Southlands Hospital

OBJECTIVE: To assess the properties of validity and reliability of instruments used to assess satisfaction in a broad sample of health service user satisfaction studies, and to assess the level of awareness of these issues among study authors. DESIGN: Examination and analysis of 195 papers published in 1994 in 139 journals. The following databases were searched: British Nursing Index, CINAHL, EMBASE, MedLine, Popline, and PsycLIT. MAIN MEASURES: Number and types of strategies used for content, criterion, and construct validity, and for stability and internal consistency. Associations between validity/reliability and other study characteristics. RESULTS: Eighty-nine (46%) of the 195 studies reported some validity or reliability data; 76 reported some element of content validity; 14 reported criterion validity, with patient's intent to return the most commonly used criterion; four reported construct validity. Thirty-four studies reported internal consistency reliability, 31 of which used Cronbach's coefficient alpha; eight studies reported test-retest reliability. Only 11 studies (6% of the 181 quantitative studies) reported content validity and criterion or construct validity and reliability. 'New' instruments designed specifically for the reported study demonstrated significantly less evidence for reliability/validity than did 'old' instruments. CONCLUSION: With few exceptions, the study instruments in this sample demonstrated little evidence of reliability or validity. Moreover, study authors exhibited a poor understanding of the importance of these properties in the assessment of satisfaction. Researchers must be aware that this is poor research practice, and that lack of a reliable and valid assessment instrument casts doubt on the credibility of satisfaction findings.

BACKGROUND: Breast-cancer-related lymphoedema is a chronic condition with estimates of incidence ranging from 6 to 83%. Lymphoedema has been associated with a variety of risk factors. However, this evidence has suffered from methodological weaknesses, and so has had little impact upon clinical practice. AIM: To examine incidence and risk factors [hospital skin puncture, surgical procedure, Body Mass Index (BMI), age, axillary node status, number of axillary nodes removed, radiotherapy and surgery on dominant side] for breast cancer-related arm lymphoedema. DESIGN: Prospective observational study, with measurement of limbs pre-operatively and at regular intervals post-operatively. METHODS: We recruited 251 women who had surgical treatment for breast cancer that involved sampling, excision or biopsy of axillary nodes, aged > or = 18 years, and free of advanced disease and psychological co-morbidities. Of these, 188 (74.9%) were available for 3-year follow-up. RESULTS: At follow-up, 39 (20.7%) had developed lymphoedema. Hospital skin puncture (vs. none) (RR 2.44, 95%CI 1.33-4.47), mastectomy (vs. wide local excision or lumpectomy) (RR 2.04, 95%CI 1.18-3.54), and BMI > or = 26 (vs. BMI 19-26) (RR 2.02, 95%CI 1.11-3.68) were the only significant risk factors. DISCUSSION: Lymphoedema remains a significant clinical problem, with 1:5 women in this sample developing the condition following treatment for breast cancer. Risk factors are identified in the development of lymphoedema that should be taken into account in clinical practice.

OBJECTIVE: The aim of this study was to compare the diagnostic performance of clinical vaginal examination with that of transvaginal sonography (TVS) in the presurgical diagnosis of deep infiltrating endometriosis. METHODS: One-hundred and fifty-five women with symptoms suggestive of endometriosis were included. One-hundred and twenty-nine patients met the inclusion criteria and were prospectively and independently assessed by vaginal examination and TVS prior to a diagnostic laparoscopy and, where appropriate, radical resection and histological confirmation of endometriosis was performed. Sensitivity, specificity, positive predictive values (PPV), negative predictive values (NPV) and positive and negative likelihood ratios (LR+ and LR-) were calculated for each test method. RESULTS: In total, 83 (64%) women had histological confirmation of endometriosis, 52 (40%) of whom had deep infiltrating endometriosis. The prevalence of endometriosis on the uterosacral ligaments, pouch of Douglas, vagina, bladder, rectovaginal space and rectosigmoid was 23.3%, 16.3%, 8.5%, 3.1%, 6.9% and 24%. PPV, NPV, LR+ and LR- for vaginal examination were 92%, 87%, 41.56 and 0.60 for ovarian endometriosis; 43%, 84%, 2.48 and 0.63 for uterosacral ligament disease; 64%, 95%, 9.14 and 0.26 for involvement of the pouch of Douglas; 80%, 97%, 42.91 and 0.28 for vaginal endometriosis; 78%, 98%, 46.67 and 0.23 for endometriosis of the rectovaginal space; 100%, 98%, 75.60 and 0.75 for bladder involvement; 86%, 84%, 18.97 and 0.63 for rectosigmoidal endometriosis. Values for TVS were similar with regard to vaginal and rectovaginal space endometriosis, but were clearly superior to vaginal examination in cases of ovarian (87%, 99%, 24.56 and 0.04), uterosacral ligament (91%, 90%, 31.35 and 0.37) and rectosigmoidal (97%, 97%, 88.51 and 0.1) endometriosis. CONCLUSIONS: TVS is a more useful test than is vaginal examination in detecting endometriosis in the ovaries and rectosigmoid.

