Improving cardiovascular disease risk communication in the UK national health service health check programme.

OBJECTIVE: To develop and test training to improve practitioners' confidence and perceived understanding when communicating cardiovascular disease (CVD) risk using novel tools and metrics. METHODS: A CVD risk communication training workshop was developed through interviews with patients and practitioners delivering Health Checks, a literature review, NICE guidance and the UK Health Check competency framework. It was pilot-tested with practitioners delivering Health Checks in the UK. Perceived practitioner understanding and confidence were measured before and up to 10 weeks after the workshop, and changes were compared with those in a control group (who received no intervention). Perceived impact was also explored through semi-structured interviews. RESULTS: Sixty-two practitioners (34 intervention, 28 control) took part. Perceived practitioner understanding (p = .030) and perceived patient understanding (p = .007) improved significantly for those delivering Health Checks in the training group compared with controls. Practitioner confidence also improved significantly more in practitioners who attended the training (p = .001). Findings were supported by interviews with a sub-sample of practitioners (n = 13). CONCLUSION: The training workshop improved practitioners' confidence and perceived understanding of CVD risk in Health Checks. PRACTICE IMPLICATIONS: The training is an important step to improving practitioner understanding of CVD risk in Health Checks and should be implemented on a wider scale.

Understanding implementation and uptake in the National Health Service Health Check Programme.

OBJECTIVES: We present findings from a national online survey of uptake and implementation of the National Health Service Health Check (NHSHC) programme. The research aimed to understand national variation in implementation of NHSHCs and to explore the relationship between uptake and different components of implementation. STUDY DESIGN: The study design was a descriptive online survey. METHODS: Data were collected via an online survey between November 2015 and August 2016. The survey was distributed nationally to practice managers in the Midlands and East of England, South of England, North of England and London via local NHSHC leads with the help of the national programme manager. RESULTS: Responses were received from 153 participants, half of who were practice managers (49.7%). Common components of implementation included using postal invitations accompanied by the national leaflet, delivering NHSHCs routinely with other appointments, offering NHSHC outside of working hours and taking blood samples during the consultation. Meaningful exploration of the relationship between uptake and components of implementation was not possible given the inaccuracy of self-reported uptake data, which was confirmed by comparison with public health data in a subsample (n = 18). The comparison also found that a number of practices were reporting more completed health checks than the total number of patients invited, which again indicates problems that may have implications for uptake figures locally and nationally. CONCLUSIONS: Overall, our findings showed considerable variation in the implementation of NHSHCs on a national scale and issues with quality of programme uptake data, which has implications for national reporting for NHSHC.

Development of a valid and reliable test to assess trauma radiograph interpretation performance.

OBJECTIVES: The purpose of this investigation was to develop and examine the preliminary validity and reliability among radiographers of a test to assess trauma radiograph interpretation performance suitable for use among health professionals. METHODS: Stage 1 examined 14,159 consecutive appendicular and axial examinations from a hospital emergency department over a 12 month period to quantify a typical anatomical region case-mix of trauma radiographs. A sample of radiographic cases representative of affected anatomical regions was then developed into the Image Interpretation Test (IIT). Stage 2 involved prospective investigations of the IIT's reliability (inter-rater, intra-rater, internal consistency) and validity (concurrent) among 41 radiographers. RESULTS: The IIT included 60 cases. The median (interquartile range) clinical experience of participants was 5 (2-10) years. Case scores were internally consistent (Cronbach's alpha = 0.90). Favourable inter-rater reliability (kappa > 0.70 for 58/60 cases, Intra-class correlation coefficient (ICC) > 0.99 for total score) and intra-rater reliability (kappa > 0.90 for 60/60 cases, ICC > 0.99 for total score) was observed. There was a positive association between radiographers' confidence in image interpretation and IIT score (coefficient = 1.52, r-squared = 0.60, p < 0.001). CONCLUSIONS: The IIT developed during this investigation included a selection of radiographic cases consistent with anatomical regions represented in an adult trauma case-mix. This study has also provided foundational preliminary evidence to support the reliability and validity of the IIT among radiographers. The findings suggest that it is possible to assess image interpretation performance of adult trauma radiographs with this test.

Semen production in adolescent cancer patients.

