Norfolk Community Health and Care NHS Trust

Anterior knee pain due to dysplasia of the extensor mechanism is common. We have studied 137 knees (103 patients) in order to identify a rapid and reproducible radiological feature which would indicate the need for further analysis. Overall, 67 knees (49%) had at least one radiological abnormality; 70 (51%) were considered normal. There were five cases of Dejour type-3 dysplasia of the femoral trochlea, nine of type-2 and 12 of type-1. There were 49 cases of patella alta and five of patella infera. Four knees had an abnormal lateral patellofemoral angle (patellar tilt), and in 15 knees there was more than one abnormality. Classification of trochlear dysplasia was difficult and showed poor reproducibility. This was also true for the measurement of the lateral patellofemoral angle. Patellar height was more easily measured but took time. The sulcus angle is an easily and rapidly measurable feature which was reproducible and was closely related to other features of dysplasia of the extensor mechanism. The finding of a normal sulcus angle suggested that seeking other radiological evidence of malalignment of the extensor mechanism was unlikely to reveal additional useful information. The severity of other features of dysplasia of the extensor mechanism correlated with increasing sulcus angle.

The aetiology of perforation of large bowel diverticula is poorly understood and a case-control study is required to identify the causes. Before such a study can be attempted, the incidence must be determined and groups at particular risk identified. Cases of perforated large bowel diverticula living in the Norwich postal code region treated between 1995 and 1997 were identified. Fifty-eight cases presented in a population of 531 241. The incidence was 4.0 cases per 100,000 per year, increased with age and was higher in men than women (5.8 vs 3.1). The most frequently used drugs were non-steroidal anti-inflammatory drugs (NSAIDs) (29%) and opiate analgesics (26% of cases). This is the first report of the incidence of perforated diverticular disease and allows a calculation of the population size needed to recruit sufficient cases for an aetiological investigation. The differences in incidence between genders should prompt a search for factors which differ between the sexes such as diet. NSAIDs are a known risk factor, although the data show that opiate analgesics should be investigated.

This study compared the quality of analgesia and incidence of adverse effects with two doses of intrathecal morphine in patients undergoing elective Caesarean section. Fifty patients were randomly allocated to receive either morphine 0.1 mg or 0.2 mg in addition to a standard intrathecal dose of 2.5 ml bupivacaine 0.5% in 8% dextrose. The quality of analgesia was assessed using visual analogue scores and the incidence of nausea, vomiting and itching were recorded during the first 24 h postoperatively. There was no statistically significant difference in the quality of analgesia nor in the incidence and severity of itching between the two groups. Fewer patients in the 0.1 mg morphine group experienced postoperative nausea and vomiting (7 versus 14, p < 0.05). We conclude that the use of 0.1 mg morphine intrathecally produces comparable analgesia to 0.2 mg after Caesarean section with significantly less nausea and vomiting.

A nterior knee pain due to dysplasia of the extensor mechanism is common. We have studied 137 knees (103 patients) in order to identify a rapid and reproducible radiological feature which would indicate the need for further analysis.

BACKGROUND: A number of cognitive appraisals have been identified as important in the manifestation of obsessive-compulsive disorder (OCD) in adults. There have, however, been few attempts to explore these cognitive appraisals in clinical groups of young people. METHOD: This study compared young people aged between 11 and 18 years with OCD (N = 28), young people with other types of anxiety disorders (N = 28) and a non-clinical group (N = 62) on three questionnaire measures of cognitive appraisals. These were inflated responsibility (Responsibility Attitude Scale; Salkovskis et al., 2000), thought-action fusion--likelihood other (Thought-Action Fusion Scale; Shafran, Thordarson & Rachman, 1996) and perfectionism (Multidimensional Perfectionism Scale; Frost, Marten, Luhart & Rosenblate, 1990). RESULTS: The young people with OCD had significantly higher scores on inflated responsibility, thought-action fusion--(likelihood other), and one aspect of perfectionism, concern over mistakes, than the other groups. In addition, inflated responsibility independently predicted OCD symptom severity. CONCLUSIONS: The results generally support a downward extension of the cognitive appraisals held by adults with OCD to young people with the disorder. Some of the results, however, raise issues about potential developmental shifts in cognitive appraisals. The findings are discussed in relation to implications for the cognitive model of OCD and cognitive behavioural therapy for young people with OCD.

