Cherida Hopper

Pathological features of lymphoid tissues in cats with natural feline immunodeficiency virus infection

Summary A range of tissues from a total of 17 cats naturally infected with the feline immunodeficiency virus was examined histologically. In 11 cases, chronic inflammatory lesions were present in various tissues including, most commonly, the intestine, brain and lung. Extensive inflammation in the intestinal wall was present in seven of the cats. No particular bacterial organisms were demonstrated in these inflammatory lesions. A range of changes was present in the lymph nodes, including hyperplasia, atrophy or a mixed pattern. Erythrophagocytosis was a consistent feature. The changes resembled those reported in human acquired immunodeficiency syndrome as a result of infection with human immunodeficiency virus.

The development and validation of a questionnaire to assess visual symptoms/dysfunction and impact on quality of life in cataract patients: the Visual Symptoms and Quality of life (VSQ) Questionnaire

The aim of the study was to develop a new questionnaire to assess visual symptoms/dysfunction and impact on vision-specific quality of life for those undergoing second eye cataract extraction. Items for the VSQ questionnaire were devised with reference to existing literature and following consultation with eye care experts (n = 18) and interviews with cataract patients (n = 40). Piloting work conducted with 53 patients indicated that the questionnaire was promising, with a high level of internal consistency, low levels of missing data and indications that it was responsive to surgery. A modified version of the questionnaire was completed by 105 patients having received ‘early’ surgery and 103 scheduled for routine surgery within a randomized controlled trial evaluating the effectiveness of second eye cataract surgery. Analyses showed that the internal consistency of both the visual symptoms/dysfunction and quality of life areas was high (Cronbachs alpha 0.82 and 0.83, respectively). Highly significant improvements were found for early surgery patients (p < 0.0001), with little change among routine surgery patients. Two final versions of the VSQ questionnaire have been produced for future use in assessing visual symptoms/dysfunction and impact on vision-specific quality of life: a scoreable short form and more detailed and sensitive long form.

Vision-related quality of life impairment in an elderly UK population: associations with age, sex, social class and material deprivation.

Purpose To describe the prevalence of vision-related quality of life (VR-QOL) impairment in an elderly UK population sample.Method The survey, using the VCM1 questionnaire, was based on an age- and sex-stratified random population sample of 2783 individuals aged 55 years or over.Results One thousand eight hundred and forty-six (69.7%) of 2647 eligible subjects responded. One thousand six hundred and eighty-three individuals completed all 10 VCM1 items. Overall the prevalence of a VCM1 score <2.0 (‘more than a little’ concern about vision) was 4.6% (95% CI = 3.7% to 5.7%), leading to an estimate of more than 550 000 individuals in England with substantial VR-QOL impairment. The prevalence increased with age from 2.1% in the 55-64 year age group to 17.9% in the group aged 85 years and older. The prevalence also increased as social class became lower, from 0 in social class I to 10.2% in social class V, and increased with increasing material deprivation, from 1.2% in the most affluent quintile to 6.8% in the most deprived quintile. Multivariable logistic regression analysis showed that age (p = 0.0001), decreasing social class (p = 0.03) and increasing material deprivation (p = 0.008) were independently associated with VR-QOL impairment (VCM1 score <2.0), whilst gender and means of questionnaire administration were not associated with VR-QOL impairment at the 5% level.Conclusions The findings suggest a substantial national prevalence of VR-QOL impairment, and are consistent with earlier studies linking ocular disease with social deprivation. Consideration should be given to directing resources more carefully towards groups at higher risk of VR-QOL impairment, in particular the very elderly and socially deprived.