OBJECTIVE: To determine the long term response, quality of life and levels of pain following the radical excision of rectovaginal endometriosis. DESIGN: A cohort study. SETTING: A tertiary referral centre for the management of advanced endometriosis. SAMPLE: All patients who had undergone radical resection. METHODS: Case note review and patient questionnaire. MAIN OUTCOME MEASURES: Surgical complications. Overall improvement. Dysmenorrhoea, dyspareunia, dyschezia and chronic pain were measured using a visual analogue scale. Quality of life was measured using the EQ-5D questionnaire. RESULTS: Twelve radical resections were performed by laparotomy, 48 by laparoscopy. Ten patients had a hysterectomy. Forty-eight patients underwent shaving of the pre-rectal fascia, two had a disc resection of the rectum, 10 had an anterior rectal resection. Two patients required a colostomy and two needed subsequent dilation of a stenosed anastomosis. Forty-four of the first 46 patients replied. The median follow up period was 12 months (range 2 to 22 months) and 86% (38/44) reported an improvement or whom 27 (61%) had a good response (pain completely gone or greatly improved). Patients having a hysterectomy or a disc or segmental resection of the rectum reported a good response and had a normal quality of life. Quality of life scores in the study group overall were lower than the background population. CONCLUSIONS: Radical resection is an effective treatment for rectovaginal endometriosis. Hysterectomy and rectal resection were associated with a better response and quality of life.

We studied prospectively 81 consecutive patients undergoing hip surgery using the Hardinge (1982) approach. The abductor muscles of the hip in these patients were assessed electrophysiologically and clinically by the modified Trendelenburg test. Power was measured using a force plate. We performed assessment at two weeks, and at three and nine months after operation. At two weeks we found that 19 patients (23%) showed evidence of damage to the superior gluteal nerve. By three months, five of these had recovered. The nine patients with complete denervation at three months showed no signs of recovery when reassessed at nine months. Persistent damage to the nerve was associated with a positive Trendelenburg test.

BACKGROUND: Inhaled fluticasone propionate (FP) is a relatively new inhaled corticosteroid for the treatment of asthma. OBJECTIVES: To assess efficacy and safety outcomes in studies that compared FP to placebo for treatment of chronic asthma. SEARCH STRATEGY: We searched the Cochrane Airways Group Specialised Register (January 2008), reference lists of articles, contacted trialists and searched abstracts of major respiratory society meetings (1997-2006). SELECTION CRITERIA: Randomised trials in children and adults comparing FP to placebo in the treatment of chronic asthma. Two reviewers independently assessed articles for inclusion and risk of bias. DATA COLLECTION AND ANALYSIS: Two review authors extracted data. Quantitative analyses were undertaken using Review Manager software. MAIN RESULTS: Eighty-six studies met the inclusion criteria, recruiting 16,160 participants. In non-oral steroid treated asthmatics with mild and moderate disease FP resulted in improvements from baseline compared with placebo across all dose ranges (100 to 1000 mcg/d) in FEV1 (between 0.1 to 0.43 litres); morning PEF (between 23 and 46 L/min); symptom scores (based on a standardised scale, between 0.44 and 0.7); reduction in rescue beta-2 agonist use (between 1 and 1.4 puffs/day). High dose FP increased the number of patients who could withdraw from prednisolone: FP 1000-1500 mcg/day Peto Odds Ratio 14.07 (95% CI 7.17 to 27.57). FP at all doses led to a greater likelihood of sore throat, hoarseness and oral Candidiasis. AUTHORS' CONCLUSIONS: Doses of FP in the range 100-1000 mcg/day are effective. In most patients with mild-moderate asthma improvements with low dose FP are only a little less than those associated with high doses when compared with placebo. High dose FP appears to have worthwhile oral-corticosteroid reducing properties. FP use is accompanied by an increased likelihood of oropharyngeal side effects.

