David Chinn

The Newcastle exercise project: a randomised controlled trial of methods to promote physical activity in primary care

Abstract Objective: To evaluate the effectiveness of combinations of three methods to promote physical activity. Design: Randomised controlled trial. Baseline assessment with post-intervention follow up at 12 weeks and 1 year. Setting: One urban general practice, 1995-7. Participants: 523 adults aged 40 to 64 years, randomised to four intervention groups and a control group. Interventions: Brief (one interview) or intensive (six interviews over 12 weeks) motivational interviewing based on the stages of change model of behaviour change, with or without financial incentive (30 vouchers entitling free access to leisure facilities). Main outcome measures: Physical activity score; sessions of moderate and vigorous activity in the preceding four weeks. Results: Response rate was 81% at 12 weeks and 85% at one year. More participants in the intervention group reported increased physical activity scores at 12 weeks than controls (38% v 16%, difference 22%, 95% confidence interval for difference 13% to 32%), with a 55% increase observed in those offered six interviews plus vouchers. Vigorous activity increased in 29% of intervention participants and 11% of controls (difference 18%, 10% to 26%), but differences between the intervention groups were not significant. Short term increases in activity were not sustained, regardless of intensity of intervention. Conclusions: The most effective intervention for promoting adoption of exercise was the most intensive. Even this did not promote long term adherence to exercise. Brief interventions promoting physical activity that are used by many schemes in the United Kingdom are of questionable effectiveness. Key messages Schemes promoting physical activity are currently popular in general practice in Britain, but few have been rigorously evaluated and their effectiveness is unknown. In this study, the most effective intervention for promoting adoption of physical activity was the most intensive, involving six motivational interviews and a financial incentive A comparatively brief intervention (one interview) was only effective in the short term in around a third of participants Short term increases in physical activity were not maintained at one year follow up and even the most intensive intervention was ineffective in promoting long term adherence to increased physical activity. National and local government, health authorities, and primary healthcare teams should be cautious about current and future expenditure on, and implementation of, exercise prescription or referral schemes

Errors in general practice: development of an error classification and pilot study of a method for detecting errors

Objective: To describe a classification of errors and to assess the feasibility and acceptability of a method for recording staff reported errors in general practice. Design: An iterative process in a pilot practice was used to develop a classification of errors. This was incorporated in an anonymous self-report form which was then used to collect information on errors during June 2002. The acceptability of the reporting process was assessed using a self-completion questionnaire. Setting: UK general practice. Participants: Ten general practices in the North East of England. Main outcome measures: Classification of errors, frequency of errors, error rates per 1000 appointments, acceptability of the process to participants. Results: 101 events were used to create an initial error classification. This contained six categories: prescriptions, communication, appointments, equipment, clinical care, and “other” errors. Subsequently, 940 errors were recorded in a single 2 week period from 10 practices, providing additional information. 42% (397/940) were related to prescriptions, although only 6% (22/397) of these were medication errors. Communication errors accounted for 30% (282/940) of errors and clinical errors 3% (24/940). The overall error rate was 75.6/1000 appointments (95% CI 71 to 80). The method of error reporting was found to be acceptable by 68% (36/53) of respondents with only 8% (4/53) finding the process threatening. Conclusion: We have developed a classification of errors and described a practical and acceptable method for reporting them that can be used as part of the process of risk management. Errors are common and, although all have the potential to lead to an adverse event, most are administrative.

Quality of life in patients with established inflammatory bowel disease: a UK general practice survey

Background : The current understanding of quality of life impairment in inflammatory bowel disease has largely been derived from selected populations and may not reflect the experience of patients in the community, where fewer than half are likely to be under specialist care.

