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1.  Cerebral autoregulation is impaired in cardioinhibitory carotid sinus syndrome 
Heart  2006;92(6):792-797.
Objectives
To compare changes in cerebral autoregulation in response to controlled, lower body negative pressure‐induced hypotension in patients with carotid sinus syndrome (CSS) and case controls.
Design
Prospective case controlled study.
Setting
Secondary and tertiary referral falls and syncope service.
Patients
17 consecutive patients with CSS and 11 asymptomatic controls.
Interventions
Hypotension insufficient to cause syncope induced by lower body negative pressure (minimum 30 mm Hg fall in systolic blood pressure (SBP)) during concomitant transcranial Doppler ultrasonography.
Main outcome measures
Cerebral autoregulation (systolic, diastolic and mean middle cerebral arterial blood flow velocities and cerebrovascular resistance) with continuous end‐tidal carbon dioxide and haemodynamic monitoring.
Results
Cerebral autoregulatory indices differed significantly between patients with CSS and controls. Systolic, diastolic and middle cerebral arterial blood flow velocities were, respectively, 9.2 m/s (95% confidence interval (CI) 2.9 to 15.4 m/s), 4.7 m/s (95% CI 1.5 to 7.9 m/s) and 6.9 m/s (95% CI 2.5 to 11.4 m/s) slower in patients with CSS. Cerebrovascular resistance was significantly greater in patients with CSS than in controls at SBP nadir and suction release; differences were 0.9 mm Hg/m/s (95% CI 0.0 to 1.7 mm Hg/m/s) and 0.8 mm Hg/m/s (95% CI 0.0 to 1.7 mm Hg/m/s), respectively. End‐tidal carbon dioxide and systemic haemodynamic variables were similar for patients and controls at baseline and during lower body negative pressure.
Conclusions
Cerebral autoregulation is altered in patients with CSS. This difference may have aetiological implications in the differential presentation with falls and drop attacks rather than syncope.
doi:10.1136/hrt.2004.053348
PMCID: PMC1860657  PMID: 16449521
ageing; carotid arteries; cerebral autoregulation; cerebrovascular circulation; syncope
2.  Central α2 adrenoceptors and the pathogenesis of carotid sinus hypersensitivity 
Heart  2004;90(8):935-936.
doi:10.1136/hrt.2002.006205
PMCID: PMC1768395  PMID: 15253974
2 adrenoceptors
3.  Water fluoridation, stillbirths, and congenital abnormalities 
doi:10.1136/jech.57.7.499
PMCID: PMC1732512  PMID: 12821692
4.  Falls and confidence related quality of life outcome measures in an older British cohort 
Postgraduate Medical Journal  2001;77(904):103-108.
Falls are common in older subjects and result in loss of confidence and independence. The Falls Efficacy Scale (FES) and the Activities-specific Balance Confidence scale (ABC) were developed in North America to quantify these entities, but contain idiom unfamiliar to an older British population. Neither has been validated in the UK. The FES and the ABC were modified for use within British culture and the internal consistency and test-retest reliability of the modified scales (FES-UK and ABC-UK) assessed. A total of 193 consecutive, ambulant, new, and return patients (n=119; 62%) and their friends and relatives ("visitors", n=74; 38%) were tested on both scales, while the last 60 subjects were retested within one week. Internal reliability was excellent for both scales (Cronbach's alpha 0.97 (FES-UK), and 0.98 (ABC-UK)). Test-retest reliability was good for both scales, though superior for the ABC-UK (intraclass correlation coefficient 0.58 (FES-UK), 0.89 (ABC-UK)). There was evidence to suggest that the ABC-UK was better than the FES-UK at distinguishing between older patients and younger patients (|tABC| = 4.4; |tFES| = 2.3); and between fallers and non-fallers (|tABC| = 8.7; |tFES| = 5.0) where the t statistics are based on the comparison of two independent samples. The ABC-UK and FES-UK are both reliable and valid measures for the assessment of falls and balance related confidence in older adults. However, better test-retest reliability and more robust differentiation of subgroups in whom falls related quality of life would be expected to be different make the ABC-UK the current instrument of choice in assessing this entity in older British subjects.