Background Inhaled beclomethasone dipropionate (BDP) has been, together with inhaled budesonide, the mainstay of anti‐inflammatory therapy for asthma for many years. A range of new prophylactic therapies for asthma is becoming available and BDP has been reformulated using a hydrofluoroalkane‐134a (HFA) propellant which is free from chlorofluorocarbon (CFC). Objectives The objectives of this review were to: (1) Compare the efficacy of BDP with placebo with both CFC and HFA propellants in the treatment of chronic asthma. (2) Explore the possibility that a dose response relationship exists for BDP in the treatment of chronic asthma. (3) To provide the best estimate of the efficacy of BDP as a benchmark for evaluation of newer asthma therapies. Search methods Electronic searches were current as of January 2003. Selection criteria Randomised parallel group design trials for a minimum period of four weeks, in children and adults comparing CFC‐BDP or HFA‐BDP with placebo in the treatment of chronic asthma. Two reviewers independently assessed articles for inclusion and methodological quality. Data collection and analysis One reviewer extracted data; authors were contacted to clarify missing information. We analysed data with RevMan Analyses 1.0.2. Main results 60 studies recruiting 6542 participants met the inclusion criteria. CFC‐BDP (57 studies): In non‐oral steroid treated patients, at doses of 400mcg/day or less CFC‐BDP produced significant improvements from baseline in a number of efficacy measures compared with placebo, including forced expiratory volume in one second (FEV1) 360 ml (95% CI 260 to 460); FEV1 (% predicted) WMD 12.41% (95% CI 8.18 to 16.64) and morning peak expiratory flow rate (am PEF) WMD 35.95 L/min (95% CI 27.85 to 44.04). BDP also led to reductions in rescue beta‐2 agonist use compared with placebo of ‐2.32 puffs/d (95% CI ‐2.55 to ‐2.09) and reduced the relative risk (RR) of trial withdrawal due to an asthma exacerbation 0.25 (95% CI 0.12 to 0.51). Subgroup analyses based on treatment duration provide support to the proposal that a treatment period of greater than four weeks is required to realise a fuller treatment effect. In oral steroid treated patients BDP led to significantly greater reductions in oral prednisolone use WMD ‐4.91 mg/d (95% CI ‐5.88 to ‐3.94 mg/d) and greater likelihood of withdrawing oral steroid treatment RR 8.02 (95% CI 3.23 to 19.92). HFA‐BDP (3 studies): In non‐oral steroid‐treated patients, HFA‐BDP was significantly more effective than placebo in improving FEV1, morning and evening PEF, FEF25 to 75%, reduced asthma symptoms and beta2‐agonists daily consumption. Significant effects for such outcomes were apparent after six weeks of treatment. In oral steroid treated patients, HFA‐BDP improved significantly FEV1 and am PEF. The summary estimates for these outcomes suggested a high level of heterogeneity, and divergent aims of the studies may contribute to the variation we observed. Limited data on adverse events were reported. Authors' conclusions This review has quantified the efficacy of CFC‐BDP and HFA‐BDP in the treatment of chronic asthma and strongly supports its use. Current asthma guidelines recommend titration of dose to individual patient response, but the published data provide little support for dose titration above 400 mcg/d in patients with mild to moderate asthma. There are insufficient data to draw any conclusions concerning dose‐response in people with severe asthma.

