Patients' views on the causes of their polymyalgia rheumatica: a content analysis of data from the PMR Cohort Study

OBJECTIVE: To explore primary care polymyalgia rheumatica (PMR) patient beliefs about the causes of their PMR. DESIGN: Qualitative content analysis was conducted on patients' written responses to the question of what they thought had caused their PMR. All data were coded and emergent categories of causal beliefs identified. SETTING: Community patients receiving primary care at general practitioner (GP) practices across England. PARTICIPANTS: Participants were recruited from a primary care PMR inception cohort (n=654). Between June 2012 and June 2014 GPs referred 739 people with a new PMR diagnosis in the past 3 years into the study. Patients were mailed a baseline self-completion questionnaire, which included the question, 'What do you think caused your PMR?'. Responses to this question form the data set for the present study. RESULTS: 296 (45%) patients gave a possible cause for their PMR, while 276 (42%) respondents wrote 'no idea'. Common attributions include ageing (45, 18%), medication (18, 5%) and personal stress (53, 14%). 24 respondents (6%) thought their PMR was as a result of another medical condition. CONCLUSIONS: This is the first study to examine causation beliefs in PMR, identifying a number of possible causes such as ageing, stress and as a complication of other medical problems. Understanding these patient beliefs may impact on treatment adherence and patient outcome

Properties of Galaxies in and around Voids

Two surveys for intrinsically faint galaxies towards nearby voids have been conducted at the MPI f\"ur Astronomie, Heidelberg. One selected targets from a new diameter limited ($\Phi \ge 5''$) catalog with morphological criteria while the other used digitized objective prism Schmidt plates to select mainly HII dwarf galaxies. For some 450 galaxies, redshifts and other optical data were obtained. We studied the spatial distribution of the sample objects, their luminosity function, and their intrinsic properties. Most of the galaxies belong to already well known sheets and filaments. But we found about a dozen highly isolated galaxies in each sample (nearest neighborhood distance $\ge 3 h_{75}^{-1} Mpc$). These tend to populate additional structures and are not distributed homogeneously throughout the voids. As our results on 'void galaxies' still suffer from small sample statistics, I also tried to combine similar existing surveys of nearby voids to get further hints on the larger structure and on the luminosity function of the isolated galaxies. No differences in the luminosity function of sheet and void galaxies could be found. The optical and infrared properties of both samples are in the normal range for samples dominated by late-type dwarfs. Follow-up HI studies show that the isolated dwarfs in both samples have unusual high amount of neutral gas for a given luminosity.Comment: 10 pages, 4 figures, latex, to appear in the proceedings of the 'Ringberg workshop on Large Scale Structure', hold Sep. 23-28, 199

A qualitative study of primary care clinicians' views of treating childhood obesity

Background: The prevalence of childhood obesity is rising and the UK Government have stated a commitment to addressing obesity in general. One method has been to include indicators relating to obesity within the GP pay-for-performance Quality and Outcomes Framework (QOF) contract. This study aimed to explore general practitioners' and practice nurses' views in relation to their role in treating childhood obesity. Methods: We interviewed eighteen practitioners (twelve GPs and six nurses) who worked in general practices contracting with Rotherham Primary Care Trust. Interviews were face to face and semi structured. The transcribed data were analysed using framework analysis. Results: GPs and practice nurses felt that their role was to raise the issue of a child's weight, but that ultimately obesity was a social and family problem. Time constraint, lack of training and lack of resources were identified as important barriers to addressing childhood obesity. There was concern that the clinician-patient relationship could be adversely affected by discussing what was often seen as a sensitive topic. GPs and practice nurses felt ill-equipped to tackle childhood obesity given the lack of evidence for effective interventions, and were sceptical that providing diet and exercise advice would have any impact upon a child's weight. Conclusion: GPs and practice nurses felt that their role in obesity management was centred upon raising the issue of a child's weight, and providing basic diet and exercise advice. Clinicians may find it difficult to make a significant impact on childhood obesity while the evidence base for effective management remains poor. Until the lack of effective interventions is addressed, implementing additional targets (for example through the QOF) may not be effective

Keele Aches and Pains Study Protocol: validity, acceptability and feasibility of the Keele STarT MSK Tool for subgrouping musculoskeletal patients in primary care

Musculoskeletal conditions represent a considerable burden worldwide, and are predominantly managed in primary care. Evidence suggests that many musculoskeletal conditions share similar prognostic factors. Systematically assessing patient’s prognosis, and matching treatments based on prognostic subgroups (stratified care), has been shown to be clinically and cost effective. This study (Keele Aches and Pains Study: KAPS) aims to refine and examine the validity of a brief questionnaire (Keele STarT MSK Tool), designed to enable risk-stratification of primary care patients with the five most common musculoskeletal pain presentations. We will also describe the subgroups of patients, and explore the acceptability and feasibility of using the tool, and how the tool is best implemented in clinical practice. The study design is mixed methods: a prospective, quantitative observational cohort study with a linked qualitative focus group and interview study. Patients who have consulted their General Practitioner or Healthcare Practitioner (GP/HCP) about a relevant musculoskeletal condition will be recruited from General practice. Participating patients will complete a baseline questionnaire (shortly after consultation), plus questionnaires 2 and 6 months later. A sub-sample of patients, along with participating GPs and HCPs, will be invited to take part in qualitative focus groups and interviews. The Keele STarT MSK Tool will be refined based on face, discriminant, construct and predictive validity at baseline and 2 months, and validated using data from 6 month follow-up. Patient and clinician perspectives about using the tool will be explored. This study will provide a validated prognostic tool (the Keele STarT MSK Tool) with established cut-points to stratify patients with the five most common musculoskeletal presentations into low, medium and high risk subgroups. The qualitative analysis of patient and healthcare perspectives will inform how to embed the tool into clinical practice using established general practice IT systems and clinician support packages

