A qualitative analysis of communication between members of a hospital-based multidisciplinary lung cancer team.

The aim of the study was to explore how patient information is communicated between health professionals within a multidisciplinary hospital-based lung cancer team and to identify mechanisms to improve these communications. A qualitative method was employed using semi-structured in-depth interviews with a representative sample (n = 22) of members of a multidisciplinary hospital-based lung cancer team including medical, nursing and allied health professionals. Analysis was undertaken using a thematic grounded theory approach to derive key themes to describe communication patterns within the team and how communication could be improved. Two themes with sub-themes were identified: (1) characteristics of communication between team members including the impact of role on direction of communications, and doctors' dominance in communications; and (2) channels of communication including, preference for face-to-face and the suboptimal roles of the Multidisciplinary Team Meeting and the hospital medical record as mediums for communication. Traditional influences of role delineation and the dominance of doctors were found to impact on communication within the multidisciplinary hospital-based lung cancer team. Existing guidelines on implementation of multidisciplinary cancer care fail to address barriers to effective team communication. The paper-based medical record does not support team communications and alternative electronic solutions need to be used.

New technologies in contraception.

New technologies in both reversible contraception and sterilisation are described. The review includes recent advances in the development of oral contraception, emergency contraception, injectable contraception, vaginal rings, subdermal implants, transdermal contraception, intrauterine devices, spermicides and barrier methods. It also covers methods of transcervical female sterilisation and more easily reversible male sterilisation. The emphasis is on the technology and its safety and effectiveness. Hormonal delivery systems are described in some detail. Mention is also made of research into vaccines and male hormonal methods, where progress has been disappointing.

The epidemiology and treatment of Bell's palsy in the UK.

The study consisted of a survey of all new cases of Bell's palsy occurring between 1992 and 1996 in practices contributing data to the UK General Practice Research Database (GPRD). Data were extracted on age, sex, date of episode of Bell's palsy, household number, episodes of herpes simplex, treatment prescribed and referral to relevant hospital departments. A total of 2473 cases of Bell's palsy were identified. The overall incidence for the study period was 20.2 per 100 000 person years of follow-up (95% CI 19.4-21.0). Incidence increased with age. There was no difference in incidence according to sex or season but there were significant changes over time: incidence was higher in the first year of the study period than in subsequent years. There was no clustering of cases in households and no evidence of any tendency for herpes simplex infections to precede Bell's palsy. About 36% of cases were treated with oral steroids and 19% of episodes resulted in hospital referral. In conclusion, Bell's palsy is seen mainly in a primary care setting. The majority of cases are treated expectantly without drugs. Lack of household clustering and lack of a tendency of herpes simplex infections to precede Bell's palsy do not support a viral aetiology.

Otitis externa in UK general practice: a survey using the UK General Practice Research Database.

BACKGROUND: Otitis externa is a common clinical problem in general practice and yet there are remarkably few data available on the demographic characteristics of patients with this condition and the approaches used by general practitioners (GPs) in the United Kingdom (UK) to manage it. AIM: To define the descriptive epidemiology of otitis externa in the general population, to describe the first-line drug treatment used by UK GPs, and to determine factors related to second disease episodes. DESIGN OF STUDY: Epidemiological data survey. SETTING: All cases of otitis externa occurring in 1997 in practices contributing data to the UK General Practice Research Database. METHOD: Data were extracted on age, sex, date of episode of otitis externa, treatment prescribed, co-existing diagnoses of eczema and diabetes, referral to ear, nose, and throat departments and occurrence of subsequent episodes of disease. Arbitrarily a second episode of disease was defined as persistence if it occurred at 28 days or fewer after the first episode and recurrence if it occurred at more than 28 days after the first episode. RESULTS: A diagnosis of otitis externa was common in all age groups and, except in the elderly, was more common in females than males. There was an increase in disease episodes at the end of the summer in all age groups except the 60 years and over group. In the majority of cases GPs prescribed ear drops (85%), but a significant proportion of patients were also prescribed oral antibiotics (21%). Referral to secondary care was uncommon (3%). Among patients prescribed ear-drop formulations, those containing both steroid and antibiotic or steroid alone were used most commonly and were associated with the lower rates of disease persistence but not recurrence. Among patients prescribed antibiotics, penicillins were prescribed most commonly. Disease persistence rates, and to a lesser extent disease recurrence rates, were higher in patients prescribed oral antibiotics. CONCLUSION: Otitis externa is a common condition and GPs can expect to see an excess of cases at the end of the summer. Topical ear drops are the most common treatment used in the UK. Patients prescribed steroid or steroid/antibiotic combination ear drops have fewer subsequent consultations for otitis externa over the following 28 days.

