Continuity within primary palliative care: an audit of general practice out-of-hours co-operatives

BACKGROUND: The transfer of information between general practitioners (GPs) and their out-of-hours providers on vulnerable patient groups is essential to ensure continuity of care. This will be critical when, in 2006, NHS Direct will triage and route all out-of-hours calls. This study investigates the current use of information handover systems for palliative care patients within four out-of-hours co-operatives. METHODS: Paper records of all 13,460 contacts during August 2002 were scrutinized. Using a standardized data extraction form we recorded details on all palliative or terminal contacts, and the existence of information handover. RESULTS: Across the four co-operatives, 2.1 per cent of all calls were from palliative care patients; co-operatives held handover information for between one (1.2 per cent) and 13 (32.5 per cent) of these patients. CONCLUSION: The systems in place to alert these co-operatives to the needs of palliative care patients are currently under-utilized. As services move towards an integrated approach, scrutiny of information transfer systems and encouragement of GPs and district nurses to update information, may help to ensure better continuity of care     

IgG-sandwich and IgM-capture enzyme-linked immunosorbent assay for the detection of antibody to Rift Valley fever virus in domestic ruminants

The recent occurrence of the first confirmed outbreaks of Rift Valley fever in humans and livestock outside the African region, namely in the Kingdom of Saudi Arabia and Yemen, is of global medical and veterinary concern. Disadvantages of classical techniques for serological diagnosis of Rift Valley fever include health risk to laboratory personnel, restrictions for their use outside endemic areas and inability to distinguish between different classes of immunoglobulins. We report on the development and validation of sandwich and capture ELISAs (both based on inactivated antigen) for detection of IgG and IgM antibody to Rift Valley fever virus in bovine, caprine and ovine sera. Compared to virus neutralisation and haemagglutination-inhibition tests, the IgG sandwich ELISA was more sensitive in detection of the earliest immunological responses to infection or vaccination with Rift Valley fever virus. Its sensitivity and specificity derived from field data sets ranged in different ruminant species from 99.05 to 100% and from 99.1 to 99.9%, respectively. The specificity of IgM-capture ELISA varied between different species from 97.4 to 99.4%; its sensitivity was 100% in sheep tested 5-42 days post-infection. Our results in field-collected, experimental and post-vaccination sera demonstrate that these assays will be useful for epidemiological surveillance and control programmes, import/export veterinary certification, early diagnosis of infection, and for monitoring of immune response in vaccinated animals. As highly accurate and safe tests, they have the potential to replace traditional diagnostic methods, which pose biohazard risks limiting their use outside of endemic areas to high containment facilities.     

Resolving disputes between clinicians and family about "futility" of treatment

Family resistance to withdrawal of life support from children presents difficult issues of clinical practice and of principle. Legal recognition of unilateral physician authority for withdrawal on grounds of clinical “futility”-even in the most extreme circumstance of brain death-creates inappropriate incentives for clinicians’ avoidance of prolonged, emotionally taxing interactions likely to persuade parents to accept the reality of their child’s impending or actual death. Although unilateral physician action withdrawing support may sometimes be necessary in response to intractable family resistance, clinicians should nonetheless always understand this course not only as a clinical failure in dealing with families but also as unjustified in principle.     

COX-2 and colorectal cancer

Metabolites of arachidonic acid participate in normal growth responses and in aberrant cellular growth and proliferation, including carcinogenesis. The key step in the conversion of free arachidonic acid to prostaglandins is catalyzed by the cyclooxygenase enzyme (COX). There are two COX enzymes, COX-1 and COX-2. COX-1 is expressed constitutively and is part of normal cell metabolic functions. COX-2, on the other hand, is induced and expressed in neoplastic growths. The connection between COX expression and carcinogenesis was first implicated in studies that demonstrated the efficacy of aspirin and non-steroidal anti-inflammatory drugs to reduce the relative risk of colon cancer and also promote tumor regression in both humans and animal models of colon cancer. Investigation of the molecular basis of these observations showed that high levels of COX-2 protein were present in both human and animal colorectal tumors. A variety of evidence gathered from epidemiological, whole animal, and cellular studies indicate that unregulated COX-2 expression is a rate-limiting step in tumorigenesis and also that the loss of regulation occurs early in carcinogenesis. The interest in the COX-2 enzyme is that specific inhibition of COX-2 could theoretically avoid the gastrointestinal and other complications observed with the use of nonspecific COX inhibitors (most NSAIDs) or COX-1 inhibitors. The mechanisms by which COX-2 inhibitors lead to decreased colon carcinogenesis are not fully understood but they involve an increase not only in COX-2 dependent but also in COX-2 independent mechanisms.     