Epidemiology and management of infertility: a population-based study in UK primary care

BACKGROUND Our current knowledge of the epidemiology of infertility is limited and outdated. Health care provision for infertility in the UK attracts public interest because of restrictions on access to services. OBJECTIVE To describe the incidence, prevalence, referral patterns and outcomes of infertile couples, presenting in general practice in UK. METHODS A population-based retrospective observational outcome study of infertile couples from general practices in Northumberland, Tyne and Wear, UK (population 1 043 513). Outcome data at 1 year were collected on all couples who presented to their GP between the 1st January 2005 and 30th June 2006 with a fertility problem. RESULTS Thirty-four per cent of general practices in the study area contributed data (population 404 263). The incidence of infertility was 0.9 couples per 1000 general population. The average age of women was 31 years, and the average time attempting conception was 18 months. Treatment end points for half of all couples were in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI). Over half of the couples in the study were not eligible for National Health Service (NHS) fertility treatment on social criteria. At 12 months, 27% of all couples in the study achieved a pregnancy spontaneously and a further 9% with treatment. CONCLUSIONS Infertile women present to their GP later in life compared with 20 years ago, and after a shorter period of infertility. Half of the couples required treatment with IVF or ICSI. Adopting the British Fertility Society recommendation of allowing couples, where one or both partners has a child in a previous relationship, will result in an additional 26% of infertile couples becoming eligible for NHS fertility treatment.

Taking simvastatin in the morning compared with in the evening: randomised controlled trial

Statins are widely prescribed for the primary and secondary prevention of coronary artery disease. They act by inhibiting the enzyme HMG CoA reductase, which controls synthesis of cholesterol in the liver. Most manufacturers of statins recommend that they are taken at night, on the basis of physiological studies which show that most cholesterol is synthesised when dietary intake is at its lowest.1 One small clinical trial found that taking smaller doses of simvastatin than are used in treatment, in the morning, was less efficient.2 However, a trial using atorvastatin found no significant difference in cholesterol concentrations between patients taking the statin in the morning and those taking it in the evening.3 Doubt has been cast on whether statins need to be taken at night,4 particularly as many patients also receive treatment with other cardioprotective drugs and compliance may be compromised by multiple …

Long‐term aminosalicylate therapy is under‐used in patients with ulcerative colitis: a cross‐sectional survey

Background : There is evidence from case–control studies that aminosalicylate drugs can reduce colorectal cancer risk by 75–81% in patients with ulcerative colitis. Patients may fail to comply with long‐term therapies, however, or may have been advised to discontinue treatment once in remission.

Bone density at the os calcis: reference values, reproducibility, and effects of fracture history and physical activity.

Aims: To establish reference values for bone mineral density (BMD) measured at the os calcis (OC) in healthy UK Caucasian children. Secondary objectives were to assess the reproducibility of the measurement and the effects of fracture history and habitual physical activity. Methods: A total of 403 children aged 5–18 were studied. Main outcome measures were: BMDoc measured by peripheral DXA, total BMD measured by whole body axial scanner, age, anthropometry, pubertal status, self-reported fracture history, and physical activity (PA) expressed as a three point score. Results: Complete data were available on 171 girls and 123 boys free of a history of fracture. BMDoc was related positively to age, body size, and total BMD, and could be predicted using a proportional model based on height alone (R2: 65% girls, 77% boys). Mean BMDoc appears to plateau in girls at 15 years and attain a value that concurs with the mean peak value in adult women. The 95% limits of agreement in repeated measures were −0.029 to 0.029 g/cm2 (n = 53). Compared with sedentary children, those doing regular sports or PA for more than five hours a week had an increased BMDoc (by about 0.03 g/cm2 or about 7% of the overall mean). A history of fracture (n = 81) was associated with a reduced BMDoc in boys but not in girls, though our study may have been underpowered for a subgroup analysis. Conclusions: BMDoc can be measured easily and quickly in children older than 5 years and provides an objective measure of areal bone density for clinical and research studies using a reference range derived from its relation to height.

Assessing and improving out-of-hours palliative care in a deprived community: a rapid appraisal study:

Recent changes to out-of-hours primary care in the UK have generated concerns about care for palliative care patients. The aim of this study was to identify key challenges and improvements to out-of-hours palliative care in a mixed urban and rural deprived area. We integrated data from three sources: interviews with patients and professionals, direct observations of services, and routine statistics. Key issues in the provision of care were the importance of good communication and having information available, the unwieldy process of accessing medical care out of hours, professionals bypassing routine out-of-hours care for palliative care patients, and out-of-hours care being provided by practitioners unaware of local services. We recommend provision to out-of-hours services of an enhanced ‘special note’ for palliative care patients, to be completed early in the course of the illness and updated regularly. The provision for certain complex patients to bypass NHS24 should be considered if routine care is not satisfactory.

