Action research: a useful method of promoting change in primary care?

BACKGROUND: Action research has been used successfully to promote change in disciplines other than medicine, but there are few examples of its use in primary care. OBJECTIVE: We aimed to discuss the benefits and difficulties of using action research in primary care using the example of child health surveillance provision in general practice. METHODS: Twenty-eight general practices were randomly allocated into two groups. Action research was used to promote change in 14 practices by facilitating practice meetings and by providing written feedback. The other 14 practices received written feedback alone. The two groups of practices were compared using the following: (i) semi-structured interviews with one health visitor and GP from each practice; (ii) observation of baby clinics; (iii) questionnaires to parents; and (iv) return rates of child health surveillance reviews from the personal child health record. RESULTS: All 14 practices in the action research arm of the study met as individual practice teams and decided to make changes to their provision of child health surveillance. Ten practices audited their child health surveillance as a result. More health visitors in the action research practices than in the comparison practices reported changes to child health surveillance, audit, communication and use of the personal child health record. The majority of health visitors and GPs thought involvement in the action research process was beneficial. However, we were unable to show a statistically significant difference between the two groups of practices in baby clinic provision, parent satisfaction or the return rate of child health surveillance reviews. CONCLUSION: Our study suggests that action research is a successful method of promoting change in primary care. However, measuring the impact of change is difficult.     

Audit of immunization policy and practice of health care workers within National Health Service Trusts in England and Wales.

The purpose of this study was to identify the variation in occupational health immunization policies and practice within NHS Trusts throughout England and Wales. Questionnaires were sent to 440 NHS Trusts and 279 were returned (a response rate of 63%). The results were compared with current Department of Health Guidelines. They highlighted the fact that NHS Trusts do not adopt a consistent approach to immunization practice and that these policies often do not reflect Department of Health Guidance. Of those responding, 249 (89%) stated that they would like additional guidance on immunization practice within the NHS workplace. The production of updated, evidence-based guidelines for immunization practice, may help to ensure that a more consistent approach is taken throughout the NHS. This would benefit both the Trusts and their employees who at present may be confused by being given different advice when moving between Trusts.     

Selective impairment in the recognition of anger induced by diazepam

Rationale: Facial expressions appear to be processed by at least partially separable neuro-cognitive systems. Given this functional specialisation of expression processing, it is plausible that these neurocognitive systems may also be dissociable pharmacologically. Objective: The present study therefore compared the effects of diazepam (15 mg) with placebo upon the ability to recognise emotional expressions. Methods: A double blind, independent group design was used to compare the effects of diazepam and matched placebo in32 healthy volunteers. Participants were presented morphed facial expression stimuli following a paradigm developed for use with patients with brain damage and asked to name one of the six basic emotions (sadness, happiness, anger, disgust, fear and surprise). Results: Diazepam selectively impaired subjects’ ability to recognise angry expressions but did not affect recognition of any other emotional expression. Conclusions: The findings are interpreted as providing further support for the suggestion that there are dissociable systems responsible for processing emotional expressions. It is suggested that these findings may have implications for understanding paradoxical aggression sometimes elicited by benzodiazepines. Received: 27 May 1999 / Accepted: 7 July 1999     

Gender and Ethnic Differences in Survival in a Cohort of HIV Positive Clients

Objectives: The purpose of this study was to examine gender and ethnic differences in survival of persons receiving treatment for HIV infection to determine if differences existed, and if they did, to assess the possibility of explaining these differences by examining other factors, such as age, disease severity when beginning treatment, alcohol, illicit drugs, tobacco, educational level, living arrangements, antiretroviral treatment, PCP prophylaxis, sexually transmitted diseases, mode of transmission and opportunistic infections.

Design: A retrospective cohort study of all clients receiving treatment at an HIV only clinic from its opening in early 1988 until the end of May 1993. Statistical methods used to examine the data included incidence density ratios, Kaplan‐Meier survival curves, Breslow (generalized Wilcoxon) tests of equality of survival curves and Cox proportional hazards models both with and without time dependent covariates.

