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Biomedical subjects

I C Grant

Publications and source records attributed to I C Grant.

11 recordsLinked to original sources
PubMed2003

Communication with general practitioners after accident and emergency attendance: computer generated letters are often deficient.

OBJECTIVES: Accident and emergency departments see large numbers of patients, and computerised administration systems are a useful tool for producing discharge communication. The purpose of this study was to determine the quality of such correspondence. METHODS: Retrospective review of 300 discharge letters and case notes. RESULTS: 29% of all computer generated discharge information was incomplete or misleading. Twenty five per cent of all correspondence was lacking or unacceptable overall. The principal reasons for substandard correspondence were inaccurate coding of diagnoses and procedures, and failure to include specific information relevant to patients' follow up. CONCLUSIONS: Computer generated discharge communication is often deficient. Staff using such systems should be made aware of the importance of accurate coding, and use added explanatory text to clarify diagnoses, management, and follow up as required.

Continuity of Patient Care↗
PubMed2000

Surgery for lumbar disc prolapse.

OBJECTIVES: The primary rationale for surgery for disc prolapse is to relieve nerve root irritation or compression due to herniated disc material. Claims of the merits of alternative surgical procedures are made without clear evidence about clinical outcomes. The objective of this review was to assess the effects of surgical interventions for the treatment of lumbar disc prolapse. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register, Medline, Embase, Biosis, Dissertation Abstracts, Index to UK Thesis, and reference lists of the retrieved articles up to March 1997 and we corresponded with experts. SELECTION CRITERIA: Randomised and quasi-randomised trials of the surgical management of lumbar disc prolapse. DATA COLLECTION AND ANALYSIS: Two reviewers assessed trial quality and extracted data from published papers. Additional information was sought from the authors if necessary. MAIN RESULTS: Twenty-seven trials were found. There were methodological weaknesses in many of the trials. Sixteen of the 27 trials were of some form of chemonucleolysis. Ten trials compared different surgical techniques, although only one of these compared surgical discectomy with conservative management. Surgical discectomy produced better clinical outcomes than chemonucleolysis with chymopapain, and chemonucleolysis produced better clinical outcomes than placebo. Three trials showed no difference in clinical outcomes between microdiscectomy and standard discectomy. Three trials failed to show a significant reduction in scar formation or improved clinical outcomes by inserting an inter-position membra ne to cover the spinal dura after discectomy. Three trials of percutaneous discectomy provided moderate evidence that it produces poorer clinical outcomes than standard discectomy or chymopapain. We found no published randomised trials of laser discectomy. REVIEWER'S CONCLUSIONS: Chemonucleolysis is more effective than placebo and it is less invasive but less effective than surgical disectomy. Surgical discectomy for carefully selected patients with sciatica due to lumbar disc prolapse provides faster relief from the acute attack than conservative management, although any positive or negative effects on the lifetime natural history of the underlying disc disease are unclear.

Diskectomy↗
PubMed2000

Surgery for degenerative lumbar spondylosis.

BACKGROUND: This section is under preparation and will be included in the next issue OBJECTIVES: Degenerative conditions affecting the lumbar spine are variously described as lumbar spondylosis or degenerative disc disease (which we regarded as one entity) and are associated with back pain, instability, spinal stenosis and degenerative spondylolisthesis. The objective of this review was to assess the effects of surgical interventions for the treatment of degenerative lumbar spondylosis. SEARCH STRATEGY: We searched the Cochrane Controlled Trials Register, Medline, Embase, Biosis, Dissertation Abstracts, Index to UK Thesis, and reference lists of the retrieved articles and we corresponded with experts. SELECTION CRITERIA: Randomised or quasi-randomised trials of surgical treatment of lumbar spondylosis DATA COLLECTION AND ANALYSIS: Two reviewers assessed trial quality and extracted data from published papers. Additional information was sought from the authors if necessary. MAIN RESULTS: Fourteen published trials of all forms of surgical treatment for degenerative lumbar spondylosis were identified. There were many serious weaknesses of trial design, including poor methods of randomisation, lack of blinding and lack of independent assessment of outcome which at times gave considerable potential for bias. Most of the published results were reporting on technical surgical outcomes with some crude ratings of clinical outcome, but few patient-centred outcomes of pain, disability or capacity for work. There was a particular lack of long-term outcomes. This review found no published trials comparing any form of surgery for degenerative lumbar spondylosis compared with natural history, placebo, or any form of conservative treatment. Nine trials randomly compared instrumented and non-instrumented fusion. Instrumented fusion produced a higher fusion rate (though that needs to be qualified by the difficulty of assessing fusion in the presence of metal-work) but did not improve clinical outcomes and there is evidence that it may be associated with higher complication rates. The few and heterogeneous trials on spondylolisthesis, spinal stenosis and nerve compression permitted very limited conclusions. REVIEWER'S CONCLUSIONS: There is no scientific evidence about the effectiveness of any form of surgical decompression or fusion for degenerative lumbar spondylosis compared with natural history, placebo, or conservative treatment.