Modelling the lung function of Caucasians during adolescence as a basis for reference values

Background: In childhood the relationship between lung size and stature changes during the adolescent growth spurt. This is not allowed for in models of lung function based on stature alone. For spirometric indices inclusion of an age × stature interaction (A × St) can overcome the difficulty. Aim: The study tested the hypothesis that this simple, interactive model might also be effective for total lung capacity and its subdivisions and the single breath transfer factor for carbon monoxide. Subjects and methods: Data were available for 695 asymptomatic non-smokers (Caucasians) aged 7–20 years (440 boys, 255 girls). Each lung function index was described using the above model and the fit was compared with that from a linear, power or polynomial model based on stature alone. Results: After allowing for stature, the A × St interaction term was significant for almost all indices. The improved fit was most apparent for the lung function of older adolescent boys. Reference values using the model are reported. Conclusions: A simple model based on stature and an interaction between stature and age can account for the changing relationship between body habitus during the growth spurt and lung size and transfer factor in a single equation encompassing children and adolescents. Its use is recommended for deriving reference values when the explanatory variables are limited to stature and age. Résumé. Arrière plan: Les modèles de fonction pulmonaire établis à partir de la seule stature, ne tiennent pas compte du fait que la relation entre taille des poumons et stature évolue au cours de la poussée de croissance de l’adolescence. Cette difficulté peut être surmontée en incluant l’interaction age × stature (A × St) dans les indices spirométriques. But: Cette étude teste l’hypothèse que ce modèle interactif simple pourrait aussi être efficace pour la capacité pulmonaire totale et ses subdivisions ainsi que pour le facteur de transfert de monoxyde de carbone d’une simple expiration. Sujets et méthodes: Des données ont été réunies sur 695 non fumeurs caucasiens asymptomatiques, âgés de 7 à 20 ans (440 garçons et 255 filles). Chaque indice de fonction pulmonaire a été décrit en utilisant le modèle ci-dessus et l’ajustement a été comparé à celui d’un modèle linéaire, puissance ou polynomial, fondé sur la seule stature. Résultats: Après contrôle de la stature, le terme d’interaction (A × St) est significatif pour presque tous les indices. L’amélioration de l’ajustement est plus particulièrement notable pour la fonction pulmonaire des garçons adolescents les plus âgés. On reporte les valeurs de référence utilisant le modèle. Conclusion: Un simple modèle fondé sur la stature et sur l’interaction entre stature et âge peut rendre compte du changement du rapport entre la conformation corporelle au cours de la poussée de croissance, la taille des poumons et facteur de transfert, par une simple équation regroupant enfants et adolescents. Son usage est recommandé pour extraire des valeurs de référence lorsque les variables explicatives sont limitées à la stature et à l’âge. Zusammenfassung. Hintergrund: In der Kindheit ändert sich die Relation von Lungengröße und Körperhöhe während des pubertären Wachstumsschubes. Dem wird in Lungenfunktionsmodellen, die allein auf Körperhöhe basieren, nicht Rechnung getragen. Für die spirometrischen Indizes kann die Schwierigkeit durch Einführung einer Alter × Körperhöhen-Interaktion behoben werden. Ziel: Die Studie untersuchte die Hypothese, dass dies einfache, interaktive Modell auch für totale Lungenkapazität und weitere atemmechanische Parameter und den CO-Transfer-Faktor (sogenannte “Diffusionskapazität”) in der Ein-Atemzug-Methode gültig sein könnte. Probanden und Methoden: Es waren Daten für 695 asymptomatische 7-20-jährige Nichtraucher kaukasischer Herkunft (440 Knaben, 255 Mädchen) verfügbar. Jeder Lungenfunktionsindex wurde nach obigem