Results: In the cohort (37% African American, 7% Hispanic American and 25% female), 220 deaths occurred during 1223 person years of follow‐up. Compared to European American males, the following incidence density ratios were observed: European American females: 0.50, Hispanic American females: 0.70, Hispanic American males: 0.96, African American females: 1.28 and African American males: 2.38. The differences were noted above for gender/ethnicity groups were significant at the p < 0.0001 level. After adjusting for disease stage (as measured by laboratory testing of CD4 positive T‐lymphocytes), educational level, and age, no differences in survival by gender or ethnicity remained. Disease stage and educational level had the greatest prognostic significance.

Conclusions: European Americans entered treatment at a much earlier disease stage (as measured by CD4 positive T‐lymphocyte counts) and had higher educational levels (a surrogate for socioeconomic status) than African Americans. These factors may explain the longer survival in European Americans as compared to African Americans in this cohort.     

Congenital pulmonary atresia with ventricular septal defect: angiographic and surgical correlates

Of 181 patients with severe congenital pulmonary atresia and ventricular septal defect or "type IV truncus" (an obsolete term), all but 11% had true central pulmonary arteries. These arteries were demonstrable by large serial biplane angiograms using multiple selective injections into collateral vessels, frequent photographic subtraction, and occasional pulmonary vein-wedge angiograms. These techniques are extremely important for accurate diagnosis and in planning corrective or palliative surgery, which was done in 77% of patients with pulmonary arteries.     

Bilateral progressive essential iris atrophy and keratoconus with coincident features of posterior polymorphous dystrophy: a case report and proposed pathogenesis.

We report the first case known to us of an apparent bilateral association of essential iris atrophy (EIA) and keratoconus (KC), with coincident features of posterior polymorphous dystrophy (PPD). Based on this case and the published natural history and findings of both the irido corneal endothelial (ICE) syndrome and PPD, we propose a new hypothesis for the pathogenesis of the ICE syndrome with associated KC and/or PPD. We suggest that, similar to the genetics of retinoblastoma, the predisposition for either the ICE syndrome or for PPD is inherited as an inactive allele, the so-called "first hit." Inactivation of the second allele, or "second hit," which could occur at any time, might be the product of the background mutation rate or of an environmental trigger. Dedifferentiation or an abnormality in normal development could occur after the first or second hit, resulting in varying clinical patterns. We also concur with other investigators that PPD could be part of the spectrum of the ICE syndrome, owing to similarities in their clinical presentations, histopathology, specular and electron microscopy, and natural history.     

Comparison of fibrin glue, bioresorbable tubing and sutures in peripheral nerve repair

Regeneration of severed rat tibial nerves was functionally and morphologically compared with repair following the use of 3 anastomosis techniques: collagen guide tubes, fibrin glue and conventional microsurgical sutures. In addition, one tibial nerve was crushed in some rats. At ten weekly intervals, functional recovery, assessed by sciatic nerve stimulated evoked contraction of the flexor digitorum muscle, was quicker and more complete following nerve crush than following the anastomosis techniques which were not different from each other. Ten weeks following the surgery, the retrograde transport morphological technique indicated that the anastomosis techniques were not different from each other. The number of labeled tibial motoneurons (tube and suture groups) was significantly less than the crush group, but the glue group was intermediate. Thus, although having less extensive recovery following crush, the quicker and easier techniques of nerve repair, i.e., collagen tubes or fibrin glue, produced comparable anatomical and functional recovery as the more time-consuming, technically demanding microsurgical repair with fine sutures.     

Murine mammary tumor virus seroepidemiology in BALB/cfC3H mice: correlation with tumor development

Serum reactivity to murine mammary tumor virus (MuMTV) was inversely related to mammary tumor risk in 8-to 22-week-old BALB/cfC3H breeding females. Mice at low tumor risk exhibited high-titered serum reactivity to MuMTV (50% end point, greater than or equal to 1:40 by radioimmunoassay) approximately 3-6 months earlier than did the mice at high tumor risk. Maternal MuMTV antibody levels were correlated with the serum anti-MuMTV reactivity of their neonatal offspring (2 wk of age). Serologic antiviral reactivity in infected mice did not change during periods of pregnancy and lactation. All infected animals had detectable serum MuMTV reactivity by 33 weeks of age. The virus-neutralizing capabilities of some of these sera were tested, Sera from some of the young, low-tumor-risk animals that had MuMTV-precipitating antibodies also had virus-neutralizing activity. Conversely, none of the sera from the high-tumor-risk animals had detectable MuMTV-neutralizing antibodies.