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2.  Single-dose and seven-day trimethoprim and co-trimoxazole in the treatment of urinary tract infection 
One hundred and sixteen adults with symptoms of acute urinary tract infection were randomly collected into four groups and given single-dose or seven-day treatment with trimethoprim or co-trimoxazole. Of the 105 patients who completed the study, bacterial urinary infection was present in 70 patients (67 per cent). The rates for symptomatic and bacterial cures were high and indistinguishable between the groups, and there was no difference in the rate of recurrence of urinary infection in the six weeks after treatment. Side effects were lower in the group receiving single-dose trimethoprim (P=0.09).
PMCID: PMC1973013  PMID: 6605424
3.  Economic evaluation of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain 
Arthritis and Rheumatism  2007;57(7):1220-1229.
To conduct an economic evaluation of the Enabling Self-Management and Coping with Arthritic Knee Pain through Exercise (ESCAPE-knee pain) program.
Alongside a clinical trial, we estimated the costs of usual primary care and participation in ESCAPE-knee pain delivered to individuals (Indiv-rehab) or groups of 8 participants (Grp-rehab). Information on resource use and informal care received was collected during face-to-face interviews. Cost-effectiveness and cost-utility were assessed from between-group differences in costs, function (primary clinical outcome), and quality-adjusted life years (QALYs). Cost-effectiveness acceptability curves were constructed to represent uncertainty around cost-effectiveness.
Rehabilitation (regardless of whether Indiv-rehab or Grp-rehab) cost £224 (95% confidence interval [95% CI] £184, £262) more per person than usual primary care. The probability of rehabilitation being more cost-effective than usual primary care was 90% if decision makers were willing to pay £1,900 for improvements in functioning. Indiv-rehab cost £314/person and Grp-rehab £125/person. Indiv-rehab cost £189 (95% CI £168, £208) more per person than Grp-rehab. The probability of Indiv-rehab being more cost-effective than Grp-rehab increased as willingness to pay (WTP) increased, reaching 50% probability at WTP £5,500. The lack of differences in QALYs across the arms led to lower probabilities of cost-effectiveness based on this outcome.
Provision of ESCAPE-knee pain had small cost implications, but it was more likely to be cost-effective in improving function than usual primary care. Group rehabilitation reduces costs without compromising clinical effectiveness, increasing probability of cost-effectiveness.
PMCID: PMC2675012  PMID: 17907207
Economic evaluation; Rehabilitation; Knee pain
4.  Clinical effectiveness of a rehabilitation program integrating exercise, self-management, and active coping strategies for chronic knee pain: A cluster randomized trial 
Arthritis and Rheumatism  2007;57(7):1211-1219.
Chronic knee pain is a major cause of disability and health care expenditure, but there are concerns about efficacy, cost, and side effects associated with usual primary care. Conservative rehabilitation may offer a safe, effective, affordable alternative. We compared the effectiveness of a rehabilitation program integrating exercise, self-management, and active coping strategies (Enabling Self-management and Coping with Arthritic Knee Pain through Exercise [ESCAPE-knee pain]) with usual primary care in improving functioning in persons with chronic knee pain.
We conducted a single-blind, pragmatic, cluster randomized controlled trial. Participants age ≥50 years, reporting knee pain for >6 months, were recruited from 54 inner-city primary care practices. Primary care practices were randomized to continued usual primary care (i.e., whatever intervention a participant's primary care physician deemed appropriate), usual primary care plus the rehabilitation program delivered to individual participants, or usual primary care plus the rehabilitation program delivered to groups of 8 participants. The primary outcome was self-reported functioning (Western Ontario and McMaster Universities Osteoarthritis Index physical functioning [WOMAC-func]) 6 months after completing rehabilitation.
A total of 418 participants were recruited; 76 (18%) withdrew, only 5 (1%) due to adverse events. Rehabilitated participants had better functioning than participants continuing usual primary care (−3.33 difference in WOMAC-func score; 95% confidence interval [95% CI] −5.88, −0.78; P = 0.01). Improvements were similar whether participants received individual rehabilitation (−3.53; 95% CI −6.52, −0.55) or group rehabilitation (−3.16; 95% CI −6.55, −0.12).
ESCAPE-knee pain provides a safe, relatively brief intervention for chronic knee pain that is equally effective whether delivered to individuals or groups of participants.
PMCID: PMC2673355  PMID: 17907147
Integrated rehabilitation; Knee pain
5.  Contribution of academic departments of general practice to undergraduate teaching, and their plans for curriculum development. 