Paraffin sections from 29 lung carcinomas (28 primary and 1 metastatic) and 9 pleural malignant mesotheliomas were immunostained with antisera to human hepatocyte growth factor/scatter factor (HGF/SF) and its receptor, met. For HGF/SF, immunoreactivity was demonstrated in all 9 mesotheliomas, 9 of 12 adenocarcinomas, and 7 of 10 squamous cell carcinomas. None of seven cases of small cell anaplastic carcinoma was positive. The adenocarcinomas frequently showed enhanced luminal staining, suggesting possible secretion of HGF/SF, and this pattern of staining was also seen occasionally in bronchial epithelium adjacent to the tumour. Stromal fibroblasts also showed immunoreactivity for HGF/SF in 6/8 cases of mesothelioma but in only 3/12 adenocarcinomas, 1/10 squamous cell carcinomas, and 1/4 small cell anaplastic carcinomas. All tumours stained for met, usually strongly. The staining was mainly cytoplasmic in nature, but some plasma membrane staining was usually evident. Adenocarcinomas showed strong luminal membrane staining, as did adjacent, histologically normal bronchial epithelium. This study demonstrates the presence of HGF/SF and met in most of the tumour types described, particularly mesotheliomas, and suggests that the HGF/SF/met signalling system may play a role in the development of these tumours, either by autocrine or by paracrine mechanisms.

Debate exists as to whether the vastus medialis oblique (VMO) can be activated to a greater degree than the vastus lateralis to produce preferential strengthening. This systematic review aims to determine whether preferential activation of VMO can be achieved by altering lower limb joint orientation or muscular co-contraction. A search of pertinent specialist journals and of the electronic databases AMED, CINAHL, the Cochrane database, EMBASE, ovid Medline, Physiotherapy Evidence Database (PEDro), PubMed, and Zetoc from their inception to February 2008 was undertaken. All English-language clinical papers assessing the electromyographic activity of the human VM against the vastus lateralis (VL) muscles, in a neutral lower limb joint orientation, compared to a different hip, knee, ankle, and foot position; or with the addition of a co-contraction were included. Twenty papers reviewing 387 participants were reviewed. These reported principally that altering lower limb joint orientation or the addition of a co-contraction does not preferentially enhance VMO activity over VL. Nonetheless, the evidence-base presented with a number of significant methodological limitations. Accordingly, well-designed studies evaluating large samples of patients with patellofemoral joint disorders are required, to rectify the present limitations in the evidence-base, and to thoroughly investigate this topic.

OBJECTIVE: The Transtheoretical Model proposes that clients' stage of change will predict their engagement in therapy. This study tested the hypotheses that clients with high Precontemplation scores would prematurely terminate from therapy and that clients with high Action scores would attend a greater number of sessions and establish a more positive therapeutic alliance. DESIGN: Using a within-subjects design, baseline measures of stage of change were used to predict the number of sessions attended, premature drop-out from therapy, and the therapeutic alliance after sessions one and three. METHODS: Sixty clients completed the Stages of Change Scales and the Brief Symptom Inventory prior to therapy. The therapeutic alliance was assessed after the first and third therapy session using the Agnew Relationship Measure. RESULTS: The specific hypotheses were not supported. Premature termination from therapy was predicted by high level of initial symptom severity and low Contemplation scores. Positive therapeutic alliance at session one and session three was predicted by high Contemplation at baseline. CONCLUSIONS: These results suggest that the Transtheoretical Model, which was developed in the context of interventions for behavioural change, may not be directly generalizable to outpatient psychotherapy populations. However, Contemplation did predict premature termination and engagement. This implies that with adaptation the model may be a useful adjunct to psychotherapy assessment.