BACKGROUND: Inhaled fluticasone propionate (FP) is a high-potency inhaled corticosteroid used in the treatment of asthma. OBJECTIVES: 1. To assess the efficacy and safety outcomes of inhaled fluticasone at different nominal daily doses in the treatment of chronic asthma.2. To test for the presence of a dose-response effect. SEARCH STRATEGY: We searched the Cochrane Airways Group Trials Register (January 2008). SELECTION CRITERIA: Randomised trials in children and adults comparing fluticasone at different nominal daily doses in the treatment of chronic asthma. Two reviewers independently assessed articles for inclusion and methodological quality. DATA COLLECTION AND ANALYSIS: One review author extracted data. These were checked and verified by a second reviewer. Quantitative analyses where undertaken using Review Manager. MAIN RESULTS: Fifty-one published and unpublished trials (representing 55 group comparisons, 10,797 participants) met the inclusion criteria. In asthmatics with mild to moderate disease who were not on oral steroids, FP did not exhibit a dose-response effect in the lower dose comparisons in FEV1 (50mcg, 100mcg, 200mcg and 4-500mcg daily). There were no statisitically significant differences between 4-500mcg and 800-1000mcg, and between 50-100 and 800-1000mcg of FP. When 200mcg was compared with 800-1000mcg daily FEV1 favoured the four/five fold increase. For PEF, a dose response was present with FP when low and moderate, and low and high doses of FP were compared. There was no evidence of a dose-response effect on symptoms or rescue beta-2 agonist use. The likelihood of hoarseness and oral candidiasis was significantly greater for the higher doses (800 to 1000 microg/day). People with oral steroid-dependent asthma treated with FP (2000 microg/day) were significantly more likely to reduce oral prednisolone than those on 1000 to 1500 microg/day (Peto odds Ratio 2.8, 95% CI 1.3 to 6.3). The highest dose also allowed a significant reduction in daily oral prednisolone dose compared to 1000 to 1500 microg/day (WMD 2.0 mg/day, 95% CI 0.1 to 4.0 mg/day). AUTHORS' CONCLUSIONS: We have not found evidence of a pronounced dose response in FEV1 with increasing doses of fluticasone. The number of studies contributing to our primary outcomes was low. At dose ratios of 1:2, there are statistically significant differences in favour of the higher dose in morning peak flow across the low dose range. The clinical impact of these differences is open to interpretation. Patients with moderate disease achieve similar levels of asthma control on medium doses of fluticasone (400 to 500 microg/day) as they do on high doses (800 to 1000 microg/day). More work in severe asthma would help to confirm that doses of FP above 500 microg/day confer greater benefit in this subgroup than doses of around 200 microg/day. In oral corticosteroid-dependent asthmatics, reductions in prednisolone requirement may be gained with FP 2000 microg/day.

An overdose of the semisynthetic, hallucinogenic amphetamine 3,4-methylenedioxymethamphetamine resulted in convulsions, hyperthermia, hyperkalaemia and rhabdomyolysis. The patient's management, which included the use of dantrolene, is discussed.

OBJECTIVE: To evaluate the efficacy and tolerance of a treatment protocol for anxiety-related and obsessive-compulsive disorders in cats. DESIGN: A study was undertaken to assess the clinical response in cats diagnosed with anxiety-related or obsessive-compulsive disorders to a treatment regimen that included clomipramine and behaviour modification. PROCEDURE: The study group of 11 cats was acquired through referral. A detailed behavioural and clinical history was obtained. Presenting signs were urine spraying in seven cases, overgrooming in three and excessive vocalisation in one. Clomipramine was administered orally once daily. The mean starting dose was 0.4 mg/kg. If necessary, the dose was adjusted according to the clinical response of each cat. A behaviour modification program was designed and the owner instructed on its implementation. Cats were to continue on medication for at least 1 month after clinical signs disappeared, then medication withdrawal was to be attempted by decreasing the clomipramine dose progressively at weekly intervals while the behaviour modification program continued. RESULTS: In all cases the presenting clinical sign was largely improved or disappeared. One cat was removed from the study by the owner. Four cats became lethargic at higher doses, but this resolved when the clomipramine dose was reduced. The average maintenance dosage was 0.3 mg/kg once daily. Clomipramine withdrawal was attempted in two cases: the behaviour returned in one case and the medication was reinstated at 0.3 mg/kg twice daily. CONCLUSION: Clomipramine was effective in controlling the signs of anxiety-related and obsessive-compulsive disorders in 10 of 10 assessable cases when used in combination with behaviour modification. Clomipramine was well tolerated.

Abstract This article examines coercion in voluntary psychiatric patients. Three main themes are highlighted using qualitative and quantitative data from a sample of 412 psychiatric patients surveyed in 1990 who had experienced at least one period of hospitalisation. The themes are: the extent to which the label of ‘voluntary’ was an indicator of the patients' experience of being in hospital of their own volition; aspects of admission which patients considered to be coercive; and the impact that coercion might have on patients' views about their problem, professionals and treatment. The findings suggest that a substantial number of nominally voluntary patients reported coercive aspects of their hospitalisation. The impact of feeling coerced was found to produce a more rejecting attitude towards psychiatric services. The findings are discussed in relation to British mental health legislation and care. I particularly want to thank David Pilgrim for his collaboration with the research which made this article possible and for his useful and supportive comments. I am also indebted to John Monahan for his helpful comments on an earlier draft of this paper.