Keywords: quality of life; falls; elderly; health status measurement
doi:10.1136/pmj.77.904.103
PMCID: PMC1741890  PMID: 11161077
5.  Effect of clinical guidelines in nursing, midwifery, and the therapies: a systematic review of evaluations 
Quality in Health Care : QHC  1998;7(4):183-191.
BACKGROUND: Although nursing, midwifery, and professions allied to medicine are increasingly using clinical guidelines to reduce inappropriate variations in practice and ensure higher quality care, there have been no rigorous overviews of their effectiveness, 18 evaluations of guidelines were identified that meet Cochrane criteria for scientific rigor. METHODS: Guideline evaluations conducted since 1975 which used a randomised controlled trial, controlled before and after, or interrupted time series design were identified through a combination of database and hand searching. RESULTS: 18 studies met the inclusion criteria. Three studies evaluated guideline dissemination or implementation strategies, nine compared use of a guideline with a no guideline state; six studies examined skill substitution: performance of nurses operating according to a guideline were compared with standard care, generally provided by a physician. Significant changes in the process of care were found in six out of eight studies measuring process and in which guidelines were expected to have a positive impact on performance. In seven of the nine studies measuring outcomes of care, significant differences in favour of the intervention group were found. Skill substitution studies generally supported the hypothesis of no difference between protocol driven by nurses and care by a physician. Only one study included a formal economic evaluation, with equivocal findings. CONCLUSIONS: Findings from the review provide some evidence that care driven by a guideline can be effective in changing the process and outcome of care. However, many studies fell short of the criteria of the Cochrane Effective Practice and Organisation of Care Group (EPOC) for methodological quality.
PMCID: PMC2483618  PMID: 10339020
6.  Measuring outpatient resource use and case mix in ophthalmology in north east England 
OBJECTIVES: To test the extent to which two existing ambulatory case mix measures (Ambulatory Visit Groups and Ambulatory Patient Groups) and other variables can explain resource use variations in ophthalmic outpatient visits. DESIGN: Three week prospective study of three consultant outpatient clinics. SETTING: One ophthalmic hospital (Sunderland Eye Infirmary, Sunderland, Tyne and Wear) and three outreach clinics (South Tyneside District Hospital, South Shields, Tyne and Wear; Dryburn Hospital, Durham, Co Durham; and Hartlepool General Hospital, Hartlepool, Cleveland). SUBJECTS: 325 patients who visited ophthalmic outpatient clinics. MAIN OUTCOME MEASURES: Mean consultation time and mean cost distributions by case mix group, analysed by analysis of variance. RESULTS: Ambulatory case mix measures can explain some of the variation in resource use for outpatient visits, but different measures differ in the extent to which they can do so. Clinicians' behaviour also accounts for a significant amount of such variation. Simpler measures of visit type, without diagnostic or procedure information, do not explain resource use variations. CONCLUSIONS: Existing measures perform reasonably well, but their data requirements may preclude their introduction in the National Health Service. Caution is required in advocating simpler measures, however. The influence of clinical practice on resource use variations is important; in this study, most differences between clinicians were not attributable to differences in case mix.
 
PMCID: PMC1756697  PMID: 9616412
7.  Are postal questionnaire surveys of reported activity valid? An exploration using general practitioner management of hypertension in older people. 
BACKGROUND: Postal questionnaire surveys are commonly used in general practice and often ask about self-reported activity. The validity of this approach is unknown. AIM: To explore the criterion validity of questions asking about self-reported activity in a self-completion questionnaire. METHOD: A comparison was made between (a) the self-reported actions of all general practitioner (GP) principals in 51 general practices randomly selected within the nine family health services authorities of the former northern regional health authority, and (b) the contents of the medical records (case notes and computerized records) of patients classified as hypertensive from a 1 in 7 random sample of all patients registered in these practices and aged between 65 and 80. Data were gathered from the GPs by self-completion postal questionnaires. Six comparisons were made for two groups of items: first, target and achieved blood pressure; secondly, patient's weight, smoking status, alcohol consumption, exercise and salt intake. The frequency with which the data items were recorded in patient records was compared with the GPs' self-reported frequency of performing the actions. RESULTS: No relationship was found between achieved blood pressure and stated target levels. For each of the other actions, more than half of the responders reported that they usually or always performed the activity. For four of these (smoking, weight, alcohol and exercise), a significant association was noted, but the size of this varied considerably. CONCLUSIONS: There is a variable relationship between what responders report that they do in self-completion questionnaires, and what they actually do as judged by the contents of their patients' medical records. In the absence of prior, knowledge of the validity of questions on reported activity, or of concurrent attempts to establish their validity, the questions should not be asked.
PMCID: PMC1313315  PMID: 10622014
8.  Case mix and content of trainee consultations: findings from the north of England study of standards and performance in general practice. 
BACKGROUND. Previous studies have examined the differences in the work of trainees and trainers. However, they have not investigated how many of these differences are due to differences in the case mix seen by trainees. AIM. A study was undertaken to investigate the effect of case mix on the content of consultations with trainee general practitioners. METHOD. Details of surgery consultations with 207 trainee general practitioners and 255 principals in 62 training practices in the north of England were prospectively recorded during one week in each of four consecutive years. RESULTS. Trainee general practitioners saw a higher proportion of younger patients and those categorized as suffering from an acute minor condition compared with principals. They saw a lower proportion of patients categorized as suffering from chronic intermediate, chronic major and female conditions. The reported content of trainee and principal consultations differed over all four years in that trainees examined more patients, issued more new prescriptions, issued fewer repeat prescriptions, arranged fewer return appointments and referred fewer patients. However, adjusting for case mix reduced the number of significant differences between trainees and principals to two: trainees issued fewer repeat prescriptions and had more consultations lasting longer than nine minutes. CONCLUSION. The case mix and content of consultations differ between trainees and principals and some of the differences in content are due to the differences in case mix; trainees generally behave more like principals than has been previously suggested. Thus, case mix is an important factor in understanding the content of trainee consultations.
PMCID: PMC1239015  PMID: 7748630
9.  Development of a symptom based outcome measure for asthma. 
BMJ : British Medical Journal  1994;309(6961):1065-1068.
Measuring symptom specific health outcome is complex, but the methodologies now exist to develop measures with the appropriate properties. As one element of a major programme to develop multidomain health outcome measures for chronic disease, a symptom based measure for asthma care has been developed for use in general practice and outpatient departments. This article outlines the development process, which used a framework recently described in the theoretical literature to show the constraints that scientific criteria place on the development of outcome measures and the means of overcoming such limiting factors. Although substantial effort is required to undertake a rigorous process of development, useful tools are the result. Two five item, symptom based outcome measures for adult asthma are described.
PMCID: PMC2541579  PMID: 7950742

Results 1-10 (10)