggest that GIPL may contribute towards the survival of the parasite in the immune hosts.

Expression of TGF-beta in attenuated Salmonella typhimurium: oral administration leads to the reduction of inflammation, IL-2 and IFN-gamma, but enhancement of IL-10, in carrageenin-induced oedema in mice.

Mice injected with carrageenin in the footpad developed local inflammation which peaked at 48 hr. This was significantly reduced in mice inoculated orally with an attenuated Salmonella construct expressing transforming growth factor-beta (TGF-beta). Administration of the Salmonella construct alone had no effect on inflammation. High levels of interleukin-2 (IL-2) and interferon-gamma (IFN-gamma) were secreted by draining lymph node cells from mice injected with carrageenin following stimulation in vitro. Prior inoculation with Salmonella enhanced the production of IL-2 and IFN-gamma from the draining lymph node cells. Administration of the Salmonella-TGF-beta construct significantly inhibited the production of these cytokines. In contrast, IL-10 only was secreted from draining lymph node cells of animals inoculated with the Salmonella-TGF-beta construct. Thus, oral administration of TGF-beta can significantly inhibit local inflammation and alter the cytokine secretion pattern of cells from lymph nodes draining the site of inflammation.

A nitric oxide synthase inhibitor reduces inflammation, down-regulates inflammatory cytokines and enhances interleukin-10 production in carrageenin-induced oedema in mice.

Mice injected in the footpad with carrageenin developed local inflammation which peaked at 48 hr. This delayed-type footpad swelling was significantly reduced in mice injected intraperitoneally (i.p.) with a specific nitric oxide (NO) synthase inhibitor, L-NGmonomethyl-arginine (L-NMMA). The draining lymph node (DLN) cells from mice injected 48 hr previously with carrageenin produced significantly higher levels of proliferation and interleukin-1 (IL-1), IL-2, IL-6 and interferon-gamma (IFN-gamma), but less IL-10, compared to cells from saline-injected controls, when stimulated with concanavalin A (Con A) in vitro. Treatment of the carrageenin-injected mice with L-NMMA had little effect on the proliferative response of the DLN cells, but significantly reduced the production of IL-1, IL-2, IL-6 and IFN-gamma, and increased the secretion of IL-10. These data demonstrate that NO plays a significant role in local inflammation and the pattern of cytokines induced in this model.

Tumor necrosis factor-alpha (TNF-alpha), interferon-gamma, and interleukin-6 but not TNF-beta induce differentiation of neuroblastoma cells: the role of nitric oxide.

Tumor necrosis factor-alpha (TNF-alpha), interferon-gamma (IFN-gamma), and interleukin-6 (IL-6), but not TNF-beta, can induce the in vitro differentiation of the neuroblastoma cell line N103 in a dose-dependent manner. Differentiation of N103 was accompanied by the arrest of cell growth and neurite formation. The induction of neuroblastoma cell differentiation by TNF-alpha and IFN-gamma can be specifically inhibited by a nitric oxide (NO) synthase inhibitor, L-NG-monomethylarginine. In contrast, the differentiation of N103 cells by IL-6 was not affected by L-NG-monomethylarginine. These results indicate that TNF-alpha and IFN-gamma, but not IL-6, induce the differentiation of neuroblastoma cells via NO. This is confirmed by the finding that the culture supernatants of N103 cells induced by TNF-alpha and IFN-gamma, but not that by IL-6, contained high levels of NO2-, the production of which was inhibited by L-NG-monomethylarginine. Furthermore, the differentiation of N103 cells can be induced directly in a dose-dependent manner by the addition of nitroprusside, a generator of NO, into the culture medium. These data therefore indicate that NO may be an important mediator in the induction of neuronal cell differentiation by certain cytokines such as TNF-alpha and IFN-gamma and that neuronal cells, in addition to the macrophage-like brain cells, can be induced by immunological stimuli to produce large quantities of NO.

Production of nitric oxide and superoxide by activated macrophages and killing of Leishmania major.

Murine macrophages can be activated to produce nitric oxide (NO) and superoxide and these two radicals can react to form peroxynitrite, a powerful oxidant which may be involved in parasite killing. We now show that murine macrophages activated with zymosan and interferon-gamma (ZYM/IFN-gamma) produced both superoxide (peaking 1-2 h after stimulation, then rapidly declining) and NO (barely detectable at 6 h, peaking by 24 h). Macrophages activated with ZYM alone produced only superoxide, while stimulation with lipopolysaccharide (LPS) and IFN-gamma induced NO but not superoxide. Cells stimulated with ZYM/IFN-gamma or LPS/IFN-gamma killed Leishmania major to a similar degree, an effect that was completely blocked by the addition of N-iminoethyl-L-ornithine. However, macrophages stimulated with ZYM alone were unable to kill L. major. S-nitroso-acetyl-penicillamine, which releases NO, was highly leishmanicidal when added directly to the parasites. 3-morpholino-sydnonimine hydrochloride which releases both NO and superoxide simultaneously, was also efficient at killing L. major and this cytotoxicity was greatly enhanced by the addition of superoxide dismutase. Finally, authentic peroxynitrite failed to induce any cytotoxic effect, even at a high concentration. Thus macrophages can produce either NO, superoxide or both, depending on the stimulus. However, the killing of L. major is dependent only on the production of NO.

Differential induction of nitric oxide synthase in various organs of the mouse during endotoxaemia: role of TNF-alpha and IL-1-beta.

BALB/c mice injected intraperitoneally with bacterial lipopolysaccharide (LPS) developed lethal septic shock. This was accompanied by significantly elevated concentrations of nitrite and nitrate in the plasma and expression of high levels of nitric oxide (NO) synthase activity in the lungs, heart, spleen and peritoneal macrophages. Mice pretreated with anti-tumour necrosis factor-alpha (TNF-alpha) monoclonal antibody or anti-interleukin-1 beta (IL-1 beta) polyclonal antibody were protected, in a dose-dependent manner, from endotoxin-induced mortality. This effect was accompanied by a significant reduction in plasma levels of nitrite and nitrate. Antibody treatment also reduced the level of NO synthase activity in peritoneal macrophages, spleen and heart but had no effect on enzyme expression in the lung. These results demonstrate that TNF-alpha and IL-1 beta play an important role in the induction of NO following administration of LPS and in the development of endotoxin-induced shock. In addition, NO synthase activity is differentially expressed in various organs and this may not always require TNF-alpha and IL-1 beta.