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1.  Chronic pain and health status: how do those not using healthcare services fare? 
Relatively little is known about the clinical importance of symptoms not presented to healthcare services. Using data from a community survey we examined the health status among those with chronic pain who reported using or not using healthcare services. Individuals with chronic pain who had used healthcare services in the previous year had poorer health than symptomatic responders who had not used services, irrespective of the severity of chronic pain. The findings suggest that there is little point in trying to detect and treat individuals not currently presenting to healthcare services with their pain.
PMCID: PMC1324844  PMID: 15296563
health services; health services research; health status indicators; pain; signs and symptoms
2.  Ascertaining the size of the symptom iceberg in a UK-wide community-based survey 
Background
The symptom iceberg describes the phenomenon that most symptoms are managed in the community without people seeking professional health care. The size of the iceberg for many symptoms is unknown, as is their association with personal characteristics, including history of a chronic disease.
Aim
To ascertain the size of the symptom iceberg in the UK.
Design of study
A UK-wide community-based postal survey.
Setting
Urban and rural communities across the UK.
Method
A postal survey was sent to an age- and sex-stratified random sample of 2474 adults, aged 18–60 years, drawn from 20 practices around the UK. Questions were aimed at investigating adults' experiences of 25 different symptoms in the previous 2 weeks.
Results
The number of symptoms experienced by one individual in the previous 2 weeks ranged from 0 to 22 (mean 3.66). Of the symptoms examined, the three most common were: feeling tired/run down; headaches; and joint pain. Univariate analysis found symptom prevalence to be significantly associated with a wide range of participant characteristics. However, after adjustment, many of these associations no longer remained significant for a number of the symptoms. Presence of a chronic condition, age, and employment status were the three factors most commonly associated with the 2-week prevalence of symptoms. Reported symptom characteristics (severity, duration, interference, and time off work) varied little by sex or age.
Conclusion
Symptoms in the UK community are common. Symptom prevalence was associated with a number of participant characteristics, although the extent of this association was less than has been reported in previous research. This study provides an important current baseline prevalence of 25 symptoms in the community for those who do, and do not, have a chronic condition.
doi:10.3399/bjgp11X548910
PMCID: PMC3020067  PMID: 21401979
community-based; epidemiology; prevalence; signs and symptoms; symptom iceberg
3.  Impact of lifestyle in middle-aged women on mortality: evidence from the Royal College of General Practitioners' Oral Contraception Study 
Background
Although many individuals have multiple lifestyle risk factors, few studies have investigated the impact of lifestyle risk factor combinations among women.
Aim
To investigate the relationship between individual and combinations of lifestyle risk factors in middle-aged women with subsequent mortality, and to estimate the associated population attributable risks.
Design of study
Prospective cohort study.
Setting
Royal College of General Practitioners' (RCGP) Oral Contraception Study, UK.
Method
In 1994–1995, women remaining under follow-up in the RCGP Oral Contraception Study were sent a lifestyle survey, from which modifiable risk factors were identified: pack-years smoked, physical inactivity, never drinking versus consuming at least 7 units of alcohol weekly, and being underweight, overweight, or obese. The cohort was followed to December 2006 or death. Population attributable risks were calculated.
Results
Of 10 059 women studied, 896 died. Pack-years smoked (11–20 years: adjusted hazard ratio [HR] = 1.82, 95% confidence interval [CI] = 1.46 to 2.27; >20 years: adjusted HR = 2.34, 95% CI = 2.00 to 2.74); never drinking alcohol (adjusted HR = 1.66, 95% CI = 1.34 to 2.05); being underweight (adjusted = HR 1.66, 95% CI = 1.03 to 2.68); and physical inactivity (<15 hours/week: adjusted HR = 1.73, 95% CI = 1.46 to 2.04) were significantly associated with mortality compared with their respective reference group. Women with multiple lifestyle risk factors had higher mortality risks than those reporting one factor. The population attributable risk of the combination of smoking, physical inactivity, body mass index outside normal range, and alcohol (never drinking or excess intake) was 59% (95% CI = 31% to 78%).
