Discussing randomised clinical trials of cancer therapy: evaluation of a Cancer Research UK training programme

Objective To evaluate a training intervention aimed at improving healthcare professionals'' communication with cancer patients about randomised clinical trials.Design Before and after evaluation of training programme.Setting Members of the National Cancer Research Network, Scottish Trials Network, and the Welsh Cancer Trials NetworkParticipants 101 healthcare professionals (33 clinicians and 68 research nurses).Intervention Four modules delivered by a trained facilitator using videotapes and interactive exercises to cover general issues about discussing randomised clinical trials with patients, problems specific to adjuvant trials, trials with palliation as the goal, and trials where patients had a strong preference for one treatment arm.Main outcome measures Before and after the intervention, participants were videotaped discussing a trial with an actor portraying a patient. These consultations were assessed for presence of information required by good clinical practice guidelines. The actor patients gave an assessment after each interview. Participants reported their self confidence about key aspects of trial discussion.Results Analysis of the videotaped consultations showed that, after intervention, significantly more participants displayed key communication behaviours such as explaining randomisation (69 v 81, odds ratio 2.33, P = 0.033), checking patients'' understanding (11 v 31, odds ratio 3.22, P = 0.002), and discussing standard treatment (73 v 88, odds ratio 4.75, P = 0.005) and side effects (69 v 85, odds ratio 3.29, P = 0.006). Participants'' self confidence increased significantly (P < 0.001) across all areas. Actor patients'' ratings of participants'' communication showed significant improvements for 12/15 key items.Conclusion This intensive 8 hour intervention significantly improved participants'' confidence and competence when communicating about randomised clinical trials.     

Mobilizing physicians to conduct clinical intervention in tobacco use through a medical-association program: 5 years' experience in British Columbia.

During the last 5 years, a program run by the medical association in British Columbia has recruited 23% of the province''s general practitioners (GPs) to take an active, systematic approach to clinical intervention in tobacco use. Another 9% of GPs (considered "semi-active") regularly use the program''s educational materials for patients, and another 25% have been trained in intervention or have been given intervention materials or both. If the cessation rate (rate of patients who quit smoking who would not otherwise have done so) was 4% among physicians actively involved in intervention and 2% among physicians considered semi-active, in 1995 an estimated 4700 smokers quit and were followed by their GPs as a result of the program. Another 135,000 smokers received brief counselling from their GPs and were also followed. This article reviews the strategies and methods used in this program to mobilize physicians.     

General practitioners' knowledge of their patients' psychosocial problems: multipractice questionnaire survey.

OBJECTIVES: To evaluate general practitioners'' knowledge of a range of psychosocial problems among their patients and to explore whether doctors'' recognition of psychosocial problems depends on previous general knowledge about the patient or the type of problem or on certain characteristics of the doctor or the patient. DESIGN: Multipractice survey of consecutive adult patients consulting general practitioners. Doctors and patients answered written questions. SETTING: Buskerud county, Norway. SUBJECTS: 1401 adults attending 89 general practitioners during one regular working day in March 1995. MAIN OUTCOME MEASURES: Doctors'' knowledge of nine predefined psychosocial problems in patients; these problems were assessed by the patients as affecting their health on the day of consultation; odds ratios for the doctor''s recognition of each problem, adjusted for characteristics of patients, doctors, and practices; and the doctor''s assessment of previous general knowledge about the patient. RESULTS: Doctors'' knowledge of the problems ranged from 53% (108/203) of "stressful working conditions" to 19% (12/63) of a history of "violence or threats." Good previous knowledge of the patient increased the odds for the doctor''s recognition of "sorrow," "violence or threats," "substance misuse in close friend or relative," and "difficult conflict with close friend or relative." Age and sex of doctor and patient, patient''s educational level and living situation, and location of practice influenced the doctor''s awareness. CONCLUSIONS: Variation in the patients'' communication abilities, the need for confidence in the doctor-patient relationship before revealing intimate problems, and a tendency for the doctors to be entrapped by their expectations may explain these findings.     

An instrument for assessment of videotapes of general practitioners' performance.