National Hospital Ambulatory Medical Care Survey: 2001 emergency department summary

OBJECTIVES: This report describes ambulatory care visits to hospital emergency departments (EDs) in the United States. Statistics are presented on selected hospital, patient, and visit characteristics. Selected trends in ED utilization from 1992 through 2001 are also presented. The report highlights new items on the continuity of care provided at ED visits, initial vital sign measurements, whether the patient's residence was a nursing home or institution, and duration of the ED visit. METHODS: The data presented in this report were collected from the 2001 National Hospital Ambulatory Medical Care Survey (NHAMCS). NHAMCS is part of the ambulatory care component of the National Health Care Survey that measures health care utilization across various types of providers. NHAMCS is a national probability sample survey of visits to emergency and outpatient departments of non-Federal, short-stay, and general hospitals in the United States. Sample data are weighted to produce annual national estimates. RESULTS: During 2001, an estimated 107.5 million visits were made to hospital EDs, about 38.4 visits per 100 persons. From 1992 through 2001, an increasing trend in the ED utilization rate was observed. Between 2 and 3 percent of ED visits were made by patients living in a nursing home or other institution. At approximately 3 percent of visits, the patient had been seen in the ED within the last 72 hours. In 2001, abdominal pain, chest pain, fever, and headache were the leading patient complaints accounting for nearly one-fifth of all visits. Acute upper respiratory infection was the leading illness-related diagnosis at ED visits. There were an estimated 39.4 million injury-related visits during 2001, or 14.1 visits per 100 persons. Diagnostic/screening services and procedures were provided at 85.4 percent and 40.9 percent of visits, respectively. Medications were provided at 74.2 percent of visits, and pain relief drugs accounted for 34.2 percent of the medications mentioned. In 2001, approximately 12 percent of ED visits resulted in hospital admission. On average, patients spent 3.0 hours in the ED.     

National Ambulatory Medical Care Survey: 2001 summary

OBJECTIVE: This report describes ambulatory care visits made to physician offices in the United States. Statistics are presented on selected characteristics of the physician's practice, the patient, and the visit. Results highlighting new items on continuity of care are presented. They include whether the visit was the first or a followup for a problem, number of visits to this provider in the past 12 months for established patients, and whether other physicians shared care for the patient's problem. The report also highlights estimates of practice characteristics for office-based physicians. METHODS: The data presented in this report were collected from the 2001 National Ambulatory Medical Care Survey (NAMCS). NAMCS is part of the ambulatory care component of the National Health Care Survey that measures health care utilization by various types of providers. NAMCS is a national probability sample survey of visits to office-based physicians in the United States. Sample data are weighted to produce annual national estimates. Selected trends from the 1992 and 1997 NAMCS are also presented. RESULTS: During 2001, an estimated 880.5 million visits were made to physician offices in the United States, an overall rate of 314.4 visits per 100 persons. From 1992 through 2001, the visit rate for persons 45 years of age and over increased by 17%, from 407.3 to 478.2 visits per 100 persons. The mean age of patients at each office visit has steadily increased from 1992 through 2001 as has the mean number of diagnoses rendered and the overall drug mention rate. The visit rate to physician offices in metropolitan statistical areas (MSAs) (338.3 visits per 100 persons) was significantly larger than the rate in non-MSAs (218.0 visits per 100 persons). Females had a higher visit rate compared with males, and white persons had a higher rate than black or African-American persons. Half of all office visits were to the patient's primary care physician (PCP). Of the visits to physicians other than the patient's PCP, about one-third (32.6 percent) were referrals. About 1 in 10 office visits were made by new patients (11.8 percent), down 20% since 1992. More than one physician shared the care for the patient's condition at about one-fifth of the office visits. Of all visits made to offices in 2001, 58.8 percent listed private insurance as the primary expected source of payment, followed by Medicare (21.8 percent) and Medicaid and/or State Children's Health Insurance Program (7.2 percent). For preventive care visits, the female visit rate was over 75% higher than the rate for males (67.1 versus 37.7 visits per 100 persons). Essential hypertension, arthropathies, acute upper respiratory infection, and diabetes mellitus were the leading illness-related primary diagnoses. There were an estimated 99.8 million injury-related visits in 2001, or 35.6 visits per 100 persons. Diagnostic and screening services were ordered or provided at 82.8 percent of visits, therapeutic and preventive services were ordered or provided at 41.4 percent of visits, and medications were prescribed or provided at 61.9 percent of visits. On average, 2.4 medications were ordered or provided at each office visit with any mention of a medication. The leading therapeutic class for drugs mentioned at office visits included cardiovascular-renal drugs (14.7 percent of mentions) and pain-relieving drugs (12.1 percent of mentions). A physician was seen at a majority of visits (95.8 percent), and a registered or licensed practical nurse was seen at 31.3 percent of visits. From 1992 through 2001, changes were observed in the leading diagnoses, therapeutic drug classes, and drug mentions. Physician estimates revealed that primary care physicians were twice as likely as specialists to make home visits during an average week of work; when they conducted them, they made twice as many (6 versus 2-3 visits per week) as specialists. Approximately 3 in 10 physicians reported not accepting new capitated, privately insured patients, whereas only 6.8 percent did not accept noncapitated, privately insured patients.     

The impact of the senior companion program on quality of life outcomes for frail older adults and their families

The Senior Companion Quality of Care Evaluation assessed the impact of a federally funded senior volunteer program on quality of life outcomes for frail clients and their families. Telephone interviews were conducted with national samples of frail Senior Companion Program (SCP) clients, family members, and comparison group participants. Multivariate procedures were used to examine study outcomes. SCP clients benefited significantly from the program at 3 months, though fewer positive effects were reported at 9 months. SCP family members benefited only modestly from the program. The SCP has been considered a low-cost way of matching the needs of community-based frail older adults with the skills of senior volunteers. Now, it has been shown to have some favorable effects on client well-being. These findings may take on greater significance given the desire to expand the SCP through the USA Freedom Corps Initiative.