Modell beschrieben, und die Güte der Kurvenanpassung wurde mit derjenigen verglichen, die sich aus einem linearen, exponentiellen oder polynomischen Modell auf der Basis von Körperhöhe allein ergibt. Ergebnisse: Nach Korrektur für Körperhöhe wurde der Terminus Alter × Körperhöhen-Interaktion für fast alle Indizes signifikant. Die verbesserte Anpassung war besonders offensichtlich für die Lungenfunktion älterer männlicher Jugendlicher. Es werden Referenzwerte auf der Basis dieses Modells angegeben. Zusammenfassung: Ein einfaches Modell auf der Basis von Körperhöhe und einer Interaktion zwischen Körperhöhe und Alter kann der wechselnden Beziehung zwischen der körperlichen Konstitution im Verlauf des Wachstumsschubes und der Lungengröße und einem Transfer-Faktor in einer einzigen Gleichung Rechnung tragen, die gleichermaßen Kinder und Jugendliche einschließt. Die Verwendung des Modells ist empfehlenswert, um Referenzwerte abzuleiten, sobald sich die Bezugsgrößen auf Körperhöhe und Alter beschränken. Resumen. Antecedentes: Durante la infancia, la relación entre el tamaño pulmonar y la estatura cambia durante el estirón puberal. Este hecho no se tiene en cuenta en los modelos de la función pulmonar basados únicamente en la estatura. La inclusión de una interacción entre la edad y la estatura (A × St) en los índices espirométricos, puede vencer esta dificultad. Objetivo: El estudio comprobó la hipótesis de que este simple modelo interactivo también podría ser efectivo para la capacidad pulmonar total y sus subdivisiones, así como para la capacidad de difusión (factor de transferencia) de monóxido de carbono mediante respiración única. Sujetos y métodos: Se disponía de datos de 695 no fumadores asintomáticos (caucásicos) de entre 7 y 20 años de edad (440 chicos, 255 chicas). Cada índice de la función pulmonar fue descrito utilizando el modelo señalado arriba y el ajuste se comparó con el de un modelo linear, potencial o polinómico, basado únicamente en la estatura. Resultados: Después de tener en cuenta la estatura, el término de interacción A × St fue significativo en casi todos los índices. El ajuste mejorado fue más aparente para la función pulmonar de los chicos adolescentes de más edad. En el trabajo se muestran los valores de referencia. Conclusiones: Un modelo simple basado en la estatura y una interacción entre la estatura y la edad pueden explicar la relación variable entre la estatura durante el estirón de crecimiento, el tamaño pulmonar y el factor de transferencia, en una ecuación simple que incluye niños y adolescentes. Se recomienda su utilización para derivar valores de referencia cuando las variables explicativas son únicamente la estatura y la edad.

Identification of Men With Reduced Bone Density at the Lumbar Spine and Femoral Neck Using BMD of the Os Calcis

We assessed the utility of os calcis (OC) bone mineral density (BMD) measurements to identify men with low BMD at the lumbar spine (LS) and femoral neck (FN). BMD was measured by dual X-ray absorptiometry (DXA). Receiver operator characteristics (ROC) analysis was applied to determine the risk of osteoporosis at the lumbar spine or femoral neck. [A total of 230 men with an average age of 59 yr were studied.] The most common reasons for referral were fracture (47%) and steroid use (46%). Twenty-six percent were osteoporotic at the LS, 21% at the FN, and 15% at the OC. Optimal classification with respect to osteoporotic measurements at the LS or FN was obtained at an OC T-score of -1.9 (BMD = 0.45 g/cm2). Osteoporosis was only weakly related to a simple cumulative risk factor score, but was strongly related to a T-score OC categorized into quartiles. Regression analysis of BMD on the major risk factors alone explained only 17% of the variance in BMD at the LS and 5% at the FN. The combination of the T-score at the OC, age, and weight provided the best model. BMD OC is superior to risk factors alone in the clinical evaluation and selection of men referred for axial densitometry.