The changing shape of general practice in Scotland: the rise of the 'megapractice'.

OBJECTIVES: To describe the trends in the nature of general practices in Scotland between 2014/15 and 2023. STUDY DESIGN: Descriptive ecological study. METHODS: We obtained data from Public Health Scotland and used general practitioner (GP) practice codes, practice names, and the General Medical Council (GMC) numbers of their listed GPs to describe trends in practice characteristics and to identify individual practices that were likely to be operating as a single entity. RESULTS: Defining practice entities is difficult because different GP practice codes are often retained when GPs are performing across multiple practices. If GP practice codes alone are used, the median practice list size increased from 5094 to 5881, and the mean from 5588 to 6289, between 2013/14 and 2020/21. There was one outlier practice that grew to have over 45,000 patients registered by 2020/21. However, this underestimates the extent of this new mega-practice phenomenon. Using the GMC numbers of GPs listed as performers to identify where the same GPs are working across multiple GP practice codes, we identified a series of mega-practices that span across health board areas and which have experienced a dramatic increase in their list size (with the two largest having list sizes of over 101,000 and 77,000 patients, respectively). CONCLUSIONS: Further research is needed to better understand: how mega-practices provide services and whether this differs from other practices; where financial rewards accumulate within mega-practices; differences in staffing between mega-practices and other models; and the impacts mega-practices have on the quality and continuity of care and on health and inequality outcomes.

Musculoskeletal chest pain prevalence in emergency department presentations: A retrospective case notes review.

OBJECTIVE: Musculoskeletal (MSK) causes of chest pain are considered common in emergency care, yet management is limited, reported outcomes are poor and prevalence data in New Zealand are lacking. The present study aims to estimate the prevalence of MSK chest pain in New Zealand EDs and describe the characteristics of MSK chest pain cases. METHODS: A retrospective chart review was conducted based on de-identified clinical notes extracted from four hospitals within the South Island of New Zealand from 3 months spanning 1 March to 31 May 2021. Individual cases were categorised to the single best-fitting cause of chest pain using systems-based categorisation, based primarily on the doctors' documented final impression. RESULTS: A total of 1344 cases were categorised in the present study. MSK chest pain had a prevalence of 15% (range 11-31%) of chest pain presentations across all study sites. This represented the second most common system responsible for chest pain, after the cardiovascular system. The mean age of MSK chest pain cases was 46.9 (standard deviation [SD] 19.1) years, compared to 55.5 (SD 19.7) years in all cases. Age and gender-specific data, data from rural hospitals and MSK sub-type data are presented. CONCLUSIONS: These data provide a conservative estimate of MSK chest pain prevalence in EDs within the South Island of New Zealand. The findings highlight MSK chest pain as common in emergency care, providing a basis and justification for further research to improve management and outcomes for people with MSK chest pain.

Monte Carlo optimization of a microbeam collimator design for use on the small animal radiation research platform (SARRP).

Microbeam radiation therapy (MRT) is a pre-clinical, spatially-fractionated treatment modality noted for its ability to achieve a large differential response between normal and tumoral tissues. In the present study, TOPAS Monte Carlo (MC) simulations were used to optimize the design of a compact, affordable multi-slit collimator (MSC) suitable for use with the small animal radiation research platform (SARRP). MRT dose distributions in a (1 × 1 × 3)cm3 water phantom were simulated for a tungsten MSC using different focal spot sizes (0.4, 3 mm), beam energies (40, 80, 220 kVp), slit widths (100, 125, 150, 175, 200 µm), collimator thicknesses (1.5, 2.5, 3 cm) and collimator-to-surface distances (CSD of 1 and 3 cm). Key MRT figures of merit, namely the peak-to-valley dose ratio (PVDR), full-width at half-maximum and peak dose rate were determined. Use of the small focal spot maximized the PVDR (~40 at surface) and reduced the system's sensitivity to changes in CSD, but decreased the collimated beam output to 55.2 cGy min-1. The large focal spot was ill-suited for large CSD irradiations, but increased the beam output by a factor of 2.8, to 153.0 cGy min-1, and decreased the sensitivity to changes in slit width. A modular MSC, using divergent plastic spacer materials in place of excavated slits, was also investigated. Polypropylene and polyethylene terephthalate material spacers were considered and while neither reduced the PVDR compared to air slits, the dose rate was reduced by 37% and 47%, respectively. Lastly, a steel parallel-slit MSC was used in a preliminary test of MRT delivery using the SARRP. Discrepancies between the results of film dosimetry and the corresponding MC simulations highlight the need to fabricate a more well-defined collimator for use in future validation and radiobiological work. The simulated results of this study are being used to inform the design of such a collimator, which will additionally boast a high degree of modularity at reasonable cost.