Decompression, Surgical↗
PubMed1999

The Cochrane review of surgery for lumbar disc prolapse and degenerative lumbar spondylosis.

STUDY DESIGN: A Cochrane review of randomized controlled trials. OBJECTIVES: To collate the scientific evidence on surgical management for lumbar-disc prolapse and degenerative lumbar spondylosis. SUMMARY OF BACKGROUND DATA: Surgical investigations and interventions account for as much as one third of the health care costs for spinal disorders, but the scientific evidence for most procedures still is unclear. METHODS: A highly sensitive search strategy identified all published randomized controlled trials. Cochrane methodology was used for meta-analysis of the results. RESULTS: Twenty-six randomized controlled trials of surgery for lumbar disc prolapse and 14 trials of surgery for degenerative lumbar spondylosis were identified. Methodologic weaknesses were found in many of the trials. Only one trial directly compared discectomy and conservative management. Meta-analyses showed that surgical discectomy produces better clinical outcomes than chemonucleolysis, which is better than placebo. Three trials showed no difference in clinical outcomes between microdiscectomy and standard discectomy, but in three other studies, both produced better results than percutaneous discectomy. Three trials showed that inserting an interposition membrane after discectomy does not significantly reduce scar formation or alter clinical outcomes. Five heterogeneous trials on spinal stenosis and degenerative spondylolisthesis permit very limited conclusions. There were nine trials of instrumented versus noninstrumented fusion: Meta-analysis showed that instrumentation may facilitate fusion but does not improve clinical outcomes. CONCLUSIONS: There is now strong evidence on the relative effectiveness of surgical discectomy versus chemonucleolysis versus placebo. There is considerable evidence on the clinical effectiveness of discectomy for carefully selected patients with sciatica caused by lumbar disc prolapse that fails to resolve with conservative management. There is no scientific evidence on the effectiveness of any form of surgical decompression or fusion for degenerative lumbar spondylosis compared with natural history, placebo, or conservative management. The Cochrane reviews will be updated continuously as other trials become available.

Databases, Factual↗
PubMed1994

Patients who attend two accident and emergency departments.

Forty-six patients were identified who attended an accident and emergency (A&E) department having previously attended a different A&E department in the same city for the same problem. Of these patients, 20% had been referred to the second department by the general practitioner (GP) or practice nurse. A diagnostic error had been made in 17.5% of patients at their first visit and some management errors were discovered. Eleven per cent of patients had an unnecessary second set of radiographs taken. A review of unplanned reattenders to an A&E department is an important opportunity for audit and normally an error will not be discovered if a patient attends a different department. We recommend that in cities where there is more than one A&E department a system should be set up whereby if a patient attends one department having previously attended another, the first department should be informed of the patients reattendance, especially if any diagnostic or management error has been discovered. Patients should be educated that if they have sought medical help for any problem and the condition does not improve, then they should return to see the same doctor or A&E department for continuity of care and avoidance of unnecessary duplication of investigations including exposure to X-rays.

Diagnostic Errors↗