Misoprostol versus dinoprostone for cervical priming prior to induction of labour in term pregnancy: a randomised controlled trial.

A prospective randomised controlled trial was performed to compare the efficacy and safety of intravaginal misoprostol to that of intravaginal dinoprostone when used for cervical priming prior to the induction of labour; 126 women were recruited to the study and randomised to receive either intravaginal dinoprostone (n = 63) or misoprostol (n = 63) for cervical priming prior to induction of labour. The mean time from insertion of the priming agent to vaginal delivery was significantly shorter in the misoprostol group (925.8 versus 1577.6 minutes), the mean duration of the active length of labour was significantly shorter in the misoprostol group (353.7 versus 496.8 minutes) and more women in the misoprostol group delivered in less than 12 hours (92% versus 76.5%). Women in the misoprostol group were less likely to require a repeated dose of prostaglandin for cervical priming and less likely to require oxytocin for augmentation of labour. There was no difference in the number of women who were delivered vaginally or by Ceasarean section between the two groups. More women developed hyperstimulation during labour in the misoprostol group; however there was no difference between the groups in neonatal outcome in respect to low cord pH or Apgar score at delivery or admission to the neonatal special care nursery.

Preferential prescribing of type of combined oral contraceptive pill by general practitioners to teenagers with acne.

OBJECTIVES: To determine the oral contraceptive prescribing patterns of general practitioners for teenagers in the UK and any preferential prescribing for those with acne. METHOD: The General Practice Research Database was used in a retrospective observational study. Records of females aged 13-19 years were examined for the years 1994 and 1997. RESULTS: In 1994, third-generation pills were widely prescribed, whereas, in 1997, levonorgestrel pills were most commonly prescribed. In those with a recent history of acne, the most commonly prescribed single product was one containing cyproterone acetate. CONCLUSION: General practitioners appear to favor cyproterone acetate-containing pills for those with acne; this proclivity became more pronounced after the pill scare. General practitioners had all but ceased using third-generation pills in 1997, even when there was a therapeutic indication.

Use of the combined oral contraceptive pill by under 16s.

The General Practice Research Database was used to examine prescribing of the combined oral contraceptive pill for females aged under 16 in England and Wales in 1997. From these data, calculations were made to estimate prevalence for these countries; family planning clinic return data were combined with the general practice estimates to give an overall figure of 4.2 per 100. This extent of use is low considering the amount of sexual activity now occurring. A weak effect of population density on prescribing was found, with higher rates in the more rural areas.

Repeated use of hormonal emergency contraception by younger women in the UK.

A cohort of women aged 14-29 in 1993 was identified from the General Practice Research Database and followed up for a period of 4 years. Patient files were searched for evidence of use of emergency contraception and regular contraception. Of the 95 007 women, 15 105 (16%) had received emergency contraception during the study period (an average of 5% per annum). There was a small year on year increase in uptake of emergency contraception between 1994 and 1997. Only 4% of emergency contraception users received emergency contraception more than twice in any year. More than 70% of those who had no previous record of use of regular contraception had used regular contraception within 1 year of using emergency contraception. Teenagers were more likely than other age groups to use emergency contraception, to be repeat users of emergency contraception and to fail to start regular contraception after first use of emergency contraception until later in the study period. These results disprove the notion of widespread repeated use of emergency contraception. They show that provision of an emergency contraception service does not result in failure to initiate regular contraception or abandonment of regular contraception; rather they show many women using regular contraception for the first time after use of emergency contraception.

Patterns of prescription of PC4 by general practitioners in England and Wales.

OBJECTIVE: To study the pattern of general practitioner prescribing of PC4, the most commonly used method of hormonal emergency contraception, in England and Wales. METHOD: The UK General Practice Research Database was used to identify, from a total population of 4.2 million people on the lists of contributing practices, all women aged 10-44 years who were prescribed PC4. Rates of prescribing were calculated to produce rates over time by age group, by day of week and month of year, and by region. RESULTS: The rate for PC4 prescribing rose from about 1.5 per 1,000 women per month in 1992 to about 3.0 in 1995, then remained relatively constant until 1998. Rates were highest among 15-19-year-old women and next highest among those aged 20-24 years. Rates were higher in Wales than in each of the English regions. Excesses of prescribing took place in the summer months and between Saturdays and Mondays. CONCLUSION: Reasons for the increase in PC4 prescribing rates in the early years of the study are unclear, although increasing knowledge of the technique among the population may have contributed. There was no evidence of an increase in prescribing following the pill scare of October 1995, although there was an increase some months earlier. The concentration of requests at weekends suggests the need for weekend access to emergency contraception. The summer peak may also indicate a heightened need in holiday areas at that time.