OBJECTIVE: To study an established triage nurse x ray requesting system to determine whether sending defined groups of patients for radiography before assessment by doctors or emergency nurse practitioners (ENPs) resulted in shorter waiting times for patients without compromising quality of care. METHODS: Prospective randomised controlled study of "walking wounded" patients attending a district general hospital. Data were collected over two separate two week periods, six months apart, in the middle of two senior house officer appointment periods. A total of 675 patients were entered into the study. Analysis of results was achieved using standard statistical methods. RESULTS: Altogether 335 patients were in the nurse x ray group and 340 in the control group. The triage categories of the groups were similar. A 36% mean time reduction of 37.2 min (95% confidence interval 30.2 to 44.2, p=0.000) from time of triage to time of treatment decision was achieved in the nurse requested group. Triage nurses requested 8% (p=0.002) fewer x rays than doctors or ENPs and had a 6% higher positive "hit" rate (p=0.03). In 7.8% (26 cases), patients in the triage nurse group were judged to require radiographs or further views by the doctor or ENP; of these, 11 cases showed a positive finding on radiography. The time from triage to assessment by doctor or ENP was not lengthened by prior requesting of radiography (nurse x ray group 64.4 min, control group 63.7 min, p=0.79). CONCLUSIONS: A triage nurse x ray requesting system speeds up the progress of walking wounded patients through the department without compromising service quality. Further benefits are staff and patient satisfaction and a greater sense of team working for all staff.

PURPOSE: This study assessed the literature to determine the efficacy and effectiveness of physiotherapy and occupational therapy interventions in the treatment of people with benign joint hypermobility syndrome (BJHS). METHODS: Published literature databases including: AMED, CINAHL, MEDLINE, EMBASE, PubMed and the Cochrane Library, in addition to unpublished databases and trial registries were searched to October 2012. All clinical trials comparing the clinical outcomes of Occupational Therapy and Physiotherapy interventions compared to non-treatment or control intervention for people with BJHS were included. RESULTS: Of the 126 search results, 3 clinical studies satisfied the eligibility criteria. The data provides limited support for the use of wrist/hand splints for school children. While there is some support for exercise-based intervention, there is insufficient research to determine the optimal mode, frequency, dosage or type of exercise which should be delivered. CONCLUSIONS: The current evidence-base surrounding Occupational Therapy and Physiotherapy in the management of BJHS is limited in size and quality. There is insufficient research exploring the clinical outcomes of a number of interventions including sensory integration, positioning and posture management and education. Longer term, rigorous multi-centre randomised controlled trials are warranted to begin to assess the clinical and cost-effectiveness of interventions for children and adults with BJHS. Implications for Rehabilitation There is an evidence-base to support clinician's use of proprioceptive-based exercises in adults, and either tailored or generalised physiotherapy regimes for children with BJHS. Clinicians should be cautious when considering the prescription of hand/wrist splints for school age children with BJHS, based on the current research. Until further multi-centre trials are conducted assessing the clinical and cost-effectiveness of interventions for children and adult with BJHS, clinical decision-making should be based on theoretical rather than evidence-based grounds for this population.

OBJECTIVES: Pulmonary rehabilitation (PR) provides benefit for patients with chronic obstructive pulmonary disease (COPD) in terms of quality of life (QoL) and exercise capacity; however, the effects diminish over time. Our aim was to evaluate a maintenance programme for patients who had completed PR. SETTING: Primary and secondary care PR programmes in Norfolk. PARTICIPANTS: 148 patients with COPD who had completed at least 60% of a standard PR programme were randomised and data are available for 110 patients. Patients had greater than 20 pack year smoking history and less than 80% predicted forced expiratory volume in 1 s but no other significant disease or recent respiratory tract infection. INTERVENTIONS: Patients were randomised to receive a maintenance programme or standard care. The maintenance programme consisted of 2 h (1 h individually tailored exercise training and 1 h education programme) every 3 months for 1 year. PRIMARY AND SECONDARY OUTCOME MEASURES: The Chronic Respiratory Questionnaire (CRQ) (primary outcome), endurance shuttle walk test (ESWT), EuroQol (EQ5D), hospital anxiety and depression score (HADS), body mass index (BMI), body fat, activity levels (overall score and activity diary) and exacerbations were assessed before and after 12 months. RESULTS: There was no statistically significant difference between the groups for the change in CRQ dyspnoea score (primary end point) at 12 months which amounted to 0.19 (-0.26 to 0.64) units or other domains of the CRQ. There was no difference in the ESWT duration (-10.06 (-191.16 to 171.03) seconds), BMI, body fat, EQ5D, MET-minutes, activity rating, HADS, exacerbations or admissions. CONCLUSIONS: A maintenance programme of three monthly 2 h sessions does not improve outcomes in patients with COPD after 12 months. We do not recommend that our maintenance programme is adopted. Other methods of sustaining the benefits of PR are required. TRIAL REGISTRATION NUMBER: NCT00925171.