BACKGROUND: Beclomethasone dipropionate (BDP) and budesonide (BUD) are commonly prescribed inhaled corticosteroids for the treatment of asthma. Fluticasone propionate (FP) is newer agent with greater potency in in-vitro assays. OBJECTIVES: To compare the efficacy and safety of Fluticasone to Beclomethasone or Budesonide in the treatment of chronic asthma. SEARCH STRATEGY: We searched the Cochrane Airways Group trial register (January 2007) and reference lists of articles. We contacted trialists and pharmaceutical companies for additional studies and searched abstracts of major respiratory society meetings (1997 to 2006). SELECTION CRITERIA: Randomised trials in children and adults comparing Fluticasone to either Beclomethasone or Budesonide in the treatment of chronic asthma. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed articles for inclusion and methodological quality. One reviewer extracted data. Quantitative analyses were undertaken using RevMan analyses 1.0.1. MAIN RESULTS: Seventy-one studies (14,602 participants) representing 74 randomised comparisons met the inclusion criteria. Methodological quality was fair. Dose ratio 1:2: FP produced a significantly greater end of treatment FEV1 (0.04 litres (95% CI 0 to 0.07 litres), end of treatment and change in morning PEF, but not change in FEV1 or evening PEF. This applied to all drug doses, age groups, and delivery devices. No difference between FP and BDP/BUD were seen for trial withdrawals. FP led to fewer symptoms and less rescue medication use. When given at half the dose of BDP/BUD, FP led to a greater likelihood of pharyngitis. There was no difference in the likelihood of oral candidiasis. Plasma cortisol and 24 hour urinary cortisol was measured frequently but data presentation was limited. Dose ratio 1:1: FP produced a statistically significant difference in morning PEF, evening PEF, and FEV1 over BDP or BUD. The effects on exacerbations were mixed. There were no significant differences incidence of hoarseness, pharyngitis, candidiasis, or cough. AUTHORS' CONCLUSIONS: Fluticasone given at half the daily dose of beclomethasone or budesonide leads to small improvements in measures of airway calibre, but it appears to have a higher risk of causing sore throat and when given at the same daily dose leads to increased hoarseness. There are concerns about adrenal suppression with Fluticasone given to children at doses greater than 400 mcg/day, but the randomised trials included in this review did not provide sufficient data to address this issue.

AIMS: We discuss a case of acute oesophageal necrosis and undertook a literature review of this rare diagnosis. METHODS: The literature review was performed using Medline and relevant references from the published literature. RESULTS: One hundred and twelve cases were identified on reviewing the literature with upper gastrointestinal bleeding being the commonest presenting feature. The majority of cases were male and the mean age of presentation is 68.4 years. This review of the literature shows a mortality rate of 38%. CONCLUSION: Acute necrotizing oesophagitis is a serious clinical condition and is more common than previously thought. It should be suspected in those with upper GI bleed and particularly the elderly with comorbid illness. Early diagnosis with endoscopy and active management will lead towards an improvement in patient outcome.

Background: the practical issues confronting older people who suffer chronic pain may not be tackled in a pain clinic setting and little is known of their strategies for coping. They seem to have little or no information on how to improve the quality of their lives or on resources available to them. Aim: the aim of this study was to ascertain from older people the practical, physical and psychosocial limitations they faced because of chronic pain, and the strategies they used to deal with them. Method: a qualitative approach to generating data was chosen using a Grounded Theory approach and unstructured interviews. Sixty-three people ranging from 60 to 87 years of age participated in the study. Audio-tapes were transcribed verbatim. The material was coded and collapsed into themes. Results: two main themes emerged: (i) the desire for independence and control; and (ii) adaptation to a life with chronic pain. The valuing of independence is in line with previous findings. With only three exceptions none of the participants were certain how or where to get help with practical issues and so they lived in fear of loss of their independence. Several subcategories formed the theme of adaptation. These were acceptance and non-acceptance, pacing oneself, helping other people, the use of prayer and 'looking good and feeling good'. When independence and control is effective, older people may adapt better to chronic pain.

HABITUAL ABORTION BRDIBPTLSH 131 knotting. But in the pregnant woman it is another matter; one must use one's own judgment; the suture should be tied with very little tension. The two incisions are then closed with catgut in the ordinary way and the patient is sent back to bed. The foot of the bed should be raised for 48 hours or more if the patient is pregnant.