Reliability of the VCM1 Questionnaire when administered by post and by telephone

PURPOSE: To assess the reliability of different methods of administration of the VCM1 vision-related quality-of-life questionnaire by: a) comparing responses obtained by post to responses obtained in a research clinic and b) comparing responses obtained by telephone to responses obtained in a research clinic. METHOD: Questionnaire responses given in advance by post (96 subjects) or by telephone (92 subjects) were compared to those subsequently given at a visit to a research clinic. The questionnaire included the VCM1 and two other questions commonly used in surveys of visual impairment (reading small print and recognising a face across the street). RESULTS: Similar levels of vision-related quality-of-life (VR-QOL) impairment were reported by post and in the research clinic. However, the participants in the telephone test group reported less VR-QOL impairment by telephone than they subsequently reported in the clinic (P = 0.0001). The mean score difference between telephone and clinic administration was 3.2% of the VCM1 questionnaire scale. Lower social class (P = 0.002) and increasing duration of interview (P = 0.003) were associated with a tendency to under-report VR-QOL impairment by telephone. Interference with reading small print (P = 0.0001) and recognising a face across the street (P = 0.0001) were also under-reported by telephone. CONCLUSIONS: Telephone interviewing caused a general bias towards under-reporting of visual problems which was not confined to the VCM1. Care is required when planning outcome studies and questionnaire surveys to ensure that different methods of questionnaire administration produce comparable results.

Effectiveness of PhysioDirect telephone assessment and advice services for patients with musculoskeletal problems: pragmatic randomised controlled trial

Objectives To assess the clinical effectiveness, effect on waiting times, and patient acceptability of PhysioDirect services in patients with musculoskeletal problems, compared with usual care. Design Pragmatic randomised controlled trial to assess equivalence in clinical effectiveness. Patients were individually randomised in a 2:1 ratio to PhysioDirect or usual care. Setting Four physiotherapy services in England. Participants Adults (aged ≥18 years) referred by general practitioners or self referred for musculoskeletal physiotherapy. Interventions PhysioDirect services invited patients to telephone a physiotherapist for initial assessment and advice, followed by face-to-face physiotherapy if necessary. Usual care involved patients joining a waiting list for face-to-face treatment. Main outcome measures Numbers of appointments, waiting time for treatment, and non-attendance rates. Primary outcome was physical health (SF-36v2 physical component score) at six months. Secondary outcomes included four other measures of health outcome, mental component score and scales from the SF-36v2, time lost from work, and patient satisfaction and preference. Participants were not blind to allocation, but outcome data were collected blind to allocation. Results Of 1506 patients allocated to PhysioDirect and 743 to usual care, 85% provided primary outcome data at six months (1283 and 629 patients, respectively). PhysioDirect patients had fewer face-to-face appointments than usual care patients (mean 1.91 v 3.11; incidence rate ratio 0.59 (95% confidence interval 0.53 to 0.65)), a shorter waiting time (median 7 days v 34 days; arm time ratio 0.32 (0.29 to 0.35)), and lower rates of non-attendance (incidence rate ratio 0.55 (0.41 to 0.73)). After six months’ follow-up, the SF-36v2 physical component score was equivalent between groups (adjusted difference in means −0.01 (−0.80 to 0.79)). Health outcome measures suggested a trend towards slightly greater improvement in the PhysioDirect arm at six week follow-up and no difference at six months. There was no difference in time lost from work. PhysioDirect patients were no more satisfied with access to physiotherapy than usual care patients, but had slightly lower satisfaction overall at six months (difference in satisfaction −3.8% (−7.3% to −0.3%); P=0.031). PhysioDirect patients were more likely than usual care patients to prefer PhysioDirect in future. No adverse events were detected. Conclusions PhysioDirect is equally clinically effective compared with usual care, provides faster access to physiotherapy, and seems to be safe. However, it could be associated with slightly lower patient satisfaction. Trial registration Current Controlled Trials ISRCTN55666618.

