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This three-year study investigated the experience of postoperative pain and its management following elective surgery in an adolescent population aged 12-18 years (n=351) in 5 NHS trusts. In addition to the adolescents, one parent of each adolescent and a range of health professionals including surgeons, anaesthetists and registered nurses were interviewed concerning their views on acute pain in adolescent patients. The results presented in this paper are those related to the management of day and inpatient surgery in this adolescent population. Data were collected pre-operatively and postoperatively (days 1 and 3) using semi-structured interviews, telephone interviews, self-completion questionnaires and standardised tools to measure pain intensity (Adolescent Pediatric Pain Tool), psychological adjustment to adolescence (Offer Self-Image Questionnaire-Revised) and emotional state (Hospital Anxiety and Depression Scale). Day cases were discharged on the day of surgery while most inpatients were discharged on the first postoperative day.
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PMID:Postoperative pain: a comparison of adolescent inpatient and day patient experiences. 1124 69

The aim of this article is to give the patients' viewpoint on the provision of infertility services by the NHS, to discuss how patients see this provision as a form of rationing and to consider the ethical aspects of this situation. Most patients seeking treatment to enable them to conceive are treatable and therefore the term subfertility should be used rather than infertility. Fertility services such as the NHS do not ration contraception and obstetric care, so why should subfertility services be different? Access to treatment is entirely dependent on where a patient lives and this situation is totally unethical. The area of reproductive medicine in which this inequality is most apparent is assisted reproductive treatments such as in vitro fertilization. The situation in the UK varies widely and this variation will soon become more marked as the Scottish Office Department of Health has announced a national service framework for commissioners of subfertility services that will ensure equity for patients. What about the rest of the UK? There are some areas in England and Wales that are quite well funded, but there are still many health authorities that refuse to fund assisted conception techniques, and in Northern Ireland there is no funding for these treatments. The emotional aspects of subfertility must not be forgotten: patients experience depression, tearfulness, anger, grief and, most worrying of all, some experience suicidal feelings. The changes to the system in Scotland were mainly due to patients and professionals campaigning together, as a partnership. Their success should be an example to the rest of the UK.
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PMID:Rationing fertility services in the NHS: the patients' viewpoint. 1184 90

BACKGROUND: Ideally, the type and quantity of services received by young people with mental health problems would be determined by need alone. In reality, however, a number of factors will influence resource-use, and thus the total cost of care. AIMS OF THE STUDY: The aim of this study was to evaluate the impact of baseline patient and family characteristics on the total cost of caring for children and adolescents who have deliberately poisoned themselves. It was hypothesised that the cost of this patient group would be associated with severity of suicidality and other psychiatric characteristics, the existence of current problems and demographic and socio-economic characteristics. METHODS: Univariate and multivariate regression analyses were used to examine the associations between baseline characteristics and both total statutory service costs and total NHS costs in 149 young people aged 16 years and under, referred to child mental health teams with a diagnosis of deliberate self-poisoning. RESULTS: Baseline variables found to be significantly associated with relatively more expensive care packages included a definite intention to die, the existence of current problems, being in foster care, poorer parental well being and not having a diagnosis of conduct disorder. No significant relationships were found between cost and measures of illness severity, including suicidal ideation, hopelessness and severity of depression. DISCUSSION: Although costs are not influenced by clinical measures of severity, service provision does appear to respond to more 'practical' notions of severity, such as intent to die and the existence of current problems. Some high-risk sub-groups, such as those with a conduct disorder and those who have experienced episodes of local authority care or accommodation, appear to be slipping through the health services net, although this may be due more to the demand-side problem of non-compliance than to issues of supply. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The evidence presented suggests that health care providers are directing more services towards those who are more in need, where need is defined in a practical rather than a clinical sense. More targeting of certain high-risk sub-groups may be needed, however, particularly those who are traditionally poor attenders and prone to drop-out. IMPLICATIONS FOR HEALTH POLICY FORMULATION: Interventions for young people who have attempted suicide should be better targeted towards high-risk groups, such as those with a diagnosis of conduct disorder. In addition, prevention schemes that target high-risk groups before a suicide attempt is made should be encouraged. IMPLICATIONS FOR FURTHER RESEARCH: This study is limited by small sample sizes. Research that focuses directly on the care of young people at high-risk for repeat suicide attempts is needed, since the results presented here can be viewed only as exploratory and not explanatory.
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PMID:Factors that influence the Cost of Deliberate Self-poisoning in Children and Adolescents. 1196 71

