Problems with a ‘target’ approach to access in primary care: a qualitative study

We report an analysis of the qualitative phase of a study of patients' and carers' views of primary care services, focusing on their experiences of access to face-to-face general practitioner (GP) consultations during the period when new access policies were being implemented. Practices interpreted the new policy in various ways; restricted interpretations, including restriction of access to telephone booking, could cause distress to patients. Patients and carers welcomed flexible interpretations of the policy that offered choice, such as a choice of GP, or of booking in advance.     

Electron bolus design for radiotherapy treatment planning: bolus design algorithms.

Computer algorithms to design bolus for electron beam radiotherapy treatment planning were investigated. Because of the significant electron multiple scatter, there is no unique solution to the problem of bolus design. However, using a sequence of operators, a bolus can be designed that attempts to meet three important criteria: adequate dose delivery to the target volume, avoidance of critical structures, and dose homogeneity within the target volume. Initial calculation of bolus shape was based upon creation operators forcing either the physical or the effective depths of the distal surface of the target volume to a specified value. Modification operators were then applied to the bolus to alter the shape to better meet the design criteria. Because the operators each address a single dosimetric issue, they can often adversely affect some other attribute of the dose distribution. In addition, an extension operator is used to design the bolus thickness outside the target volume. Application of these operators is therefore carried out in certain sequences and each may be used more than once in the design of a particular bolus. The effects of these operators on both the bolus and the resulting dose distribution are investigated for test geometries and patient geometries in the nose, parotid, and paraspinal region.     

The Rochester Diabetic Neuropathy Study: design, criteria for types of neuropathy, selection bias, and reproducibility of neuropathic tests

A cross-sectional survey and subsequent longitudinal study among diabetic residents of Rochester, MN--The Rochester Diabetic Neuropathy Study (RDNS)--is population-based and uses quantitative, validated, and unique end points to detect, classify, and stage neuropathy. Nondiabetic persons, drawn from the same population, serve as controls. For patients 10 to 70 years old, the RDNS cohort is representative of diabetics living in Rochester, MN. We assessed reproducibility of tests used to characterize and quantitate severity of neuropathy in 20 diabetic subjects without neuropathy and with varying severities of neuropathy. Using intraclass correlation coefficient (rI) as a measure of test reproducibility, we found high rI (usually 0.9 or better) with small confidence intervals for the Neurologic Disability Score (NDS); weakness subset of NDS (W-NDS); vibratory and cooling detection thresholds (using computer-assisted sensory examination [CASE] IV); compound muscle action potentials; sensory nerve action potentials; and motor nerve conduction velocities. There was good agreement among three trained observers for NDS and the W-NDS.     

Ankle-brachial index and extent of atherothrombosis in 8891 patients with or at risk of vascular disease: results of the international AGATHA study.

AIMS: AGATHA (a Global Atherothrombosis Assessment) was designed to assess the extent of atherothrombosis and the use of the ankle-brachial index (ABI) in vascular patients. The principal hypotheses were that (1) in diseased patients, a low ABI was related to the number and site of vascular beds affected and (2) in at-risk patients without disease, a low ABI was related to the number of risk factors present. METHODS AND RESULTS: Patients were recruited consecutively by 482 clinicians in 24 countries and the ABI measurement was performed at a single visit. Of 8891 patients recruited, 1792 were defined as at risk and 7099 as with disease. Of the with-disease patients, 65.2% had one arterial bed affected, 27.6% two and 7.1% all three. Abnormal ABI (< or =0.9) was present in 30.9% of at-risk and 40.5% of with-disease patients. A lower ABI was weakly associated with an increasing number of risk factors in at-risk patients (r=-0.056, P=0.02) and with the site and number of arterial beds affected in with-disease patients (P<0.001). CONCLUSION: This large international study confirms that atherothrombotic disease often occurs at more than one site. The ABI is related to the risk factor profile and to the site and extent of atherothrombosis.     

The value of technetium-99M renography for the detection of renal artery stenosis in patients with aortic and lower limb vascular disease.

The results of technetium renography were compared with arteriography to determine whether this is a satisfactory screening test for renal artery stenosis (RAS). Sixty-three patients were studied before aortic surgery. All were investigated by aortography and isotope renography. These tests were assessed blind and all arteriograms were graded by a single independent radiologist. Renal artery stenosis was detected by arteriography in 34 (54%) patients. Twenty-three (37%) had mild (less than 50%) stenosis, seven (11%) had moderate (50-80%) stenosis and four (6%) had severe (greater than 80%) stenosis. Of these 34 patients, only 6 (18%) were correctly diagnosed by isotope renography. None of the four with severe stenosis were identified. Isotope renography resulted in six true positives, six false positives, 23 true negatives and 28 false negatives. It was concluded that isotope renography did not fulfil the criteria for a screening test for the detection of RAS and appeared to be of no value in those patients undergoing aortic surgery in whom arteriography was not indicated.     

The reconstruction aides.

The reconstruction aides, civilian women who served in World War I, are credited with an influential role in the development of occupational therapy. Their task was to provide treatment in the form of occupation to enable servicemen suffering from wounds or battle neurosis to return to the battlefront. Although some occupational therapy aides were occupational therapists, many were teachers, artists, and craftspersons. This paper traces the history of the reconstruction aides, describes the women who served, and recounts their experiences. The relationships between reconstruction aides and other professions suggest the origins of current problems of professional identity and role delineation.     

Noise in polymer gel measurements using MRI

With the development of conformal radiotherapy, particularly intensity modulated radiation therapy (IMRT), there is a clear need for multidimensional dosimeters. A commercial polymerizing gel, BANG-2 gel (MGS Research, Inc., Guilford, CT), has recently been developed that shows potential as a multi-dimensional dosimeter. This study investigates and characterizes the noise and magnetic resonance (MR) artifacts from imaging BANG-2 gels. Seven cylindrical vials (4 cm diam, 20 cm length) were irradiated end on in a water bath and read using MRI (B0=1.5 T, TE=20 ms/100 ms, TR=3000 ms). The gel calibration compared the measured depth-dose distributions in water against the change in solvent-proton R2 relaxivity of the gel. A larger vial (13 cm diam, 14 cm length) was also irradiated to test the calibration accuracy in a vial of sufficient volume for dose distribution measurements. The calibration curve proved accurate to within 1.3% in determining the depth dose measured by the larger vial. An investigation of the voxel-to-voxel (IXIX 3 mm3) noise and sensitivity response curve showed that the voxel-to-voxel variation dominated the dose measurement uncertainty. The voxel-to-voxel standard deviation ranged from 0.2 Gy for the unirradiated gel to 0.7 Gy at 20 Gy. Slice-to-slice R2 magnitude deviations were also observed corresponding to 0.2 Gy. These variations limited the overall accuracy of the gel dose measurements and warrant an investigation of more accurate MR readout sequences.     

Utilization review of the use of BACTEC PLUS high-volume blood culture bottles.

The BACTEC PLUS 26 (NR26) (Becton Dickinson, Towson, Md.) high-volume blood culture bottle replaced the less expensive smaller-volume NR6A bottle in our hospital. An audit carried out several months after their introduction revealed that only 17.5% of the NR26 bottles received the required blood volume. Several audits and educational programs were required in order to achieve a compliance rate of > 60%.