OBJECTIVES--To identify those important characteristics of doctors'' and patients'' behaviour that distinguish between "good" and "bad" consultations when viewed on videotape; to use these characteristics to develop a reliable instrument for assessing general practitioners'' performance in their own consultations. DESIGN--Questionnaires completed by patients, general practitioner trainers, and general practitioner trainees. Reliability of draft instrument tested by general practitioner trainers. SETTING--All vocational training schemes for general practice in the Northern region of England. SUBJECTS--First stage: 76 patients in seven groups, 108 general practice trainers in 12 groups, and 122 general practice trainees in 10 groups. Second stage: 85 general practice trainers in 12 groups. MAIN OUTCOME MEASURES--Trainers'' ratings of importance; alpha coefficients of draft instrument by trainee, group, and consultation. RESULTS--6890 characteristics of good and bad consultations were consolidated into a draft assessment instrument consisting of 46 pairs of definitions separated by six point bipolar scales. Nine statement pairs given low importance ratings by trainers were eliminated, reducing the instrument to 37 statement pairs. To test reliability, general practitioner trainers used the instrument to assess three consultations. With the exception of one group of trainers, all alpha coefficients exceeded the acceptable level of 0.80. CONCLUSION--The instrument produced is reliable for assessing general practitioners'' performance in their own consultations.     

Patients' accounts of being removed from their general practitioner's list: qualitative study

Objective To explore patients'' accounts of being removed from a general practitioner''s list.Design Qualitative analysis of semistructured interviews.Setting Patients'' homes in Leicestershire.Participants 28 patients who had recently been removed from a general practitioner''s list.Results The removed patients gave an account of themselves as having genuine illnesses needing medical care. In putting their case that their removal was unjustified, patients were concerned to show that they were “good” patients who complied with the rules that they understood to govern the doctor-patient relationship: they tried to cope with their illness and follow medical advice, used general practice services “appropriately,” were uncomplaining, and were polite with doctors. Removed patients also used their accounts to characterise the removing general practitioner as one who broke the lay rules of the doctor-patient relationship. These “bad” general practitioners were rude, impersonal, uncaring, and clinically incompetent and lied to patients. Patients felt very threatened by being removed from their general practitioner''s list; they experienced removal as an attack on their right to be an NHS patient, as deeply distressing, and as stigmatising.Conclusions Removal is an overwhelmingly negative and distressing experience for patients. Many of the problems encountered by removed patients may be remediable through general practices having an explicit policy on removal and procedures in place to help with “difficult” patients.     

Effects of dietary l-glutamine supplementation on specific and general defense responses in mice immunized with inactivated Pasteurella multocida vaccine

Little is known about effects of dietary glutamine supplementation on specific and general defense responses in a vaccine-immunized animal model. Thus, this study determined roles for dietary glutamine supplementation in specific and general defense responses in mice immunized with inactivated Pasteurella multocida vaccine. The measured variables included: (1) the production of pathogen-specific antibodies; (2) mRNA levels for pro-inflammatory cytokines, toll-like receptors and anti-oxidative factors; and (3) the distribution of P. multocida in tissues and the expression of its major virulence factors in vivo. Dietary supplementation with 0.5 % glutamine had a better protective role than 1 or 2 % glutamine against P. multocida infection in vaccine-immunized mice, at least partly resulting from its effects in modulation of general defense responses. Dietary glutamine supplementation had little effects on the production of P. multocida-specific antibodies. Compared to the non-supplemented group, dietary supplementation with 0.5 % glutamine had no effect on bacterial burden in vivo but decreased the expression of major virulence factors in the spleen. Collectively, supplementing 0.5 % glutamine to a conventional diet provides benefits in vaccine-immunized mice by enhancing general defense responses and decreasing expression of specific virulence factors.     

Pyrogen release in vitro by lymphoid tissues from patients with Hodgkin's disease

The mechanism of fever in patients with Hodgkin''s disease was investigated by examining endogenous pyrogen production by blood, spleen, and lymph node cells incubated in vitro. Blood leucocytes from febrile or afebrile patients with Hodgkin''s disease did not produce pyrogen spontaneously. Spleen cells, however, frequently released pyrogen during initial incubations, unlike spleen cells from patients with non-malignant diseases. Pyrogen production occurred from spleens without observed pathologic infiltrates of Hodgkin''s disease. Lymph nodes involved with Hodgkin''s disease produced pyrogen more frequently than did nodes involved with other diseases. Pyrogen production by tissue cells was prolonged, required protein synthesis, and in some cases was due to mononuclear cells; it did not correlate with fever in the patient. These studies demonstrate spontaneous production of endogenous pyrogen in vitro by lymphoid tissue cells from patients with Hodgkin''s disease.     

