bluuebunny/crossref_metadata_2025_split huggingface dataset:
Trust relations in a changing health service
Authors: Calnan Michael , Rowe Rosemary 
Published: September 2008

Objective: Trust in health care is an important policy area although research has tended to focus on interpersonal trust between patient and practitioner and has neglected trust relations at the organizational and institutional levels. Each of these levels of trust may have been influenced by recent policy and organizational changes in the NHS as well as wider cultural changes. Our aim was to explore the relationship between patients, practitioners and managers to identify if there was any evidence of changes in trust relations. Method: A comparative case study design in two different clinical and organizational settings. Results: Trust is still important for effective therapeutic and working relationships but the nature of that trust and how it is lost and won appears to be affected by the organizational context in which health services are delivered. The increasing partnership between patients and clinicians in managing health problems and the greater interdependence of clinicians and managers in providing multidisciplinary shared care have changed how patients, clinicians and managers trust each other. For many informants trust can no longer be assumed, it is conditional and has to be earned. However, the sources of trust are the quality of the patient- clinician interaction, the competence and empathy that is displayed rather than informed trust based on abstract disembodied data. Likewise in inter-practitioner relationships and clinician-manager relations trust no longer appears to be primarily based on professional status and seniority, instead it appears to be conditional and may be earned through a variety of strategies that demonstrate honesty, reliability, competence, accessibility and an indication that colleagues share similar values and have a common agenda. Conclusion: Trust is still important for effective therapeutic and working relationships.
Reducing the burden of chronic wounds: Prevention and management of the diabetic foot in the context of clinical guidelines
Authors: Searle Aidan , Gale Lone , Campbell Rona , Wetherell Mark , Dawe Karen , Drake Nikki , Dayan Colin , Tarlton John , Miles Jeremy , Vedhara Kavita 
Published: September 2008

Objectives: Chronic wounds such as diabetic foot and venous leg ulcers are a major burden for health services. Our programme was developed to explore the psychological and behavioural factors that may influence both the incidence of chronic wounds and their progression. The present article focuses on two particular aspects of the programme: patient knowledge of diabetic foot ulceration and factors influencing foot-related behaviour in patients with and without foot ulcers; and patient and podiatrist perspectives of consultations for diabetic foot ulcers. Methods: Two independent qualitative studies were undertaken: one with diabetic patients without a history of ulceration; and the other with diabetic patients with active ulceration and podiatrists treating these patients. Results: We found that patients may find it difficult understanding the rationale underlying prevention and treatment of foot ulcers; ulcerated patients may find it difficult to engage in the management of their foot ulcer outside consultations; and some podiatrists feel frustrated and unsupported in their attempts at empowering and building partnerships with patients. Conclusion: Patient and practitioner factors may contribute to the effective implementation of clinical guidelines regarding education, partnership building and shared decision-making. These findings are discussed in relation to patient education, partnership building and shared decision-making as recommended in NICE guidelines.
Patient preferences for treatment for angina: An overview of findings from three studies
Authors: Bowling Ann , Reeves Barnaby , Rowe Gene 
Published: September 2008

Background: Access to cardiac treatments has been documented to vary with patients’ age. It is unknown whether these variations reflect patients’ treatment preferences. We aimed to investigate patients’ preferences for cardiology treatments and develop a Patients’ Preferences Questionnaire. Methods: Semi-structured interviews with primary care patients with diagnosed angina with postal follow-up. The resulting Patients’ Preferences Questionnaire was tested with newly admitted inpatients with acute coronary syndrome and with patients in primary care. Results: The Patients’ Preferences Questionnaire was psychometrically sound. Analyses of preference subscale scores showed that the most positive preference scores were for medication. Angioplasty scored highest at the negative end of the scale. Detailed analyses showed that older people and women were less likely to prefer coronary artery bypass surgery (CABG), reflecting its greater level of invasiveness. Older people (aged over 75 years, compared to people aged under 75 years), but not women, were also more cautious in their strength of preference for angioplasty. More positive attitudes towards CABG surgery, and more negative attitudes towards medication, were associated with greater impact of the condition on life. Conclusions: The research resulted in a psychometrically sound Patients’ Preferences Questionnaire. There was some evidence to support the view that older people's weaker preferences for CABG may contribute slightly to variations in the provision of re-vascularization. There was also variation in preferences within age groups, cautioning against the assumption that all or most older people are more reluctant than younger people to undergo invasive procedures.
Locomotor disability: Meaning, causes and effects of interventions
Authors: Ebrahim Shah , Adamson Joy , Ayis Salma , Beswick Andrew , Gooberman-Hill Rachael 
Published: September 2008

