"Abnormal" illness behaviour in chronic fatigue syndrome and multiple sclerosis
Peter Trigwell, Simon Hatcher, Michael Johnson, Philip Stanley, Allan House
Abstract
Objective - To investigate the presence of abnormal illness behaviour in patients with a diagnosis of chronic fatigue syndrome.
Design - A cross sectional descriptive study using the illness behaviour questionnaire to compare illness behaviour scores and illness behaviour profiles of patients with chronic fatigue syndrome and patients with multiple sclerosis.
Setting - A multidisciplinary fatigue clinic and a teaching hospital neurology outpatient clinic.
Subjects - 98 patients satisfying the Oxford criteria for chronic fatigue syndrome and 78 patients with a diagnosis of multiple sclerosis.
Main outcome measure - Responses to the 62 item illness behaviour questionnaire.
Results - 90 (92%) patients in the chronic fatigue syndrome group and 70 (90%) in the multiple sclerosis group completed the illness behaviour questionnaire. Both groups had significantly high scores on the general hypochondriasis and disease conviction subscales and significantly low scores on the psychological versus somatic concern subscale, as measured in relation to normative data. There were, however, no significant differences in the subscale scores between the two groups and the two groups had identical illness behaviour profiles.
Conclusion - Scores on the illness behaviour questionnaire cannot be taken as evidence that chronic fatigue syndrome is a variety of abnormal illness behaviour, because the same profile occurs in multiple sclerosis. Neither can they be taken as evidence that chronic fatigue and multiple sclerosis share an aetiology. More needs to be known about the origins of illness beliefs in chronic fatigue syndrome, especially as they are important in determining outcome.
High Royds Hospital Menston Leeds LS29 6AQ Peter Trigwell senior registrar in psychiatryUniversity of Leeds Leeds LS2 9LT Simon Hatcher lecturer in psychiatry
St James's University Hospital Leeds LS9 7TF Michael Johnson consultant neurologist
Seacroft Hospital Leeds LS14 6UH Philip Stanley consultant in infectious diseases
The General Infirmary at Leeds Leeds LSI 3EX Allan House consultant in liaison psychiatry
Correspondence to: Dr Trigwell.
Stroke patients' views on their admission to hospital
Pandora Pound, Michael Bury, Patrick Gompertz, Shah Ebrahim
Abstract
Objective - To explore which components of care were valued by patients admitted to hospital following a stroke.
Design - Qualitative study using in depth interviews 10 months after the stroke.
Setting - Two adjacent districts in North Thames Regional Health Authority.
Subjects - 82 survivors of stroke taken consecutively from a stroke register, 40 of whom agreed to be interviewed.
Results - Patients reported that during the acute stage of the stroke they wanted to put their faith in experienced and trusted experts who would help them make sense of the event, take all the actions necessary to ensure survival, and provide comfort and human warmth during the crisis. In addition to being reassured by the clinical tests and practical nursing help they received, patients valued feeling cared about by the staff. In most cases patients reported that their needs were met; however, the institutional nature of the hospital sometimes obstructed the fulfilment of their needs.
Conclusion - Patients have important psychosocial needs during the acute stage of the stroke, which are often met by hospital admission. Patients gained benefits from their admission over and above those measurable in terms of morbidity or function. They used a combination of criteria to evaluate their care, focusing on the process as well as the outcome of care. Researchers and clinicians should do likewise.
Department of Public Health Royal Free Hospital School of Medicine London NW3 2PF Pandora Pound research sociologist Patrick Gompertz research fellow Shah Ebrahim professor of clinical epidemiologyDepartment of Social Policy and Social Science Royal Holloway College, University of London Egham Hill Surrey TW20 0EX Michael Bury professor of sociology
Correspondence to: Ms Pound.
J M M Evans, A D McMahon, M M McGilchrist, G White, F E Murray, D G McDevitt, T M MacDonald
Abstract
Objective - To evaluate the relation between topically applied non-steroidal anti-inflammatory drugs and upper gastrointestinal bleeding and perforation.
Design - A case-control study with 1103 patients admitted to hospital for upper gastrointestinal bleeding or perforation between January 1990 and December 1992 (cases). Two different control groups were used, with six community controls and with two hospital controls for each case. Previous exposure to topical and oral non-steroidal anti-inflammatory drugs and ulcer healing drugs was assessed.
Study population - The population of 319465 people who were resident in Tayside and were registered with a Tayside general practitioner between January 1989 and October 1994. A record linkage database containing all data on hospital events and dispensed drugs between 1989 and 1992 was used for this population.
Main outcome measures - Unadjusted and adjusted odds ratios of exposure in those admitted to hospital compared with controls.
Results - Significant unadjusted associations were detected between all three classes of drug and upper gastrointestinal complications. The significant association detected for topical non-steroidal anti-inflammatory drugs was no longer evident in analyses which adjusted for the confounding effect of concomitant exposure to oral anti-inflammatories and ulcer healing drugs (odds ratio= 1.45; 95% confidence interval 0.84 to 2.50 with community controls; 1.06; 0.60 to 1.88 with hospital controls).
Conclusion - In this study topical non-steroidal anti-inflammatory drugs were not significantly associated with upper gastrointestinal bleeding ant perforation after adjustment for the confounding effects of concomitant use of oral anti-inflammatories and ulcer healing drugs.