BACKGROUND: Fractional exhaled nitric oxide (FeNO) is a surrogate marker of eosinophilic airway inflammation and good predictor of corticosteroid response. AIM: To evaluate how FeNO is being used to guide primary care asthma management in the United Kingdom (UK) with a view to devising practical algorithms for the use of FeNO in the diagnosis of steroid-responsive disease and to guide on-going asthma management. METHODS: Eligible patients (n = 678) were those in the Optimum Patient Care Research Database (OPCRD) aged 4-80 years who, at an index date, had their first FeNO assessment via NIOX MINO® or Flex®. Eligible practices were those using FeNO measurement in at least ten patients during the study period. Patients were characterized over a one-year baseline period immediately before the index date. Outcomes were evaluated in the year immediately following index date for two patient cohorts: (i) those in whom FeNO measurement was being used to identify steroid-responsive disease and (ii) those in whom FeNO monitoring was being used to guide on-going asthma management. Outcomes for cohort (i) were incidence of new ICS initiation at, or within the one-month following, their first FeNO measurement, and ICS dose during the outcome year. Outcomes for cohort (ii) were adherence, change in adherence (from baseline) and ICS dose. OUTCOMES: In cohort (i) (n = 304) the higher the FeNO category, the higher the percentage of patients that initiated ICS at, or in the one month immediately following, their first FeNO measurement: 82%, 46% and 26% of patients with high, intermediate and low FeNO, respectively. In cohort (ii) (n = 374) high FeNO levels were associated with poorer baseline adherence (p = 0.005) but greater improvement in adherence in the outcome year (p = 0.017). Across both cohorts, patients with high FeNO levels were associated with significantly higher ICS dosing (p < 0.001). CONCLUSIONS: In the UK, FeNO is being used in primary practice to guide ICS initiation and dosing decisions and to identify poor ICS adherence. Simple algorithms to guide clinicians in the practical use of FeNO could improved diagnostic accuracy and better tailored asthma regimens.

A large number of severity of illness scoring systems have been developed and they are widely used in intensive care practice. However, they are complex systems with their basis in mathematics. To use such systems effectively, it is important to appreciate what factors influence their performance so that they can be compared fairly and used most appropriately. The purpose of this review is to describe the methods commonly used to assess the various facets of performance in severity of illness scoring systems. The performance of the most frequently used scoring systems in adult intensive care practice are presented. The shortfalls, misuse and strengths of scoring systems are also discussed.

AIMS: Poor communication of clinical information between healthcare settings is associated with patient harm. In 2008, the UK National Prescribing Centre (NPC) issued guidance regarding the minimum information to be communicated upon hospital discharge. This study evaluates the extent of adherence to this guidance and identifies predictors of adherence. METHODS: This was an audit of discharge summaries received by medical practices in one UK primary care trust of patients hospitalized for 24 h or longer. Each discharge summary was scored against the applicable NPC criteria which were organized into: 'patient, admission and discharge', 'medicine' and 'therapy change' information. RESULTS: Of 3444 discharge summaries audited, 2421 (70.3%) were from two teaching hospitals and 906 (26.3%) from three district hospitals. Unplanned admissions accounted for 2168 (63.0%) of the audit sample and 74.6% (2570) of discharge summaries were electronic. Mean (95% CI) adherence to the total NPC minimum dataset was 71.7% [70.2, 73.2]. Adherence to patient, admission and discharge information was 77.3% (95% CI 77.0, 77.7), 67.2% (95% CI 66.3, 68.2) for medicine information and 48.9% (95% CI 47.5, 50.3) for therapy change information. Allergy status, co-morbidities, medication history and rationale for therapy change were the most frequent omissions. Predictors of adherence included quality of the discharge template, electronic discharge summaries and smaller numbers of prescribed medicines. CONCLUSIONS: Despite clear guidance regarding the content of discharge information, omissions are frequent. Adherence to the NPC minimum dataset might be improved by using comprehensive electronic discharge templates and implementation of effective medicines reconciliation at both sides of the health interface.