This paper provides a synopsis of a long-term programme of MRC-funded work on locomotor disability in older people. Specifically it describes the meaning and experience of disability, examines the risk factors for disability and systematically reviews the evidence from randomized trials of complex interventions for disability. We undertook a national prospective study of a representative sample of 999 people aged 65 years or more plus in-depth interviews with a small subsample and a selected sample obtained from hospital sources. Secondary analysis of several large prospective studies was carried out and a systematic review and meta-analysis of published randomized controlled trials of the effects of complex interventions for disability. Very few participants subscribed to the constructs of longstanding illness, disability or infirmity that surveys often use. A wide range of social and psychological factors, independently of chronic diseases, were strongly associated with disability. People with greater functional reserve capacity and those with greater self-efficacy were generally less likely to suffer from catastrophic decline in ability and had better quality of life in the face of disability. In reviewing 89 trials (over 97,000 participants) of complex interventions for disability, evidence of benefits was found although no relationship with intensity of intervention was apparent. Our findings on the meaning and experience of disability suggest the need for modifications to routinely used survey questions and for different ways of understanding the need for and receipt of care among older people with disabilities. The diverse risk factors for disability suggest that novel approaches across social, psychological as well as more traditional rehabilitation and behavioural risk factor modification would be worth exploring. Complex interventions appeared to help older people to live independently and limit functional decline irrespective of age and health status.
Measuring and valuing mental health for use in economic evaluation
Authors: Brazier John 
Published: September 2008

This article presents research undertaken as part of a wider programme of work concerned with measuring and health and wellbeing for economic evaluation. The focus is on developing quality adjusted life years (QALYs) in mental health, but the issues are common across all areas of health care. The article begins by reviewing the issues of what should be valued (health or broader notions of wellbeing), how mental health and wellbeing should be described, how mental health states should be valued and who should do the valuing. The article presents four pieces of work. The first is a re-analysis of the ONS Psychiatric Morbidity 2000 Survey to provide evidence on the relevance of generic measures across different mental health disorders. It found that common mental health problems, such as anxiety and depression, had a significant impact on the generic preference-based measure of health in the SF-6D, but psychosis and personality disorders did not. The article then presents two studies using the ratings of people experiencing the states of health. Both studies found that people experiencing different health states gave mental health greater weight than physical health compared to members of the general public trying to imagine the health states. Finally, the article presents a study developing a condition-specific preference-based measure for calculating QALYs from an existing measure of mental health, the CORE-OM, using modern psychometric methods to construct health states amenable to valuation. It also considers a proposal to develop an entirely new QALY measure in mental health.
MOBILE and the provision of total joint replacement
Authors: Dieppe Paul , Dixon Diane , Horwood Jeremy , Pollard Beth , Johnston Marie 
Published: September 2008

Modern joint replacements have been available for 45 years, but we still do not have clear indications for these interventions, and we do not know how to optimize the outcome for patients who agree to have them done. The MOBILE programme has been investigating these issues in relation to primary total hip and knee joint replacements, using mixed methods research. There have been five main strands: (1) Epidemiological investigations to find out who is receiving total hip and knee replacements in the National Health Service (NHS). This has shown that there are extensive variations in different regions of the UK, with inequalities and probable inequities in the provision of these operations; (2) Epidemiological work to ascertain the population-based needs for the operations, showing under-provision of knee joint replacements, and a relative reluctance of both patients and GPs to consider knee surgery; (3) Quantitative and qualitative research into the views of patients, health care professionals and the public on the indications for, and prioritization of, total hip and knee joint replacements. This has shown lack of agreement within or between professional groups, as well as a mismatch between the views of patients and the public, and those of professionals; (4) Theoretical and experimental work on patient-related outcome measures, and the development of new instruments to assess both pain and function in people with osteoarthritis, based on the International Classification of Function, as well as a new integrated model of function; (5) Cohort studies of patients undergoing hip or knee joint replacements to find out what the determinants of good and bad outcomes are. These studies have emphasized the huge variation in disease severity at the time of surgery. The challenge now is to use and implement our findings for maximum patient benefit.
Using qualitative research methods to improve recruitment to randomized controlled trials: The Quartet study
Authors: de Salis Isabel , Tomlin Zelda , Toerien Merran , Donovan Jenny 
Published: September 2008