The aims of this study were to describe a population of patients with cancer referred for complementary therapies to an NHS homeopathic hospital, and to explore the homeopathic approach to symptom control and its impact on mood disturbance and quality of life. One hundred consecutive patients attending a designated research cancer clinic were seen for a consultation, lasting up to 60 min, and prescription of a homeopathic remedy. A maximum of three symptoms were identified and rated by the patient as a problem, using a numerical self-rating scale. The effect these symptoms have on daily life and overall sense of well being were recorded using similar scales. Patients completed the Hospital Anxiety and Depression Scale (HADS) and the European Organization for Research and Treatment in Cancer--Quality of Life Questionnaire--Core 30 (EORTC QLQ-30) at the initial consultation and at four to six consultations later. After this time, the patients completed a final assessment questionnaire asking about satisfaction with the homeopathic approach, how helpful they had found the approach for the targeted symptoms and what factors they felt may have contributed to the changes perceived. One hundred patients were entered into the study. Thirty-nine patients had metastatic disease. Nine patients were refusing conventional cancer treatments. The most common symptoms were pain, fatigue and hot flushes. Symptom scores for fatigue and hot flushes improved significantly over the study period but not for pain scores. Side effects included a transient worsening of symptoms in a few cases, which settled on stopping the remedy. Fifty-two patients completed the study, and in those patients satisfaction was high, and 75% (n=38) rated the approach as helpful or very helpful for their symptoms. Results suggest that further research is warranted to explore the management of hot flushes in women with breast cancer and fatigue in the cancer diagnosis.
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PMID:The homeopathic approach to symptom control in the cancer patient: a prospective observational study. 1204 99

In response to many influences, palliative care services in the UK are evolving rapidly, and are increasingly challenged to demonstrate equity, access and effectiveness. This article discusses the principles, philosophy and status of palliative care in the UK in the context of recent NHS developments. A case study is employed in order to critically evaluate the implementation of the palliative care approach, focusing on the specific issue of the assessment of anxiety and depression in the cancer setting. The provision of a comprehensive and integrated clinical service is a constant challenge in this patient group. In order to increase awareness and facilitate further development of patient services, and ultimately improve clinical practice, several factors are highlighted. These include the impact of multiprofessional team care, the problems inherent in the diagnosis of depression and the question of whether cancer nurses are adequately prepared to handle patients' psychological morbidity.
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PMID:Palliative care provision and its impact on psychological morbidity in cancer patients. 1227 Dec 49

Measures of cognition are often used to define and measure the progress of dementia and outcomes of intervention. This paper examines whether measures of psychosocial disability used with those of cognition are more useful than measures of cognition alone, particularly in early dementia. A measure of cognition and two instruments of caregiver burden, used as routine clinical outcome measures of three types of Old Age Psychiatry dementia services, were examined. All cases with dementia in a memory clinic (MC; n = 149), a community mental health service for older people (CMHT; n = 120) and a specialist dementia day hospital (DH; n = 118), in one NHS district were followed up at 12 months. Measures of cognition (MMSE), behaviour, caregiver coping (Problem Checklist; PC) and caregiver mood (Hospital Anxiety and Depression Scale; HAD) were taken at baseline (MC, n = 48; CMHT, n = 113; DH, n = 55) and at follow-up (MC, n = 35; CMHT, n = 34; DH, n = 23). At baseline, all three groups had an average MMSE score of "mild impairment" but measures of behaviour and caregiver burden showed subtle between-group differences. At the 12-month follow-up, cognition remained stable in all groups, but the frequency of day-to-day problems increased and caregiver mood deteriorated in families receiving DH support. The use of psychosocial measures of disability in conjunction with those of cognition, are important in the definition and longitudinal measurement of intervention and support in early dementia.
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PMID:Defining "early dementia" and monitoring intervention: what measures are useful in family caregiving? 1260 61

A cluster of clinical cases of occupational mental illness has not previously been reported. A prospective cross-sectional study of patients referred for examination and advice about rehabilitation was undertaken to ascertain a variety of employer's rates of occupational mental illness. A background rate of referral for occupational mental illness of 3.1/1,000 employees per year was found apart from in one NHS trust where the rate was 25.6/1,000. Most patients were nurses and diagnoses were anxiety and/or depression with a median length of time off work of four months. There was no evidence that patients from this employer were vulnerable to mental illness. The high rate of occupational mental illness was associated with organisational change and a hostile working climate. This study shows that NHS trusts may be associated with unhealthy working practices. A cluster of occupational mental illness should be statutorily reportable to the Health and Safety Executive for further investigation.
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PMID:A cluster of occupational mental illness in an NHS trust. 1788 53