Contraceptive use in a rural general practice.

All women aged 20-49 in a general practice were sent a questionnaire about their reproductive health, and 72% responded. 78% of respondents were using a method of fertility control. More than a quarter of women were obtaining their contraceptive supplies (condoms especially) from non-medical outlets. Knowledge of the existence of emergency contraception was high (83%). The general practitioner (GP) was the most popular source of contraceptive supplies for those aged under 40 years and more than four-fifths of women said that they would rather turn to their GP than to other sources for future contraceptive advice.

PIP: Although UK general practitioners are providing a growing share of family planning services, little is known about contraceptive use patterns in general practice. This paper reports the findings of a reproductive health questionnaire mailed to all women 20-49 years of age enrolled in a rural general practice near Bedfordshire, England, in 1992. 1370 women (72.2%) returned the questionnaire; 84.8% were married or cohabitating and 99.8% were sexually active. 77.7% of responders were using a fertility control method at the time of the survey. The most commonly reported methods were female sterilization (13.9%), vasectomy (17.7%), the pill (21.5%), condoms (16.4%), and the IUD (5.1%). 31.8% reported having had an unplanned pregnancy and 14.6% had undergone induced abortion. 83.4% had heard of emergency contraception, but only 8.2% had requested the method. The major sources for contraceptive supplies were general practitioner (59.0%), over-the-counter (25.6%), and a family planning clinic (10.8%). Preferred outlets were general practitioner (84.4%) and National Health Service family planning clinic (12.6%). Adequate family planning training for general practitioners is essential given their importance as a source of contraceptive care.

Physiology of pain in labour.

Labour pain is the result of many complex interactions. Although not fully determined, the pain arises from distension of the lower uterine segment and cervical dilatation. The neural mechanism of labour has some features similar to other forms of acute pain; nociceptive information is relayed in small A delta and C afferent fibres to the dorsal horn of the spinal cord, mediated by neurotransmitters; from there it may be involved in the initiation of segmental spinal reflexes or pass through the spinothalamic tract to the brain. Many factors are activated during labour which may modify the nociceptive impulse at different stages of its passage. Some of these factors act synergistically to promote anti-nociception that peaks at delivery.

Prenatal ultrasound findings in a fetus diagnosed with Gaucher's disease (type 2) at birth.

A 26-year-old woman with no significant history was found to have a fetus with hepatosplenomegaly and neurological abnormalities in utero on ultrasound. The baby was found to have a severe clinical manifestation of type 2 Gaucher's disease.

Thromboembolism treated with low molecular weight heparin in a pregnancy complicated by major placenta praevia: a case report.

The concurrent problems of bleeding placenta praevia and thromboembolism present a difficult management problem. We present a case of pulmonary embolism successfully treated with low molecular weight heparin in a woman with a major grade placenta praevia, who required emergency operative delivery.

Treatment of preterm cervical dilatation with glyceryl trinitrate, a nitric oxide donor.

We report an observational study on the use of transdermal glyceryl trinitrate as a treatment to delay delivery of women presenting in pregnancy with dilatation of the cervix. Ten women found to have cervical dilatation more than 2 cm (range 2 to 8 cm) at gestations between 16 and 32 weeks were studied. These women were treated with 50 mg glyceryl trinitrate patches. The mean prolongation of gestation from the time of admission was 46.2 days (range 1 to 130 days). There was 1 stillbirth in a 22.6-week fetus and 1 neonatal death secondary to prematurity. Vaginal delivery occurred in all but 3 cases. All babies were of size appropriate for gestational age at delivery. The only reported maternal side-effect was headache. No adverse fetal effects were noted. We conclude that glyceryl trinitrate may provide an effective and safe method of tocolysis, well suited for long-term use. The purpose of reporting this study is to highlight the mounting accumulation of data on glyceryl trinitrate and reinforce the need to evaluate its use in randomized controlled trials.