Objective: Randomized controlled trials (RCTs) are considered the optimum method for evaluating health care interventions, yet many fail to recruit sufficient participants in a timely manner. The ProtecT (Prostate testing for cancer and Treatment) study employed qualitative research methods as part of a complex intervention to improve recruitment to the RCT. The Quartet (Qualitative research to improve recruitment to trials) study was set up to evalute whether the ProtecT study's success in increasing randomization rates could be replicated in other trials experiencing recruitment difficulties. This paper reports on the issues that emerged from the attempts to apply qualitative research methods to improve recruitment rates in RCTs collaborating with the Quartet team. Methods: The methods used were: investigation of RCT documents; semi-structured interviews and focus groups with RCT staff; audio-recording of recruitment appointments; and individual and group feedback sessions for RCT staff. Data were analysed using content and thematic analysis. Results: Barriers arose when we attempted to establish collaborations with RCTs. Difficulties were encountered in securing the commitment of all relevant staff because of poor communication between lead investigators and other staff as well as RCT staff's concerns about having recruitment appointments audio-recorded. Recruitment processes were often more complex than anticipated. Governance procedures took considerable time and resources, limiting the time available for data collection and implementation of the intervention before recruitment closure. Conclusion: Straightforward replication of the ProtecT complex intervention was more complicated than expected. However, the study has increased understanding of RCT recruitment and identified ways to overcome barriers to collaboration. Such research is more easily undertaken in the feasibility stage of an RCT, and greater success will be achieved if the research is integrated into the everyday conduct of RCTs.
Policy-makers’ attitudes to decision support models for coronary heart disease: A qualitative study
Authors: Taylor-Robinson David , Milton Beth , Lloyd-Williams Ffion , O'flaherty Martin , Capewell Simon 
Published: September 2008

Objectives: To explore attitudes to the use of models for coronary heart disease to support decision-making for policy and service planning. Methods: Qualitative study using semi-structured interviews with 33 policy- and decision-makers purposively sampled from the UK National Health Service (NHS) (national, regional and local levels), academia and voluntary organizations. Interviews were transcribed, coded and emergent themes identified using framework analysis aided by NVivo software. Results: Policy-makers and planners were generally enthusiastic about models to assist in decision-making through: predicting trends; assessing the effect of interventions on health inequalities; quantifying the impact of population level and targeted interventions, and facilitating economic evaluation. The perceived advantages of using models included: more rational commissioning; the facility for scenario testing; advocacy for population level interventions and off-the-shelf synthesis to aid real time decision-making. However, although participants were aware of models to support decision-making, these were not being used routinely. Some participants felt that models oversimplify complex situations and that there is a lack of shared understanding as to how models work. Factors that increase confidence in decision support models included: rigorous validation and peer review, the availability of user-support and increased transparency. Conclusion: Policy-makers and planners were generally enthusiastic about the use of models to support decision-making, illustrating the potential uses for models and the factors that improve confidence in them. However, existing models are often not being used in practice. So new models that are fit for practice need to be developed.
A practical approach to using spot urine protein/creatinine ratios for assessing proteinuria in pregnancy
Authors: Marnoch Catherine A , Larson Lucia , Weitzen Sherry , Phipps Maureen G , Sung C James , Powrie Raymond O 
Published: September 2008

Objective: The aim of this study is to assess the diagnostic accuracy of the spot urine protein/creatinine ratio compared with the 24-hour urine protein in pregnancy. Study Design: In this prospective cohort study of inpatient pregnant women, the protein/creatinine ratio and dipstick protein were assessed from a single urine sample collected at the start of the 24-hour urine. Both tests were compared with the 24-hour urine protein for correlation and test characteristics. Results: In the 196 specimens analysed, we found a strong correlation between the spot urine protein/creatinine ratio and 24-hour urine protein ( r2 = 0.78, P < 0.01). A protein/creatinine ratio <0.1 ruled out significant proteinuria (≥300 mg/day) with sensitivity and negative predictive value 100%. A protein/creatinine ratio ≥0.4 detected significant proteinuria (specificity and positive predictive value of 100%). A protein/creatinine ratio ≥4.6 had a specificity and positive predictive value of 100% for detecting severe proteinuria (≥5000 mg/day). Urine dipsticks correlated poorly with the 24-hour urine protein ( r2 = 0.40, P = 0.826). Nineteen percent of dipsticks reading nil or trace were false-negative results. Conclusion: The spot urine protein/creatinine ratio correlated well with the 24-hour urine protein and performed better than the urine dipsticks. Significant proteinuria in pregnancy was excluded if the protein/creatinine ratio was <0.1 and identified when it was ≥0.4.
Non-invasive detection of colorectal cancer – do we still need the guaiac-based fecal occult blood test?1
Authors: Stein Jürgen , Loitsch Stefan M. , Shastri Yogesh 
Published: September 2008