BACKGROUND: The influence of an accompanying person (parent, guardian or nurse) on the ability of an adolescent (post-pubescent, <20 years of age) to produce a semen sample for cryopreservation, is undetermined, as is the potential for use of urine samples to retrieve sperm in those adolescents that are unable to produce a semen sample. METHODS: The records from 1991-2000 inclusive were reviewed to derive those adolescent patients who were unable to produce semen for cryopreservation prior to undergoing treatment for a malignant condition. RESULTS: During the study period 238 adolescents attended our unit of whom 205 (86.1%) banked semen ('producers'). The remaining 33 adolescents (13.9%) were initially unable to produce a sample ('non-producers'), four of these provided a urine specimen for analysis (12.1%) and of these one had sufficient sperm for cryopreservation. Of the 'accompanied' patients 29.7% (19/64) were non-producers while in the 'unaccompanied' patients only 8.0% (14/174) were non-producers (chi(2) = 16.58, P < 0.001). The relative risk (RR) of not producing a semen sample for the accompanied group of patients was greater than that for the unaccompanied group (RR = 3.689, 95% confidence interval: 2.0-6.9). One patient returning alone successfully provided a semen sample for storage. CONCLUSION: Units should consider the effect of the presence of an accompanying person when an adolescent is unable to produce a semen sample and should consider requesting urine to retrieve sperm.

Exploring the sexual histories of older GUM clinic attenders.

Little is known either of the factors motivating clinic attendance in later life, or the sexual health histories of older clinic attenders. A self-administered questionnaire study linked to patient note data aiming to explore these issues was undertaken within 3 genitourinary medicine (GUM) clinics in the Trent region. Participants comprised 224 individuals aged 50 years and older attending the 3 clinics during the study period. The majority of study participants were attending the clinic with a suspected sexually transmitted infection (STI) (n = 145, 64.7%) and approximately half (n=119, 53.1%) were first-time GUM clinic attenders. Data available for participants recruited from the Sheffield clinic indicated that, although the majority of participants reported having had only one sexual partner during the last 12 months, a significant minority reported considerably higher numbers of partners, including those classed 'higher risk' for STI acquisition. These data indicate that older people engage in behaviours that place them at risk of STI acquisition and many attend GUM clinics for the first time in later life.

A rational algorithm for duplex scan surveillance after carotid endarterectomy.

PURPOSE: This study was undertaken to determine the appropriate timing and frequency of duplex ultrasound scanning after carotid endarterectomy (CEA) for the detection of high-grade stenosis caused by recurrent carotid stenosis or contralateral atherosclerotic disease progression. METHODS: In 221 patients who underwent 242 CEAs, duplex scanning was performed before, during, and after operation (in 3-month to 6-month intervals). High-grade internal carotid artery (ICA) stenosis (peak systolic velocity, >300 cm/s; diastolic velocity, >125 cm/s; ICA/common carotid artery ratio, >4) prompted the recommendation for repair. An average of four postoperative scanning procedures was performed during a mean follow-up period of 27.4 months. RESULTS: Intraoperative duplex scan results prompted the immediate revision of 12 repairs (4.9%), and one perioperative stroke (<1%) occurred. Six CEAs (2.7%) had asymptomatic recurrent stenosis (>50% diameter-reduction [DR]; systolic velocity, >125 cm/s) develop. Only one of six patients had >75% DR stenosis develop and underwent reoperation (<1% yield for CEA surveillance). The yield of surveillance of the unoperated ICA was higher (P =.003), and 12% of unoperated sides had progressive stenosis (n = 21) or occlusion (n = 3) develop, which led to seven CEAs for high-grade stenosis. Disease progression to >75% DR stenosis was five times as frequent (P =.002) in patients with >50% DR stenosis initially. All patients but one who required contralateral endarterectomy for disease progression had >50% ICA stenosis when first seen. During the follow-up period, no disabling strokes ipsilateral to an operated carotid artery occurred, but three strokes occurred in the hemisphere of the contralateral unoperated ICA. CONCLUSION: The yield of duplex scan surveillance after CEA was low. Only 13 patients (5.9%) had severe disease develop to warrant additional intervention. Progression of contralateral disease rather than restenosis was the most common abnormality that was identified. Duplex scanning at 1-year to 2-year intervals after CEA is adequate when a technically precise repair is achieved and minimal contralateral disease (<50% DR) is present. A policy of duplex scan surveillance and reoperation for high-grade stenosis was associated with a 1.6% incidence rate of disabling stroke during the follow-up period.

Haematospermia associated with malignant hypertension.

Haematospermia is generally regarded as a benign, self limiting condition. Although no obvious cause is found in most cases, an uncommon but important predisposing factor is severe uncontrolled hypertension. We describe a case illustrating the need to routinely measure blood pressure in such instances.

Delay in symptom presentation among a sample of older GUM clinic attenders.