BACKGROUND. In 1991, the General Medical Council suggested the development of a new undergraduate curriculum, on a 'core plus electives' basis. The combination of National Health Service reforms and the rising profile of academic departments of general practice had led to a consideration of general practice as an alternative teaching environment. These departments now face escalating expectations from their medical schools of their ability to provide additional community based teaching. AIM. The aim of this study was to investigate the present contribution of academic departments of general practice to undergraduate teaching and their plans for curriculum development, including the introduction of community-based clinical skills teaching. METHOD. A questionnaire was circulated in June 1993 to all academic departments of general practice in the United Kingdom and Eire. RESULTS. Twenty seven out of 28 questionnaires were returned. Twenty two departments provided pre-clinical teaching and all provided a clinical practice attachment. Eight medical schools were organizing community-based clinical skills teaching, and in two this formed the basis for a community-based medical attachment. Eight planned to reduce the factual content of their curricula and introduce problem-based learning while nine were contemplating a 'core plus electives' option. Fourteen medical schools had primary care input in teaching basic clinical skills and an additional seven planned to introduce this. Problems encountered by the general practitioner tutors in teaching clinical skills included insufficient time and resources and poor self-esteem; they identified a need for good central and peripheral organization. CONCLUSION. Compared with a 1988 study, academic departments of general practice are increasingly involved in teaching both general practice and general medical skills at undergraduate level. Curriculum change is occurring rapidly, with an increasing trend towards community teaching; the implications for both academic departments and general practitioner tutors are discussed.
PMCID: PMC1239044  PMID: 7748644
6.  Guidelines on appropriate indications for upper gastrointestinal endoscopy. Working Party of the Joint Committee of the Royal College of Physicians of London, Royal College of Surgeons of England, Royal College of Anaesthetists, Association of Surgeons, the British Society of Gastroenterology, and the Thoracic Society of Great Britain. 
BMJ : British Medical Journal  1995;310(6983):853-856.
Upper gastrointestinal endoscopy is a valuable diagnostic tool, but for an endoscopy service to be effective it is essential that it is not overloaded with inappropriately referred patients. A joint working party in Britain has considered the available literature on indications for endoscopy, assessed standard practice through a questionnaire, and audited randomly selected cases using an independent panel of experts and an American database system. They used these data to produce guidelines on the appropriate and inappropriate indications for referral for endoscopy, although they emphasise that under certain circumstances there may be reasons to deviate from the advice given. The need for endoscopy is most difficult to judge in patients with dyspepsia, and this aspect is discussed in detail. Early endoscopy will often prove more cost effective than delaying until the indications are clearer.
PMCID: PMC2549224  PMID: 7711627
7.  General practitioners' views about the statutory annual practice report. 
BMJ : British Medical Journal  1994;309(6958):849-852.
OBJECTIVE--To ascertain the views of primary care professionals about the current purpose, uses, potential, and workload implications of the statutory general practice annual report. DESIGN--Postal questionnaire survey. SETTING--General practices in the Northern region. SUBJECTS--All practices in the region that were singlehanded, fundholding, non-fundholding and with more than five partners, and a one in three random sample of all non-fundholding practices (n = 318). RESULTS--263 practices responded (83%). The report took a median of 12 hours to produce (95% confidence interval 11 to 15 hours; interquartile range 7-35). The main perceived purpose of the report was to monitor practice activity (165 respondents; 63% (95% confidence interval 57% to 69%)), but 44 respondents (17%; 13% to 22%) produced it only because it was contractually required. Practices included statutory and non-statutory data in these reports and would have liked comparative practice activity information (155 respondents; 59%) and "good ideas" (165 respondents; 63%) fed back to them. Respondents would have liked the annual report used to improve practice development planning (122 respondents; 46% (40% to 52%)), to facilitate audit (115 respondents; 44% (38% to 50%)), and to influence resource allocation (104 respondents; 40% (34% to 46%)). One hundred and eighteen practices (45%; 39% to 51%) would produce an annual report even if not contractually required. Data collected were perceived to be already available elsewhere. CONCLUSIONS--Primary care professionals have concerns about the current annual report. They would prefer to collect relevant, standardised data which could lead to better audit, planning, and resource allocation.
PMCID: PMC2541081  PMID: 7950616
9.  Dyspepsia in England and Scotland. 
Gut  1990;31(4):401-405.