Abstract
Given the simplicity of the method and how it can be applied, as well as proof that it lowers the mortality rate, fecal occult blood testing (FOBT) is currently the most commonly used screening method for colorectal cancer (CRC). However, the test suffers from poor sensitivity, particularly with respect to detecting early stages, as well as low acceptance among the population. Preliminary data on detecting calprotectin and tumour-M2-PK in the stool indicated that a better screening performance could be expected. But these tests also suffer from low sensitivity in detecting early stages and from poor specificity, thus limiting the usefulness of the tests as a result of high follow-up costs. Recently developed immunological tests (I-FOBT) demonstrate significantly increased sensitivity and specificity. I-FOBTs use antibodies specific to human hemoglobin and are therefore not affected by diet and drugs, leading to improved patient partipication. At present, I-FOBTs seem to be the most cost-effective approach for non-invasive screening. The detection of tumour-DNA in the stool opens up a new era in early diagnosis of colorectal cancer. Small trials have pointed to a very high sensitivity of these methods: 62–91% for colorectal cancer and between 26% and 73% for adenomas, with a very high level of specificity (93–100%). The major drawback of this type of testing, compared with other screening tests available today, is its high cost.
Dendritic cells and immunosuppression after organ transplantation1
Authors: Daniel Volker 
Published: September 2008

Abstract
Dendritic cells (DC) start out on every immune reaction. They can initiate or suppress an immune response against antigen. Their diagnostic and therapeutic utilization is a research topic in transplantation medicine. One goal of studies in transplantation-immunology is the identification of transplanted patients, whose immunosuppressive treatment can be reduced or potentially discontinued without an impairment of graft function. The induction of tolerogenic DCs and their immunological monitoring in the patient blood would be an option for the realization of this goal. In experiments with cell cultures and animals, DCs were identified as target cells of immunosuppressive drugs. Clinical studies with transplant recipients showed alterations of DC subpopulations in the patient blood depending on the immunosuppressive drugs and their dosage. Up to now, no DC sub-population could be identified in the blood of transplant recipients that would allow prospectively a discontinuation of the immunosuppressive protocol. Further studies in vitro and in vivo are necessary to define the DC subsets that are relevant for the induction and maintenance of transplant tolerance.
Marriage as Prostitution in Berg's Lulu
Authors: dos Santos Silvio José 
Published: September 2008

Abstract
Writing to Schoenberg on August 7, 1930, Berg explained the differences between the libretto for his new opera and the original plays by Frank Wedekind, and in particular the return of Lulu's “victims” (her husbands) as her clients in the final scene of the opera. While Berg sought to create a large-scale symmetry with this return, he also posited a link between marriage and prostitution that did not exist in Wedekind's texts. Significantly, Berg was not alone in equating these two institutions; numerous Victorian writers had already made arguments in this regard. In fin-de-siècle Vienna this issue was widely debated and reflected some prevailing views of female sexuality, including those expressed in the influential works of Otto Weininger and Karl Kraus. Indeed, as is well documented, Berg was keenly engaged in these issues.
The association of marriage with prostitution was a crucial element in Berg's conception of the opera. Evidence found in the autograph manuscripts and the finished work confirms that Berg represented these institutions as essentially the same at several levels of the work. This is revealed in his musical portrayal of Lulu, the Prince, the Man servant, and the Marquis, as well as in such musical choices as his borrowing of Wagner's wedding march from Lohengrin and his use of Wedekind's Konfession, a song about prostitution. Indeed, the representation of the two institutions is directly linked to the opera's musical language, particularly the transition from tonal to twelve-tone structures in the final act. Most importantly, this representation reflects Berg's construction of identities for the main characters in the opera and, by extension, the sociocultural issues portrayed in this seminal work.