The population requirement for cataract extraction: A cross-sectional study

Purpose To examine the distribution in the population of indications for cataract extraction in order to relate demand for this procedure to the capacity for satisfying it.Methods An age-stratified random population sample of 2783 individuals aged 55 years and over was taken from inner-city, urban and rural areas of Avon and Somerset. The requirement for cataract extraction was estimated on the basis of measures of vision-related quality of life, refracted visual acuity, and application of the Oxford Clinical Cataract Classification and Grading System. Data were also collected concerning suitability for surgery, including relative contraindications to surgery and whether participants considered their eyesight bad enough to merit surgery. Three sets of composite indications were defined.Results Estimated prevalent requirements for cataract extraction for the three sets of composite criteria were: 29 per 1000 aged over 55 years (95% CI 20-41) for the most inclusive criterion; 17 per thousand (95% CI 10-27) for the intermediate criterion; and 7 per thousand (95% CI 3-14) for the most stringent criterion. These rates are equivalent to a national prevalent requirement for England of 384 000 for the most inclusive criterion. If the approximately 15% of individuals whose desire or fitness for surgery was questionable are removed from this estimate, the prevalent requirement, including the backlog from previous unsatisfied demand, becomes 325 000 individuals.Conclusions The findings suggest only a modest imbalance between supply and demand for cataract surgery. In particular there was a very small prevalence of untreated severe cataract, less than the annual health service surgical capacity, suggesting that the current National Health Service surgical capacity is adequate for cases of severe cataract.

'PhysioDirect' telephone assessment and advice services for physiotherapy: protocol for a pragmatic randomised controlled trial

BackgroundProviding timely access to physiotherapy has long been a problem for the National Health Service in the United Kingdom. In an attempt to improve access some physiotherapy services have introduced a new treatment pathway known as PhysioDirect. Physiotherapists offer initial assessment and advice by telephone, supported by computerised algorithms, and patients are sent written self-management and exercise advice by post. They are invited for face-to-face treatment only when necessary. Although several such services have been developed, there is no robust evidence regarding clinical and cost-effectiveness, nor the acceptability of PhysioDirect.Methods/DesignThis protocol describes a multi-centre pragmatic individually randomised trial, with nested qualitative research. The aim is to determine the effectiveness, cost-effectiveness, and acceptability of PhysioDirect compared with usual models of physiotherapy based on patients going onto a waiting list and receiving face-to-face care. PhysioDirect services will be established in four areas in England. Adult patients in these areas with musculoskeletal problems who refer themselves or are referred by a primary care practitioner for physiotherapy will be invited to participate in the trial. About 1875 consenting patients will be randomised in a 2:1 ratio to PhysioDirect or usual care. Data about outcome measures will be collected at baseline and 6 weeks and 6 months after randomisation. The primary outcome is clinical improvement at 6 months; secondary outcomes include cost, waiting times, time lost from work and usual activities, patient satisfaction and preference. The impact of PhysioDirect on patients in different age-groups and with different conditions will also be examined.Incremental cost-effectiveness will be assessed in terms of quality adjusted life years in relation to cost.Qualitative methods will be used to explore factors associated with the success or failure of the service, the acceptability of PhysioDirect to patients and staff, and ways in which the service could be improved.DiscussionIt is still relatively unusual to evaluate new forms of service delivery using randomised controlled trials. By combining rigorous trial methods with economic analysis of cost-effectiveness and qualitative research this study will provide robust evidence to inform decisions about the widespread introduction of PhysioDirect services.Trial registrationCurrent Controlled Trials ISRCTN55666618

A pragmatic randomised controlled trial of 'PhysioDirect' telephone assessment and advice services for patients with musculoskeletal problems: economic evaluation.