Age Concern says that the majority of older people who have depression go undiagnosed and untreated. Its Down, But Not Out campaign urges the government to make depression in old age a priority for the NHS.
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PMID:Lifting the gloom. 1905 78

This paper presents a summary of the evidence review group (ERG) report into the clinical and cost-effectiveness of rimonabant for the treatment of obese or overweight patients based upon a review of the manufacturer's submission to the National Centre for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The submission's main evidence came from four randomised controlled trials. Rimonabant resulted in a significantly greater benefit than placebo for all primary weight loss outcomes. At 1 year, rimonabant had a statistically significant beneficial effect on systolic blood pressure, high-density lipoprotein cholesterol, triglycerides and fasting plasma glucose in diabetics and non-diabetics, and glycosylated haemoglobin in diabetics. Improvements were maintained over 2 years with rimonabant; withdrawal of rimonabant at 1 year resulted in a reduction in weight loss until there was no difference from placebo at 2 years. Psychiatric adverse events were experienced by 26% and 14% of rimonabant and placebo patients respectively; figures for symptoms of depression were 9% and 5% respectively. Pairwise comparisons of orlistat, sibutramine and rimonabant showed beneficial effects of rimonabant over orlistat and sibutramine for weight loss outcomes; however, response hurdles imposed on orlistat or sibutramine in clinical practice may not have been applied in the orlistat and sibutramine trials. The manufacturer's Markov cohort model evaluated rimonabant versus orlistat, sibutramine and diet and exercise alone for three base-case populations. The incremental cost-effectiveness ratio (ICER) of rimonabant varied from 10,534 pounds to 13,236 pounds per quality-adjusted life-year (QALY) versus diet and exercise, to 8977 pounds to 12,138 pounds per QALY versus orlistat, to 1463 pounds to 3908 pounds per QALY versus sibutramine. In subgroup analysis there was a wider variation in the ICER estimates although none exceeded 20,000 pounds per QALY. The ICER of rimonabant remained under 20,000 pounds per QALY in reanalyses by the manufacturer and the ERG, with the results sensitive to the source of health-related quality of life (HRQoL) benefits in the model. Four treatment strategies were modelled in comparisons of rimonabant versus diet and exercise alone and orlistat and sibutramine in which rimonabant was continued only in patients achieving 5% weight loss at 3, 6, 9 or 12 months. In pairwise comparisons rimonabant remained below a threshold of 30,000 pounds per QALY in 70% of the comparisons reported. The results were most sensitive to the decrement applied to depression and the costs of screening for depression. In conclusion, areas of uncertainty remain in relation to the clinical effectiveness and cost-effectiveness of rimonabant, for example lack of evidence on long-term outcomes and the effect of rimonabant on cardiovascular events, developing diabetes and mortality, and lack of data on the HRQoL benefits associated with rimonabant. The lack of response hurdles applied to sibutramine and orlistat means that the comparator strategies were not considered by the ERG to reflect their respective product licenses or current NHS use. The NICE guidance issued as a result of the STA states that rimonabant is recommended as an adjunct to diet and exercise for adults who are obese or overweight and who have had an inadequate response to, are intolerant of or are contraindicated to orlistat and sibutramine.
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PMID:Rimonabant for the treatment of overweight and obese people. 1984 24

Ninety-three claims (total cost 4,915,450 pounds) filed under 'anaesthesia' in the NHS Litigation Authority database between 1995 and 2007, alleging patient harm directly by drug administration error or by an allergic reaction, were analysed. Alleged errors were categorised using systems employed by the National Coordinating Council for Medication Error Reporting and Prevention, the American Society of Anesthesiologists Closed Claims Project and the UK Health and Safety Executive. The severity of outcome in each claim was categorised using adapted National Patient Safety Agency definitions. Sixty-two claims involved alleged drug administration errors (total cost 4,283,677 pounds) and 15 resulted in severe harm or death. Half alleged the administration of the wrong drug, in most (16) a neuromuscular blocker. Of the claims alleging the wrong dose had been given (25), nine alleged opioid overdose including by neuraxial routes. The most frequently recorded adverse outcomes were awake paralysis (19 claims; total cost 182,347 pounds) and respiratory depression requiring intensive care treatment (13 claims; total cost 2,752,853 pounds). Thirty-one claims involved allergic reactions (total cost 631,773 pounds). In 20 claims, the patient allegedly received a drug to which they were known to be allergic (total cost 130,794 pounds). All claims in which it was possible to categorise the nature of the error involved human error. Fewer than half the claims appeared likely to have been preventable by an 'ideal double checking process'.
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PMID:Litigation related to drug errors in anaesthesia: an analysis of claims against the NHS in England 1995-2007. 1984 78


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