Medicines Monitoring Unit Department of Clinical Pharmacology Ninewells Hospital and Medical School Dundee DDI 9SY J M M Evans research assistant A D McMahon statistician M M McGilchrist senior computer programmer G White senior computer programmer F E Murray consultant physician D G McDevitt professor of clinical pharmacology T M MacDonald senior lecturer
Correspondence to: Dr MacDonald.
Robin C Fraser, Azhar Farooqi, Roz Sorrie
Abstract
Objectives - To encourage active participation of Leicestershire general practitioners and their staff in audit; to examine the use of vitamin B-12 injections and to achieve a more appropriate use.
Design - lmplementation of an agreed audit protocol, with central analysis and feedback of anonymous and aggregated data by a medical audit advisory group.
Setting - All 147 Leicestershire practices.
Main outcome measures - Participation in the complete audit cycle, comparison of actual use of vitamin B-12 injections with agreed criteria of use, and assessment of improvement in use.
Results - 264 general practitioners (55% of all doctors from 49% of all Leicestershire practices) completed both phases of the audit cycle, and 321 (67%) completed phase 1 only. Twenty four (16%) practices failed to participate from the outset, and a further 58 (35%) dropped out at various stages. Only 10 of the 37 singlehanded practices completed the audit, although 34 initially agreed to participate. If singlehanded practices were excluded, 56% (61) of practices completed both phases of the audit cycle. In total 1714 patients received B-12 injections. Appropriate use increased from 62% in phase 1 to 72% in phase 2 of the audit; there was a 32% reduction in the number of patients inappropriately receiving B-12 (521 to 352), and the proportion of patient~ receiving B-12 at the correct frequency rose from 58% to 72%. The proportion of patients in whom all the diagnostic criteria for pernicious anaemia were established before treatment with B-12 was 27% in phase 1 and 28% in phase 2.
Conclusion - Our study suggests that single topic audits organised by a medical audit advisory group can encourage large numbers of general practitioners to participate and can bring about changes in behaviour resulting in improvements in standards of care. Nevertheless, advisory groups will need to devise strategies to encourage even higher levels of involvement, most particularly from singlehanded practices.
Leicestershire Medical Audit Advisory Group Department of General Practice University of Leicester Leicester General Hospital Leicester LE5 4PW Robin C Fraser professor of general practice Azhar Farooqi senior clinical research fellow Roz Sorrie senior medical audit liaison officer
Correspondence to: Professor Fraser
Richard Baker, Noelle Robertson, Azhar Farooqi
Abstract
Objective - To identify the factors influencing participation in a single topic audit initiated by a medical audit advisory group.
Design - Interview and questionnaire survey of general practitioners who had been invited to take part in an audit of vitamin B-12.
Setting - All 147 general practices in Leicestershire.
Main outcome measures - Aspects of structure, attitude, ant behaviour that influenced participation or non-participation.
Results - 75 practices completed the audit, 49 withdrew after initial agreement, and 23 refused to take part at the outset. Participants were more likely than those who refused to view the advisory group as useful or a threat and to have positive thoughts about audit but less likely to have previously undertaken audit entailing implementation of change. Participants were more likely than those who withdrew to have positive thoughts about audit and to have discussed whether to take part within the practice but were less likely to view the advisory group as useful. The most common reason given for withdrawal was lack of time.
Conclusions - Participation was influenced by attitudes towards audit in general and the advisory group in particular and by aspects of behaviour such as communication within the practice. Practical support and resources may help some practices undertake audit, but advisory groups must also deal with attitudes and unsatisfactory communication in practice teams.
Eli Lilly National Clinical Audit Centre Department of General Practice University of Leicester Leicester General Hospital Leicester LE5 4PW Richard Baker director Noelle Robertson lecturerDepartment of General Practice University of Leicester Leicester Azhar Farooqi senior clinical research fellow
Correspondence to: Dr Baker.
When is it futile for ambulance personnel to initiate cardiopulmonary resuscitation?
Andrew K Marsden, G Andre Ng, Kirsty Dalziel, Stuart M Cobbe
Abstract
Objective - To determine whether patients with unexpected prehospital cardiac arrest could be identified in whom ambulance resuscitation attempts would be futile.
Design - Review of ambulance and hospital records; detailed review of automated external defibrillator rhythm strips of patients in whom no shock was advised.
Setting - Scottish Ambulance Service; all cardiopulmonary resuscitation attempts after cardiorespiratory arrest during 1988-94 included in the Heartstart Scotland database.
Subjects - 414 cardiorespiratory arrest patients with no pulse or breathing on arrival of ambulance personnel, no bystander cardiopulmonary resuscitation performed, and more than 15 minutes from time of arrest to arrival of ambulance. Patients were stratified into those with "shockable" and "non shockable" rhythms.
Main outcome measures - Return of spontaneous circulation, or survival to reach hospital alive, or survival to discharge, or all three.
Results - No patient with a non-shockable rhythm who met the entry criteria for analysis survived a resuscitation attempt. Review of the defibrillator rhythm strips of these patients failed to find any case in which the tracing was deemed compatible with survival.
Conclusions - On the basis that it would be inappropriate to initiate vigorous resuscitation in patients who can be identified as "dead" and beyond help an algorithm was prepared to guide ambulance personnel.
Scottish Ambulance Service National Headquarters Edinburgh EHIO 5UU Andrew K Marsden consultant medical directorDepartment of Medical Cardiology Royal Infirmary Glasgow G4 OSF G Andre Ng research fellow in cardiology Kirsty Dalziel research statistician Stuart M Cobbe professor of medical cardiology
Correspondence to. Mr Marsden.