Effects of increasing the number of players and memory size in the iterated Prisoner's Dilemma: a numerical approach

The Prisoner''s Dilemma has become a paradigm for the evolution of altruistic behaviour. Here we present results of numerical simulations of the infinitely iterated stochastic simultaneous Prisoner''s Dilemma considering players with longer memory, encounters of more than two players as well as different pay-off values. This provides us with a better foundation to compare theoretical results to experimental data. We show that the success of the strategy Pavlov, regardless of its simplicity, is far more general by having an outstanding role in the iterated N-player N-memory Prisoner''s Dilemma. Besides, we study influences of increased memory sizes in the iterated two-player Prisoner''s Dilemma, and present comparisons to results of experiments with first-year students.     

Cytotaxonomy ofCalliphoridae (Diptera)

A modification of the general system of classification ofCalliphoridae is proposed in this report. Information about the chromosome complements of about 90 species is provided including references to the earlier literature on chromosomes of this family. With one exception all species studied by us or by earlier investigators have 2n=12. The total complement length of 556 complements from 83 species averaged 66.4 μ. Most species have a short heteromorphic sex pair but the size and morphology vary considerably and one species,Hemipyrellia fernandica, seems to have a quadrivalent sex-chromosome complex in a 2n=14 complement. The autosomal pairs vary in both length and arm ratios between the species but seem to be more stable than the sex chromosomes. Only minor variations were found between different collections of the same species except for two collections ofCalliphora croceipalpis. Although presently available data on the chromosomes of Diptera species suggest that increases in total complement length accompany evolutionary progress, no such general trends were obvious in either the total complement lengths or chromosome morphology, either within or between the tribes ofCalliphoridae. Thus the karyotypical reorganizations in the family have apparently not been directly associated with changes in the general morphological features of the adults which may have responded in these respects more extensively to genetic mutations.     

Consultations in general practice: a comparison of patients' and doctors' satisfaction.

OBJECTIVE--To provide an objective means of assessing patients'' and doctors'' satisfaction with a consultation. DESIGN--Questionnaire study of patients and general practitioners after consultations. SETTING--Urban general practice. SUBJECTS--250 Patients attending consecutive consultations conducted by five general practitioners. MAIN OUTCOME MEASURE--Identification of deficiencies within a consultation as perceived by both doctors and patients. RESULTS--The doctor''s and patient''s questionnaires for each consultation were matched and the results analysed on a group basis. The response rate for individual questions was high (81-89%). The doctors and patients significantly disagreed about the doctors'' ability to assess and put patients at ease, to offer explanations and advice on treatment, and to allow expression of emotional feelings and about the overall benefit that the patients gained from the consultation. In all cases of disagreement the doctor had a more negative view of the consultation than the patient. CONCLUSIONS--The results of giving structured questionnaires on consultations to both patients and doctors could be a useful teaching tool for established doctors or those in training to improve the quality and sensitivity of care they provide.     

Should general practitioners call patients by their first names?

OBJECTIVE--To assess the acceptability to patients of the use of patients'' first names by doctors and doctors'' first names by patients in general practice. DESIGN--An administered questionnaire survey. SETTING--5 General practices in Lothian. PATIENTS--475 Patients consulting 30 general practitioners. MAIN OUTCOME MEASURE--Response by patients to questionnaire on attitude to use of first names. RESULTS--Most of the patients either liked (223) or did not mind (175) being called by their first names. Only 77 disliked it, most of whom were aged over 65. Most patients (324) did not, however, want to call the doctor by his or her first name. CONCLUSIONS--General practitioners should consider using patients'' first names more often, particularly with younger patients.     