A validated postal questionnaire has been used to establish the prevalence of dyspeptic symptoms in five geographical locations from the south coast of England to the north of Scotland. The six month period prevalence of dyspepsia in the 7428 respondents to the questionnaire is 41% and equal between the sexes, with similar prevalence rates in the centres studied. There is considerable overlap between upper abdominal symptoms and symptoms of heartburn; 56% of patients with dyspepsia experience both groups of symptoms. Symptom frequency falls progressively with age in men and women, but the proportion of people seeking medical advice for dyspepsia rises with age. One quarter of the dyspeptic patients studied have consulted a general practitioner about their symptoms. This study suggests that the prevalence of dyspepsia in the community has changed little over the last 30 years, despite evidence that the frequency of peptic ulcer disease is falling. Symptom prevalence is unrelated to social class, but this factor is associated with consultation behaviour, the consultation rate rising from 17% in social class 1 to 29% in social class 4. The use of investigations--barium meal and endoscopy--is similarly related to social class; the lowest rate for ulcer diagnosis (4.7%) is found in social class 1 and the highest (17.1%) in social class 5.
PMCID: PMC1378412  PMID: 2338264
12.  Rifampicin-associated pseudomembranous colitis. 
British Medical Journal  1980;281(6249):1180-1181.
PMCID: PMC1714520  PMID: 7427627
13.  Therapeutic effect of cimetidine in patients undergoing haemodialysis. 
British Medical Journal  1979;1(6164):650-652.
Blood concentrations of cimetidine were measured and the therapeutic effect of the drug assessed patients undergoing maintenance haemodialysis. Thirteen patients were given a single oral 200-mg dose of cimetidine a mean of 2.7 hours before the start of dialysis. Dialysing for 6--12-6 m2 hours led to a mean fall of 71% in blood cimetidine concentration during haemodialysis. Nine patients with various upper gastrointestinal lesions diagnosed endoscopically were treated for up to six weeks with a reduced cimetidine dose of 200 mg 12-hourly; two patients received two courses of treatment. Repeat endoscopy after treatment disclosed satisfactory healing, and the drug did not accumulate. This lower dose regimen is recommended for patients receiving dialysis who develop upper gastrointestinal lesions for which a histamine H2-receptor antagonist is indicated.
PMCID: PMC1598296  PMID: 435708
15.  Haemodialysis-triggered asthma. 
British Medical Journal  1978;2(6138):701.
PMCID: PMC1607390  PMID: 698677
16.  Cimetidine: prophylaxis against upper gastrointestinal haemorrhage after renal transplantation. 
British Medical Journal  1978;1(6110):398-400.
The incidence of upper gastrointestinal haemorrhage within four months of renal transplantation was studied in two groups of patients. Thirty patients who received prophylactic cimetidine suffered no episodes of upper gastrointestinal haemorrhage, while six of the 33 patients who did not receive cimetidine suffered haemorrhages and one of them died as a result. The difference between the groups was significant. The results suggest that the prophylactic use of cimetidine in patients receiving renal transplants is worth while.
PMCID: PMC1602961  PMID: 342062
17.  Haemoperfusion with R-004 Amberlite resin for treating acute poisoning. 
British Medical Journal  1977;2(6100):1453-1456.
Eleven patients who had taken overdoses of barbiturates, glutethimide, tricyclic antidepressants, and chloroquine were treated by resin haemoperfusion using an R-004 haemoperfusion cartridge containing XAD-4 resin. All but one patient showed rapid clinical recovery and the drugs were cleared rapidly from the plasma. There were few complications. Resin haemoperfusion is more effective than dialysis and other perfusion methods, especially in poisoning with tricyclic antidepressants. Although haemoperfusion is expensive, it greatly reduces the length of the patient's stay in an intensive care unit and hence is cost-effective.
PMCID: PMC1632645  PMID: 589264
18.  Congenital thrombocytopenia and milk allergy. 
Archives of Disease in Childhood  1977;52(9):744-745.
PMCID: PMC1544737  PMID: 579081
19.  Growth and subculture of pathogenic T. pallidum (Nichols strain) in BHK-21 cultured tissue cells. 
The growth and nine subcultivations of the experimental Nichols strain of pathogenic Treponema pallidum were successfully accomplished in cultured baby hamster kidney tissue cells (BHK-21) using serum-free media. The number (motile and non-motile cells occurring extracellulary) of cell generations generally increased with each subcultivation, the largest increases (greater than 3-0) occurring in subcultures 4, 5, 7, 8, and 9. Also, the number of motile cells decreased with each subcultivation. Virulent organisms were demonstrated in subcultures 1, 4, 5, 7, and 8, and their numbers estimated with the use of standards established by the animal inoculation titration of counted numbers of organisms freshly harvested from experimental infections; the estimated number of virulent organisms was higher than or equal to the counted cultivated treponemes injected, which may be attributable to uncounted virulent spirochaetes occurring intracellularly.