The manufacturing industry is shifting its emphasis from a traditional supplier of products to a supplier of increasingly integrated products and services, or product-service systems (PSSs). The new paradigm of PSS requires new design methodologies and supporting tools for the effective design and delivery of these enhanced services and integrated PSSs. A case study has been carried out to identify and classify service knowledge applied in practice, both in the service operation and in product design. This paper describes the service issues and service knowledge that has an impact on product design. An initial attempt is made to describe the role of service knowledge in design and also to describe in detail how to apply service knowledge in the conceptual design stage based on an existing requirements management framework modified for this context. This research makes an important contribution to the developing knowledge and information requirements of PSS design

BACKGROUND: Inhaled budesonide is a widely used inhaled corticosteroid for asthma. OBJECTIVES: The objectives of this review was to compare the efficacy of budesonide with placebo in the treatment of chronic asthma. SEARCH STRATEGY: The Cochrane Airways Group Trial Register and reference lists of articles was searched. We contacted trialists for additional studies and searched abstracts of major respiratory society meetings (1997-1999). SELECTION CRITERIA: Randomised trials in children and adults comparing budesonide to placebo in the treatment of chronic asthma. DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed articles for inclusion and methodological quality. One reviewer extracted data. MAIN RESULTS: 43 studies met the inclusion criteria (2801 subjects). In non-oral steroid treated asthmatics, budesonide led to significant improvements in a number of measures of airway function. These included FEV1, Weighted Mean Difference (WMD) 3.7% predicted (95% CI 0.1, 7.2%); improvement in morning peak flow (PEF) from baseline WMD 29 L/min (95% CI 22, 36 L/min); improvement in evening PEF from baseline WMD 21 L/min (95% CI 13, 29 L/min). Varying methods of reporting symptoms limited the pooling of studies but all high methodological quality studies demonstrated significant improvements compared to placebo. Health status was not reported. Risk of trial withdrawal due to asthma exacerbation was lower with budesonide compared to placebo, relative risk 0.17 (95% CI 0.09, 0.33). Doses of 500-800 mcg/d appeared to have slightly larger effect sizes than lower doses, but no advantage for high doses were apparent. A single high quality RCT reported significant reductions in daily prednisolone requirement and the number of patients able to discontinue prednisolone completely in budesonide treated subjects compared to placebo. No difference in risk of oropharyngeal soreness/hoarseness or oral Candidiasis was apparent for budesonide compared to placebo. Long-term risk of adrenal insufficiency was not reported. REVIEWER'S CONCLUSIONS: This review strongly supports use of budesonide in chronic asthma. Consensus guidelines for chronic asthma suggest titrating inhaled steroid dose to individual requirements. Evidence from this review of trials does not present a case for routine dose titration above 800 mcg/d.

The importance of malnutrition in elderly hip fracture patients has long been recognised. All patients operated upon for a hip fracture over a five-year period were assessed according to two nutritional markers : a) serum albumin levels and b) peripheral blood total lymphocyte count. Patients were subdivided into groups according to the four possible combinations of these results. Outcomes according to four clinical outcome parameters were validated: a) waiting time to operation b) length of hospitalisation, c) in-hospital mortality, and d) one-year postoperative mortality. Significant differences were found between malnourished patients and those with normal laboratory values with regard to surgical delay and one year postoperative mortality. Malnourished patients were also more likely to be hospitalised longer than a month and to die during their hospital stay, but the difference was not significant. The combination of serum albumin level and total lymphocyte count can be used as an independent prognostic factor in hip fracture patients.

Insulin pens offer the advantages of simplicity, convenience, and more accurate dosing to insulin-using patients with diabetes. The usefulness of insulin pens is not limited to certain subsets of individuals but extends to all patients who might choose this delivery system. By facilitating acceptance and consistent implementation of multiple-dose insulin regimens, pens hold the potential to promote improved blood glucose control and thus reduce the risk of the chronic complications of diabetes. Both clinical experience and the supporting literature suggest that pen delivery systems are an option that should be routinely offered to all insulin users.

Background: After decades of paternalistic health service provision, National Health Service users in the United Kingdom are encouraged to express preferences for services; “the patient is king”. Whilst the mental health service user voice is encouraged in multiple forums, it is in satisfaction research (especially using the survey method) as a commentary on services provided that it is primarily heard. However, methodological concerns exist regarding the use of satisfaction surveys as a measure of healthcare quality.Aim: To discuss the arguments against and for using satisfaction surveys in mental health research.Method: A review of the existing literature on satisfaction surveys.Results: There are a number of significant criticisms of satisfaction surveys and their continued use in mental health research.Conclusions: Despite these criticisms, the limitations of satisfaction surveys do not merit their abandonment. The authors indicate possible future directions for the satisfaction research agenda.Declaration of interest: None.