Prior research undertaken with predominantly youthful populations has established that delay between symptom recognition and health-care presentation is a common feature of sexually transmitted infection (STI) related illness behaviour. However, it is not known whether similar behaviours are exhibited by older populations with genitourinary symptoms. The present analyses therefore aim to clarify this issue by focusing upon (1) extent of delay behaviour, (2) reasons for delay behaviour and (3) variables predicting delay behaviour among a sample of genitourinary medicine (GUM) clinic attenders aged over 50 years. A self-administered questionnaire study linked to patient note data was undertaken within 3 GUM clinics in the Trent region between January 1997 and March 1998 (Sheffield, Nottingham and Leicester). Of 121 symptomatic older attenders with suspected STI, 43.8% (n=53) waited over 2 weeks between symptom recognition and clinic attendance. Reasons given for delay included wanting to 'wait and see' if symptoms improved and being embarrassed or afraid to attend clinic. A logistic regression analysis identified that delay behaviour was predicted by history of HIV testing. Comparisons with previous research undertaken in this field indicate that levels of delay behaviour reported by this older sample are higher than those exhibited by youthful populations with genitourinary symptoms. This finding has significant implications for health-care professionals working both within a GUM setting, and with older people, especially when viewed in the context of an ageing population.

Isolated microscopic haematuria in the genitourinary clinic: the value of renal biopsy.

Isolated microscopic haematuria is a common finding in the genitourinary clinic. The conventional approach to investigation includes urological referral for cystourethroscopy if renal imaging is normal. However the diagnostic yield is very low; in particular urothelial malignancy at age < 40 years is rare. Glomerular disease is increasingly recognized as a common cause of microscopic haematuria. In this study 50 patients with persistent microscopic haematuria detected at a genitourinary clinic underwent renal biopsy. Twelve (24%) had an abnormal biopsy--IgA nephropathy 6 (12%), thin membrane nephropathy 3 (6%), other glomerulonephritis 3 (6%). In 7 others no abnormality was found but information was incomplete as electron microscopy was unavailable. It is important to establish these diagnoses since some patients will develop progressive renal disease. In this clinical setting renal biopsy will give diagnostic and prognostic information, protects from repeated urological investigation, and allows reassurance if renal histology is normal. Renal biopsy is recommended for patients age < 40 years with persistent microscopic haematuria. An algorithm for the investigation of microscopic haematuria is presented.

Prostatitis--clinical and bacterial studies.

Forty men with clinical prostatitis were studied to determine the value of symptomatology and categorization and 30 (75%) were classified as having prostatitis on the basis of prostatic localization studies. Of these 3 (10%) had chronic bacterial prostatitis, 18 (60%) had chronic abacterial prostatitis, and 9 (30%) had prostatodynia. No patient had acute bacterial prostatitis. Although Enterobacteriaciae were isolated from the 3 men with chronic bacterial prostatitis, these bacteria along with Staphlococcus aureus, Streptococcus faecalis, and Chlamydia trachomatis were isolated from a further 6 patients. The mean pH of the expressed prostatic secretion was measured for each group and was found to be 7.6 for those with chronic bacterial prostatitis, 7.1 for chronic abacterial prostatitis, 6.5 for prostatodynia, and 6.9 for those with urethritis suggesting that this test may be of value in the diagnosis of chronic bacterial prostatitis.

Quantification of Candida albicans morphology in vaginal smears.

The morphology index (Mi) of Candida albicans cells was determined by microscopic image analysis in vaginal smears from 26 patients. The morphology of the cells typically showed a broad distribution of forms, but the mean Mi was greater than 2.0 in 23/26 instances, indicating a preponderance of pseudohyphal and hyphal forms. No association could be found between Mi and the clinical assessment of signs or symptoms of Candida infection. Comparison of these 26 patients with 43 others who had Candida-positive vaginal smears but with fewer than 15 fungal cells in the smear revealed significantly lower scores for vulvovaginal symptoms among the latter.

Candida species and C. albicans biotypes in women attending clinics in genitourinary medicine.

Yeasts were isolated from two or more anatomical sites in 198 women attending genitourinary clinics on at least two occasions. The yeast biotypes isolated concurrently from the vagina and urethra were the same in 138 (99%) of 140 instances, and 94% of 124 concurrent genital and anal isolates were of matching types, whereas only 75% of concurrent genital and oral isolates were of the same type. Mixtures of Candida spp. or C. albicans biotypes were encountered only five times among 545 yeast-positive samples. In instances where Candida spp. were isolated at successive times from the same site in a patient, the same yeast type was encountered on 97 (87%) of 112 occasions when the interval between samples was less than 15 weeks, and on 19 (66%) of 29 occasions when the interval was 15 weeks or more. These data indicate a tendency to carriage of phenotypically consistent types of Candida among most women attending genitourinary clinics.