Apolipoprotein E ( ApoE ) gene polymorphism is a major factor in lipid metabolism. It has been suggested that this polymorphism can modulate colorectal tumour risk. We tested this hypothesis for colorectal cancer (CRC). ApoE genotype was determined in 206 patients with CRC and 353 healthy controls from the East Anglia region of the U.K. Compared with individuals possessing the most common epsilon 3/epsilon 3 genotype, those with the epsilon 2/epsilon 3 genotype had an increased risk of colon cancer [odds ratio (OR) = 1.91; 95% confidence interval 1.05-3.45]. However, this association was strongly affected by gender. Separate analysis of male and female subjects revealed a highly significant association in men (OR = 2.71; 95% confidence interval 1.30-5.65), but no association in women (OR = 1.01; 95% confidence interval 0.37-2.77). Likewise, the proportion of male patients with more advanced tumours (Dukes' C&D) was significantly increased among those with the ApoE epsilon 2/epsilon 3 genotype (OR = 4.16; 95% confidence interval 1.36-12.75). No significant effect of the presence of the epsilon 4 allele on CRC risk was found; however, there were no epsilon 4/epsilon 4 homozygotes among patients with proximal colon cancers. The ApoE epsilon 3/epsilon 3 majority genotype appeared to be associated with the lowest risk of CRC. These results suggest that ApoE genotype can influence both CRC risk and prognosis of the existing disease in a gender-dependent manner.

Despite current guidelines and decades of evidence on the benefits of a self-management approach, self-management of COPD remains relatively under-utilized in clinical care compared with other chronic diseases. However, self-management interventions can play a valuable role in supporting people with COPD to respond to changing symptoms, and thereby make appropriate decisions regarding the management of their own chronic condition. In this review, we discuss the history and evolution of the concept of self-management, assess current multidisciplinary support programs and clinical interactions designed to optimize self-management, and reflect on how effective these are in terms of clinical and humanistic outcomes. We also evaluate the mechanisms for encouraging change from protocol-based care towards a more personalized care approach, and discuss the role of digital self-management interventions and the importance of addressing health inequalities in COPD treatment, which have been accelerated by the COVID-19 pandemic. Reflecting on the importance of self-management in the context of symptom monitoring and provision of educational support, including information from patient organizations and charities, we discuss the ideal components of a self-management plan for COPD and provide six key recommendations for its implementation: 1) better education for healthcare professionals on disease management and consultation skills; 2) new targets and priorities for patient-focused outcomes; 3) skills gap audits to identify barriers to self-management; 4) best practice sharing within primary care networks and ongoing professional development; 5) enhanced initial consultations to establish optimal self-management from the outset; and 6) negotiation and sharing of self-management plans at the point of diagnosis.

This article reports the results of a survey of acupuncture practice in chronic pain clinics in the United Kingdom. The survey reveals that acupuncture is widely used in the treatment of chronic pain with 84% of those responding stating that is was available at their clinics. The majority of practitioners had attended a course at one of the 'acupuncture schools' but in about one fifth of the clinics the practitioner had not received any formal training.

In two linked studies we examined children's performance on tasks required for participation in cognitive therapy. In Study 1 we piloted some new tasks with children aged 5 to 11 years. In study 2 the effects of IQ, age and educational experience were examined in children aged 5 to 7 years. In study 1, 14 children aged 5 to 11 completed three tasks related to cognitive therapy; generating post-event attributions, naming emotions, and linking thoughts and feelings. Study 2 used a between-subjects design in which 72 children aged 5, 6, or 7 years from two primary schools completed the three tasks and the Block Design and Vocabulary sub-tests from the WISC III or WPPSI-R. Children were tested individually during the school day. All measures were administered on the same occasion. In study 2 administration order of the cognitive therapy task and the WISC III/WPPSI-R were randomized. The majority of children demonstrated some ability on each of the three tasks. In study 2, performance was associated with school and with IQ but not with age. There were no gender differences. Children attending a school with an integrated thinking skills programme and those with a higher 1Q were more successful on the cognitive therapy tasks. These results suggest that many young children could engage in cognitive therapy given age-appropriate materials. The effects of training in relevant meta-cognitive skills on children's ability to use concepts in CBT may warrant further research.

Controversy exists regarding the clinical and radiological differences in outcomes between fixed- and mobile-bearing total knee replacements (TKR). The aim of this study was to compare these two TKR designs using a meta-analysis of the electronic databases MEDLINE, EMBASE, CINAHL and AMED in addition to a review of unpublished material. All included papers were critically appraised using a modified PEDro critical appraisal tool. Thirty-three studies were eligible, assessing the outcomes of 3532 TKRs. Analysis suggested that there was no significant difference in clinical or radiological outcomes and complication rates between fixed- and mobile-bearing TKRs.