PMCID: PMC1045204  PMID: 769912
20.  Treatment of acute otitis media: a controlled study of 142 children 
Results of the use of ampicillin, penicillin G and symptomatic therapy in the treatment of acute otitis media in 142 children were compared. Antibiotic therapy conveyed significant benefit. No major differences were observed between penicillin and ampicillin, except in the age group under 3 years where ampicillin was associated with the best results. Ampicillin appears to be the drug of choice. Its superiority over symptomatic therapy was statistically significant. Long-term sequelae were not observed in any of the three treatment groups. The relative merits of erythromycin and ampicillin require further study.
PMCID: PMC1946394  PMID: 4190002
21.  Bacteriophage Types and Antibiotic Sensitivity of Staphylococci from Bovine Milk and Human Nares1 
Applied Microbiology  1965;13(5):725-731.
The number, phage types, and antibiotic sensitivity of coagulase-positive staphylococci from grade A raw milk samples produced on 40 farms in the Athens, Ga., milkshed were determined. Counts of mannitol-positive staphylococci in milk ranged from 100 to 3,580 per milliliter, with an arithmetic mean of 1,047. Examination of the nares of 48 dairymen on 34 of the farms also revealed that 13 (27%) were carriers of coagulase-positive staphylococci. Isolates from milk (412) and from nares (39) were tested against the Coles, Seto-Wilson, and International phage sets and 87, 68, and 56%, respectively, proved typable. Nine isolates were not typable. Each of the 33 phages used lysed one or more of the isolates. Staphylococcal phage types per milk sample ranged from 0 to 5, 0 to 7, and 0 to 8, with arithmetic means of 1.9, 2.3, and 2.3, respectively. Of the 13 narial carriers, 7 harbored staphylococci of one or more of the same phage types as those isolated from the milk at the respective farms. Randomly selected isolates were tested against high and low concentrations of 12 common antibiotics. All were either moderately sensitive or resistant to polymixin B. Over 30% were moderately sensitive or resistant to dihydrostreptomycin and penicillin individually. With but few exceptions, all isolates were sensitive to chlortetracycline, bacitracin, carbomycin, chloramphenicol, erythromycin, neomycin, novobiocin, oxytetracycline, and tetracycline individually.
PMCID: PMC1058332  PMID: 5325936
22.  Pilonidal Sinus 
British Medical Journal  1954;2(4894):990.
PMCID: PMC2079727
24.  Problems with implementing guidelines: a randomised controlled trial of consensus management of dyspepsia. 
Quality in Health Care  1993;2(4):217-221.
OBJECTIVE--To determine the feasibility and benefit of developing guidelines for managing dyspepsia by consensus between general practitioners (GPs) and specialists and to evaluate their introduction on GPs' prescribing, use of investigations, and referrals. DESIGN--Randomised controlled trial of effect of consensus guidelines agreed between GPs and specialists on GPs' behaviour. SETTING--Southampton and South West Hampshire Health District, United Kingdom. SUBJECTS--179 GPs working in 45 practices in Southampton district out of 254 eligible GPs, 107 in the control group and 78 in the study group. MAIN MEASURES--Rates of referral and investigation and costs of prescribing for dyspepsia in the six months before and after introduction of the guidelines. RESULTS--Consensus guidelines were produced relatively easily. After their introduction referral rates for upper gastrointestinal symptoms fell significantly in both study and control groups, but no significant change occurred in either group in the use of endoscopy or radiology, either in terms of referral rates, patient selection, or findings on investigation. No difference was observed between the control and study group in the number of items prescribed, but prescribing costs rose by 25% (from 2634 pounds to 3215 pounds per GP) in the study group, almost entirely due to an increased rate of prescription of ulcer-healing agents. CONCLUSION--Developing district guidelines for managing dyspepsia by consensus between GPs and specialists was feasible. However, their acceptance and adoption was variable and their measured effects on some aspects of clinical behaviour were relatively weak and not necessarily associated with either decreased costs or improved quality of care.
PMCID: PMC1055149  PMID: 10132454
25.  Management of cardiac arrest in the community: a survey of resuscitation services. 
A survey of the English health regions identified nine ambulance based resuscitation schemes. Their structure and function are heterogeneous and their impact on patient survival is often speculative. There is considerable medical, paramedical, and lay enthusiasm for resuscitation schemes but this cannot be harnessed until medicolegal uncertainties are removed and guidelines for development are set out. Better documentation of the benefits of existing schemes should be undertaken so that advanced training of ambulance personnel can proceed rationally.
PMCID: PMC1549224  PMID: 6412910

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