Vitamin E and selenium supplementation in geriatric patients

Sodium selenate (8 mg/d), organic selenium (50 μg/d) andd-alpha-tocopherol acetate (400 mg/d) were administered for 1 yr to 15 geriatric patients. Fifteen comparable controls received placebo. The mean age of both groups was 76 yr. The patients were assessed every 2 mo independently by two nurses using the Sandoz Clinical Assessment Geriatric-scale (SCAG). The propositae, showed significant improvement in the following SCAG parameters: depression, anxiety, self-care, mental alertness, emotional lability, motivation and initiative, hostility, interest in the environment, fatigue, anorexia, and general impression. A distinct improvement of the general condition was noticed after only 2 mo and the improvement continued up to the end of the 1-yr study period. The high selenium and vitamin E doses were well tolerated; there were no side effects whatsoever.     

Evalution of Home Nurse Attachment in Bristol

By the end of June 1969 home nurses in Bristol were attached to 18 general practices caring for about 137,000 patients, or about one-third of the city''s population. Attachment was associated with an increase by about one-third in the number of patients referred by general practitioners for home nursing. Additional benefits derived from attachment during the nine months from January to September 1969 were 2,047 items of service performed by nurses in general practitioners'' surgeries, 65 home visits to patients who were not receiving domiciliary nursing care, improved communications between general practitioners and nurses, and opportunities for both doctors and nurses to widen their fields of work. The travelling expenses paid to Bristol''s nurses increased by 9·5%.It is suggested that the benefits to patients, doctors, and nurses of attachment far outweigh the costs and that there is scope for extending the role of the attached nurse in the surgery and in home visiting.     

Mutations that permit residual CFTR function delay acquisition of multiple respiratory pathogens in CF patients

Background

Lung infection by various organisms is a characteristic feature of cystic fibrosis (CF). CFTR genotype effects acquisition of Pseudomonas aeruginosa (Pa), however the effect on acquisition of other infectious organisms that frequently precede Pa is relatively unknown. Understanding the role of CFTR in the acquisition of organisms first detected in patients may help guide symptomatic and molecular-based treatment for CF.

Methods

Lung infection, defined as a single positive respiratory tract culture, was assessed for 13 organisms in 1,381 individuals with CF. Subjects were divided by predicted CFTR function: ''Residual'': carrying at least one partial function CFTR mutation (class IV or V) and ''Minimal'' those who do not carry a partial function mutation. Kaplan-Meier estimates were created to assess CFTR effect on age of acquisition for each organism. Cox proportional hazard models were performed to control for possible cofactors. A separate Cox regression was used to determine whether defining infection with Pa, mucoid Pa or Aspergillus (Asp) using alternative criteria affected the results. The influence of severity of lung disease at the time of acquisition was evaluated using stratified Cox regression methods by lung disease categories.

Results

Subjects with ''Minimal'' CFTR function had a higher hazard than patients with ''Residual'' function for acquisition of 9 of 13 organisms studied (HR ranging from 1.7 to 3.78 based on the organism studied). Subjects with minimal CFTR function acquired infection at a younger age than those with residual function for 12 of 13 organisms (p-values ranging: < 0.001 to 0.017). Minimal CFTR function also associated with younger age of infection when 3 alternative definitions of infection with Pa, mucoid Pa or Asp were employed. Risk of infection is correlated with CFTR function for 8 of 9 organisms in patients with good lung function (>90%ile) but only 1 of 9 organisms in those with poorer lung function (<50%ile).

Conclusions

Residual CFTR function correlates with later onset of respiratory tract infection by a wide spectrum of organisms frequently cultured from CF patients. The protective effect conferred by residual CFTR function is diminished in CF patients with more advanced lung disease.     

Improving care: a study of orthopaedic outpatient referrals.