Objectives To compare the cost-effectiveness of PhysioDirect with usual physiotherapy care for patients with musculoskeletal problems. Design (1) Cost-consequences comparing cost to the National Health Service (NHS), to patients, and the value of lost productivity with a range of outcomes. (2) Cost-utility analysis comparing cost to the NHS with Quality-Adjusted Life Years (QALYs). Setting Four physiotherapy services in England. Participants Adults (18+) referred by their general practitioner or self-referred for physiotherapy. Interventions PhysioDirect involved telephone assessment and advice followed by face-to-face care if needed. Usual care patients were placed on a waiting list for face-to-face care. Primary and secondary outcomes Primary clinical outcome: physical component summary from the SF-36v2 at 6 months. Also included in the cost-consequences: Measure Yourself Medical Outcomes Profile; a Global Improvement Score; response to treatment; patient satisfaction; waiting time. Outcome for the cost-utility analysis: QALYs. Results 2249 patients took part (1506 PhysioDirect; 743 usual care). (1) Cost-consequences: there was no evidence of a difference between the two groups in the cost of physiotherapy, other NHS services, personal costs or value of time off work. Outcomes were also similar. (2) Cost-utility analysis based on complete cases (n=1272). Total NHS costs, including the cost of physiotherapy were higher in the PhysioDirect group by £19.30 (95% CI −£37.60 to £76.19) and there was a QALY gain of 0.007 (95% CI −0.003 to 0.016). The incremental cost-effectiveness ratio was £2889 and the net monetary benefit at λ=£20 000 was £117 (95% CI −£86 to £310). Conclusions PhysioDirect may be a cost-effective alternative to usual physiotherapy care, though only with careful management of staff time. Physiotherapists providing the service must be more fully occupied than was possible under trial conditions: consideration should be given to the scale of operation, opening times of the service and flexibility in the methods used to contact patients.

PhysioDirect: Supporting physiotherapists to deliver telephone assessment and advice services within the context of a randomised trial

Physiotherapy-led telephone assessment and advice services for patients with musculoskeletal problems have been developed in many services in the UK, but high quality trial data on clinical and cost effectiveness has been lacking. In order to address this ‘The PhysioDirect trial’ (ISRCTN55666618), was a pragmatic randomised trial of a PhysioDirect telephone assessment and advice service. This paper describes the PhysioDirect system used in the trial and how physiotherapists were trained and supported to use the system and deliver the PhysioDirect service. The PhysioDirect system used in the trial was developed in Huntingdon and now serves a population of 350,000 people. When initiating or providing physiotherapy-led telephone assessment and advice services training and support for physiotherapists delivering care in this way is essential. An enhanced skill set is required for telephone assessment and advice particularly in listening and communication skills. In addition to an initial training programme, even experienced physiotherapists benefit from a period of skill consolidation to become proficient and confident in assessing patients and delivering care using the telephone. A computer-based system assists the delivery of a physiotherapy-led musculoskeletal assessment and advice service. Clinical Trials Registration Number (ISRCTN55666618).

Comparing sensitivity to change of two patient-reported outcome measures in a randomised trial of patients referred for physiotherapy services

The SF-36 Physical Component Summary (PCS) and the Measure Yourself Medical Outcome Profile (MYMOP) are respectively generic and individualised self-report tools to assess health. The aim of this study was to compare responsiveness to change in these outcomes among patients with musculoskeletal problems referred for physiotherapy. Data were collected at baseline, 6 weeks and 6 months from 3714 participants recruited to the PhysioDirect randomised trial. Utilising change from baseline scores among participants responding as ‘slightly better’ on a global item, three different response statistics – standardised response mean, effect size, Guyatt’s response index – were calculated for MYMOP and PCS. These were formally compared using a modified jacknife procedure. MYMOP response statistics were 0.88, 1.08 and 1.11 at 6 weeks and 0.83, 1.16 and 1.16 at 6 months for SRM, ES and GRI respectively. Values for PCS were 0.57, 0.50 and 0.70 at 6 weeks and 0.63, 0.62 and 0.86 at 6 months. There was strong evidence that MYMOP was more sensitive to change than PCS at both time points (p<0.001 for all comparisons). There was evidence that MYMOP was more responsive among women than men at 6 weeks but not at 6 months, and that both MYMOP and PCS were more sensitive among younger than older participants at both times points. MYMOP was more responsive to change than PCS, and responsiveness remained more stable over time. Allowing trial participants to define and measure symptoms that cause them greatest problems may allow detection of smaller but clinically important effects than generic outcomes.