Conclusion
Assuming a causal relationship between lifestyle and mortality, avoidance of four lifestyle risk factors would have prevented 60% of the deaths. The importance of avoiding smoking and undertaking physical inactivity during midlife should continue to be emphasised.
doi:10.3399/bjgp10X515052
PMCID: PMC2913736  PMID: 20822689
epidemiology; follow-up studies; lifestyle; mortality; women
4.  Increased mortality among women with Rose angina who have not presented with ischaemic heart disease. 
BACKGROUND: Little is known about the clinical importance of disease that is not presented to healthcare services. AIM: To determine the 5-year mortality among those with angina symptoms, known or not known by their general practitioner (GP) to have ischaemic heart disease (IHD). DESIGN: A prospective cohort study. SETTING: The study was conducted in the United Kingdom as part of the Royal College of General Practitioners' Oral Contraception Study. METHOD: In 1994-1995 women (n = 11,797) still under GP observation were sent a questionnaire that inquired about their smoking habits, other lifestyle issues, general health, and selected symptoms (including chest pain, assessed using the Rose angina questionnaire). The main outcome measure was the chances (odds) of dying during the next 5 years, among those with and without exertional chest pain, Rose angina or Rose myocardial infarction (MI), stratified by documented history of IHD. RESULTS: Overall, the lifetime prevalence of any exertional chest pain was 10.1% (95% confidence interval [CI] = 9.5 to 10.8); grade I Rose angina was 6.1% (95% CI = 5.6 to 6.6); grade II Rose angina was 1.3% (95% CI = 1.1 to 1.6); and Rose MI was 4.4% (95% CI = 4.0 to 4.9). The prevalence of each condition tended to increase with age, social class, parity, body mass index, and documented history of IHD. The proportion of women documented as having IHD was 23% among those with any exertional chest pain, 21.7% for grade I Rose angina, 37.7% for grade II Rose angina, and 31.4% for Rose MI. Compared to women without Rose angina, significantly higher odds ratios for all-cause mortality were observed among women with grade I Rose angina and no documented history of IHD (adjusted odds ratio [AOR] = 1.71, 95% CI = 1.05 to 2.79); those with grade II Rose angina and documented IHD (AOR = 3.94, 95% CI = 1.58 to 9.83); and women with grade II Rose angina and no documented history of IHD (AOR = 3.35, 95% CI = 1.47 to 7.62). CONCLUSIONS: Women with angina symptoms that have not been documented by their GP appear to have an increased risk of future mortality. Research is needed to determine the best way of identifying and managing these individuals.
PMCID: PMC1314711  PMID: 14601354
5.  Pain and subsequent mortality and cancer among women in the Royal College of General Practitioners Oral Contraception Study. 
Recent research suggested associations between pain and subsequent all-cause and cancer-specific mortality. This study examined death and cancer development within six years of reporting pain, among women in the Royal College of General Practitioners Oral Contraception Study. We found no associations between 'any' or 'chronic' pain and subsequent all-cause mortality or cancer. We found a higher risk of death from respiratory disease among women reporting pain (adjusted odds ratio [AOR] = 2.5), a higher mortality among women reporting chronic chest pain (AOR = 1.75), and a higher risk of subsequent cancer among women reporting head or abdomen pain. Given the high prevalence of pain symptoms, these findings may be important, and warrant further research.
PMCID: PMC1314492  PMID: 12564277
6.  Assessing change in chronic pain severity: the chronic pain grade compared with retrospective perceptions. 
BACKGROUND: There is no standard method of measuring change in chronic pain severity. Clinical trials commonly use serial assessment scales, completed at two points in time, to estimate change in pain severity, while clinicians usually ask patients to make a retrospective assessment of change. How the two methods compare is not known. AIM: To assess different methods of measuring change in chronic pain severity, by comparing changes in scores on a serial measure of chronic pain severity using the Chronic Pain Grade (CPG) questionnaire and responders' retrospective perception of change in pain severity. DESIGN OF STUDY: Postal self-completion questionnaires. SETTING: The Grampian region of Scotland. METHOD: Postal questionnaires were sent in March and September 1998 to a random sample of 535 adults with chronic pain, drawn from responders to a postal survey of the region conducted in 1996. RESULTS: Corrected response rates of 87.5% and 90.7% were obtained. Over a six-month period poor levels of agreement were found, with responders' retrospective perceptions mirroring recorded changes in 41.8% of individuals (kappa = 0.081). A low partial correlation coefficient between the two measures (-0.209) was also found. Over a two-year period there were again poor levels of agreement, with responders' retrospective perceptions mirronng recorded changes in 35.2% of individuals (kappa = 0.071). A low partial correlation coefficient (-0.401) was again found. CONCLUSION: There was poor agreement and low correlation between two commonly used methods for assessing change in pain severity over time. This finding has important implications for both service practitioners and researchers.
PMCID: PMC1314266  PMID: 11942442

Results 1-6 (6)