Magnetic resonance imaging protocols for paediatric neuroradiology

Increasingly, radiologists are encouraged to have protocols for all imaging studies and to include imaging guidelines in care pathways set up by the referring clinicians. This is particularly advantageous in MRI where magnet time is limited and a radiologist’s review of each patient’s images often results in additional sequences and longer scanning times without the advantage of improvement in diagnostic ability. The difficulties of imaging small children and the challenges presented to the radiologist as the brain develops are discussed. We present our protocols for imaging the brain and spine of children based on 20 years experience of paediatric neurological MRI. The protocols are adapted to suit children under the age of 2 years, small body parts and paediatric clinical scenarios

Stratified primary care versus non-stratified care for musculoskeletal pain: findings from the STarT MSK feasibility and pilot cluster randomized controlled trial

Background: Musculoskeletal (MSK) pain from the five most common presentations to primary care (back, neck, shoulder, knee or multi-site pain), where the majority of patients are managed, is a costly global health challenge. At present, first-line decisionmaking is based on clinical reasoning and stratified models of care have only been tested in patients with low back pain. We therefore, examined the feasibility of; a) a future definitive cluster randomised controlled trial (RCT), and b) General Practitioners (GPs) providing stratified care at the point-of-consultation for these five most common MSK pain presentations. Methods: The design was a pragmatic pilot, two parallel-arm (stratified versus nonstratified care), cluster RCT and the setting was 8 UK GP practices (4 intervention, 4 control) with randomisation (stratified by practice size) and blinding of trial statistician and outcome data-collectors. Participants were adult consulters with MSK pain without indicators of serious pathologies, urgent medical needs, or vulnerabilities. Potential participant records were tagged and individuals sent postal invitations using a GP point-of-consultation electronic medical record (EMR) template. The intervention was supported by the EMR template housing the Keele STarT MSK Tool (to stratify into low, medium and high-risk prognostic subgroups of persistent pain and disability) and recommended matched treatment options. Feasibility outcomes included exploration of recruitment and follow-up rates, selection bias, and GP intervention fidelity. To capture recommended outcomes including pain and function, participants completed an initial questionnaire, brief monthly questionnaire (postal or SMS), and 6-month follow-up questionnaire. An anonymised EMR audit described GP decision-making. Results: GPs screened 3063 patients (intervention=1591, control=1472), completed the EMR template with 1237 eligible patients (intervention=513, control=724) and 524 participants (42%) consented to data collection (intervention=231, control=293). Recruitment took 28 weeks (target 12 weeks) with >90% follow-up retention (target >75%). We detected no selection bias of concern and no harms identified. GP stratification tool fidelity failed to achieve a-priori success criteria, whilst fidelity to the matched treatments achieved “complete success”. Conclusions: A future definitive cluster RCT of stratified care for MSK pain is feasible and is underway, following key amendments including a clinician-completed version of the stratification tool and refinements to recommended matched treatments

Stratified care versus usual care for management of patients presenting with sciatica in primary care (SCOPiC): a randomised controlled trial

Background Sciatica has a substantial impact on individuals and society. Stratified care has been shown to lead to better outcomes among patients with non-specific low back pain, but it has not been tested for sciatica. We aimed to investigate the clinical and cost-effectiveness of stratified care versus non-stratified usual care for patients presenting with sciatica in primary care. Methods We did a two-parallel arm, pragmatic, randomised controlled trial across three centres in the UK (North Staffordshire, North Shropshire/Wales, and Cheshire). Eligible patients were aged 18 years or older, had a clinical diagnosis of sciatica, access to a mobile phone or landline number, were not pregnant, were not currently receiving treatment for the same problem, and had no previous spinal surgery. Patients were recruited from general practices and randomly assigned (1:1) by a remote web-based service to stratified care or usual care, stratified by centre and stratification group allocation. In the stratified care arm, a combination of prognostic and clinical criteria associated with referral to spinal specialist services were used to allocate patients to one of three groups for matched care pathways. Group 1 was offered brief advice and support in up to two physiotherapy sessions; group 2 was offered up to six physiotherapy sessions; and group 3 was fast-tracked to MRI and spinal specialist assessment within 4 weeks of randomisation. The primary outcome was self-reported time to first resolution of sciatica symptoms, defined as “completely recovered” or “much better” on a 6-point ordinal scale, collected via text messages or telephone calls. Analyses were by intention to treat. Health-care costs and cost-effectiveness were also assessed. This trial is registered on the ISRCTN registry, ISRCTN75449581. Findings Between May 28, 2015, and July 18, 2017, 476 patients from 42 general practices around three UK centres were randomly assigned to stratified care or usual care (238 in each arm). For the primary outcome, the overall response rate was 89% (9467 of 10 601 text messages sent; 4688 [88%] of 5310 in the stratified care arm and 4779 [90%] of 5291 in the usual care arm). Median time to symptom resolution was 10 weeks (95% CI 6·4–13·6) in the stratified care arm and 12 weeks (9·4–14·6) in the usual care arm, with the survival analysis showing no significant difference between the arms (hazard ratio 1·14 [95% CI 0·89–1·46]). Stratified care was not cost-effective compared to usual care. Interpretation The stratified care model for patients with sciatica consulting in primary care was not better than usual care for either clinical or health economic outcomes. These results do not support a transition to this stratified care model for patients with sciatica