Multi-institutional MicroCT image comparison of image-guided small animal irradiators.

To recommend imaging protocols and establish tolerance levels for microCT image quality assurance (QA) performed on conformal image-guided small animal irradiators. A fully automated QA software SAPA (small animal phantom analyzer) for image analysis of the commercial Shelley micro-CT MCTP 610 phantom was developed, in which quantitative analyses of CT number linearity, signal-to-noise ratio (SNR), uniformity and noise, geometric accuracy, spatial resolution by means of modulation transfer function (MTF), and CT contrast were performed. Phantom microCT scans from eleven institutions acquired with four image-guided small animal irradiator units (including the commercial PXi X-RAD SmART and Xstrahl SARRP systems) with varying parameters used for routine small animal imaging were analyzed. Multi-institutional data sets were compared using SAPA, based on which tolerance levels for each QA test were established and imaging protocols for QA were recommended. By analyzing microCT data from 11 institutions, we established image QA tolerance levels for all image quality tests. CT number linearity set to R 2 > 0.990 was acceptable in microCT data acquired at all but three institutions. Acceptable SNR > 36 and noise levels <55 HU were obtained at five of the eleven institutions, where failing scans were acquired with current-exposure time of less than 120 mAs. Acceptable spatial resolution (>1.5 lp mm-1 for MTF = 0.2) was obtained at all but four institutions due to their large image voxel size used (>0.275 mm). Ten of the eleven institutions passed the set QA tolerance for geometric accuracy (<1.5%) and nine of the eleven institutions passed the QA tolerance for contrast (>2000 HU for 30 mgI ml-1). We recommend performing imaging QA with 70 kVp, 1.5 mA, 120 s imaging time, 0.20 mm voxel size, and a frame rate of 5 fps for the PXi X-RAD SmART. For the Xstrahl SARRP, we recommend using 60 kVp, 1.0 mA, 240 s imaging time, 0.20 mm voxel size, and 6 fps. These imaging protocols should result in high quality images that pass the set tolerance levels on all systems. Average SAPA computation time for complete QA analysis for a 0.20 mm voxel, 400 slice Shelley phantom microCT data set was less than 20 s. We present image quality assurance recommendations for image-guided small animal radiotherapy systems that can aid researchers in maintaining high image quality, allowing for spatially precise conformal dose delivery to small animals.

Vaginal examination does not improve diagnostic accuracy in early pregnancy bleeding.

OBJECTIVE: The study aims to determine if a vaginal examination improves diagnostic accuracy when assessing women who present to the ED with vaginal bleeding in the first trimester of pregnancy. METHODS: One hundred and thirty-five women with first trimester bleeding were randomised to have a vaginal examination (n = 61) or not (n = 74). They were given a provisional diagnosis, and then a final diagnosis after ultrasound, beta-human chorionic gonadotropin and gynaecological follow up. The provisional diagnosis was considered accurate if it matched the final diagnosis. RESULTS: The provisional and final diagnoses matched in a little over half of the cases, and there was no statistical difference between the two groups (χ(2) = 0.005, P = 0.94). CONCLUSION: In a stable patient presenting to the ED with first trimester bleeding, clinical diagnosis is highly inaccurate and is not improved by vaginal examination. Routine vaginal examination is not necessary as part of the initial patient assessment.

A patient survey assessing the awareness and acceptability of the emergency care summary and its consent model in Scotland.

BACKGROUND: The Emergency Care Summary (ECS) was introduced in 2006 to allow aspects of the general practitioner (GP; family doctor, equivalent to primary care physician) medical record to be viewed in hospitals and out-of-hours centers in Scotland. Records were automatically uploaded unless patients actively opted out. This study investigated patient awareness and acceptance of this process. METHODS: This was a questionnaire survey of patients in a GP surgery (office) in Paisley, Scotland. RESULTS: Survey results indicated that 42 percent of patients were aware of the ECS, and 16 percent said that they recognized the leaflet posted to households. Of those who recognized the leaflet, 92 percent said they were happy for their record to be part of the system, while the others did not realize their record was to be included. Having read the leaflet, 97 percent said that they were happy for their record to be included in the ECS. CONCLUSIONS: This study shows that most patients were not aware of the Emergency Care Summary or did not remember seeing the leaflet posted to households. Having read the leaflet, the vast majority of patients were happy for their records to be included in the system. The low awareness of the ECS calls into question the validity of an implied consent model using an information leaflet distributed by post.