OBJECTIVE--To identify aspects of outpatient referral in which general practitioners'', consultants'', and patients'' satisfaction could be improved. DESIGN--Questionnaire survey of general practitioners, consultant orthopaedic surgeons, and patients referred to an orthopaedic clinic. SETTING--Orthopaedic clinic, Doncaster Royal Infirmary. SUBJECTS--628 consecutive patients booked into the orthopaedic clinic. MAIN OUTCOME MEASURES--Views of the general practitioners as recorded both when the referral letter was received and again after the patient had been seen, views of the consultants as recorded at the time of the clinic attendance, and views of the patients as recorded immediately after the clinic visit and some time later. RESULTS--Consultants rated 213 of 449 referrals (42.7%) as possibly or definitely inappropriate, though 373 of 451 patients (82.7%) reported that they were helped by seeing the consultant. Targets for possible improvement included information to general practitioners about available services, communication between general practitioners and consultants, and administrative arrangements in clinics. Long waiting times were a problem, and it seemed that these might be reduced if general practitioners could provide more advice on non-surgical management. Some general practitioners stated that they would value easier telephone access to consultants for management advice. It was considered that an alternative source of management advice on musculoskeletal problems might enable more effective use to be made of specialist orthopaedic resources. Conclusion--A survey of patients'' and doctors'' views of referrals may be used to identify aspects in which the delivery of care could be made more efficient. Developing agreed referral guidelines might help general practitioners to make more effective use of hospital services.     

District programme to reduce smoking: effect of clinic supported brief intervention by general practitioners.

By encouraging and supporting general practitioners to undertake brief intervention on a routine basis smokers'' clinics could reach many more smokers than are willing to attend for intensive treatment. In a study with 101 general practitioners from 27 practices 4445 cigarette smokers received brief intervention with the support of a smokers'' clinic, brief intervention without such support, or the general practitioners'' usual care. At one year follow up the numbers of smokers who reported that they were no longer smoking cigarettes were 51 (13%), 63 (9%), and 263 (8%), respectively (p less than 0.005). After an adjustment was made for those cases not validated by urine cotinine concentrations the respective success rates were 8%, 5%, and 5%. Use of nicotine chewing gum was associated with higher self reported success rates. General practitioners providing supported brief intervention encouraged not only more smokers to use the gum but also more effective use; gum users in this group reported a success rate of 27% at one year. Compliance by the general practitioners in recording smoking state averaged 45%, and significantly higher success rates were reported by patients whose smoking state had been recorded. Brief intervention by general practitioners with the support of a smokers'' clinic thus significantly enhanced success rates based on self reports. Better results might be obtained if general practitioners'' compliance with the procedure could be improved and if they encouraged more of their patients to try nicotine gum. Collaboration of this kind between a smokers'' clinic and local general practitioners could deliver effective help to many more smokers than are likely to be affected if the two continue to work separately.     

Value of Routine Multiple Blood Tests in Patients Attending the General Practitioner

The paper describes the investigation of 296 patients selected at random from those attending the general practitioners'' surgery and studied by means of multiple biochemical and haematological tests. The tests that would not normally have been requested led to a new diagnosis of clinical significance in 16·9% of patients, in most instances requiring an alteration of the patient''s therapy. The effect of the profile tests on patient follow-up, referral of patients to hospital, and the need for subsequent investigations was studied by comparing the patients profiled with a control group of patients not having a blood profile. The place of such an investigation in general practice is considered.     

TRISETHYLENE-IMINO-S-TRIAZINE (TRIETHYLENE MELAMINE OR TEM) IN THE TREATMENT OF NEOPLASTIC DISEASES

Trisethylene-imino-s-triazine (triethylene melamine or TEM) produced minimal effects in inhibiting transplantable lymphoma and mammary adenocarcinoma in mice. In strain A mice, injection of the compound induced pulmonary tumors.TEM was tried on 32 patients with neoplastic disease, including nine patients with Hodgkin''s disease and five with lymphosarcoma and lymphatic leukemia. The therapeutic and toxic effects were similar to those observed with nitrogen mustard (HN2). Satisfactory remissions of up to three months were observed in Hodgkin''s disease and lymphosarcoma following parenteral administration of TEM. It is the authors'' impression that the remissions obtained with TEM were not as complete and did not last as long as those obtained with HN2.TEM is effective by the oral route as well as parenterally, and produces much less emetic reaction than HN2. On the other hand, the chemotherapeutic range is narrower than that of HN2. Patients who do not respond to HN2 show no response to TEM.TEM is a drug of some clinical usefulness in the same conditions and with the same general limitations and toxic effects as HN2. The ease of administration of TEM increases its hazards, and close clinical and hematologic observations are essential on patients receiving the agent.