Norwich Community Hospital

A brief look at the definition of “threshold concepts” in an effort to provide clarity and direction to health professional education.

BackgroundChronic prostatitis otherwise known as chronic pelvic pain syndrome is a common urological diagnosis that causes many men significant morbidity and has a detrimental effect on their quality of life. Standard treatment with antibiotics and simple analgesia are often ineffective and many patients are managed by the chronic pain services.Cognitive behavioural therapy has been shown to be helpful in the management of many chronic diseases and has recently been proposed as an effective treatment for chronic prostatitis. Furthermore, a self management programme administered to groups of men with lower urinary tract symptoms has been shown to be more effective than standard treatments including surgery.Therefore, we have developed a cognitive behavioural therapy programme specifically for men with chronic prostatitis. This novel treatment approach will be compared to conventional therapy in the pain clinic such as atypical analgesia and local anaesthetic injections in the context of a randomised controlled trial.Methods/DesignMen will be recruited from general urology outpatient clinics following the exclusion of other diagnoses that could be responsible for their symptoms. Men will be randomised to attend either a self management healthcare and education programme or to pain clinic referral alone. The self management programme will be administered by a clinical psychologist to small groups of men over six consecutive weekly sessions each lasting two hours. Patients will be taught techniques of problem-solving and goal-setting and will learn coping mechanisms and how to modify catastrophic cognition.The primary outcome will be change from baseline in the National Institute of Health Chronic Prostatitis Symptom Index, a validated instrument for the assessment of men with chronic prostatitis. Secondary outcomes include generic quality of life scores and analgesic and drug usage. Outcomes will be assessed at 2, 6 and 12 months.DiscussionIf this group administered self management programme is shown to be effective in the treatment of men with chronic prostatitis it may become the new standard of care for these patients. Furthermore, it may be adapted for use in women with interstitial cystitis, a condition which is analogous to chronic prostatitis in men.Trial RegistrationCurrent Controlled Trials ISRCTN21012555

Critical Appraisal of Medical Literature. By D Marchevsky. (Pp 288; £55.25.) Kluwer Academic/Plenum Publishers, 2000. ISBN0-306-46474-8.\**\*|\* The aim of this book is to instruct the reader in the techniques of assessing medical literature and information. The first section explains the basic principles of studies and statistics including sections …

To determine the extent of unregistered blind and partial sight visual loss amongst primary open angle glaucoma (POAG) patients in an outpatient clinic. A 13 year follow-up study was carried out of all patients with POAG attending the outpatient clinics at the Leicester Royal Infirmary during the first 4 months of 1982. Ninety (35%) of 258 patients achieved eligibility for registration and 47 patients (18%) were registered, consisting of 39 who were eligible and 8 who were not. Fifty-seven per cent of eligible patients remained unregistered. Patients with visual loss due to visual acuity loss were much more likely to be registered than patients with either visual field loss (p < 0.001) or mixed visual acuity/visual field loss (p < 0.001). All categories of eligible patients experienced a delay between eligibility and registration. This delay was much longer for the visual field loss patients (median delay 61.8 months). Patients with untreatable disease were more likely to be registered. The rates of registration are improving. A large proportion of glaucoma patients who are eligible for registration as either blind or partially sighted remain unregistered. Those who are registered often experience prolonged delays before becoming registered.

To evaluate primary vitrectomy for the treatment of pseudophakic and aphakic retinal detachments. Primary vitrectomy may enable better identification of retinal breaks than scleral buckling procedures. A prospective study was performed of primary vitrectomy for the treatment of 25 consecutive cases of pseudophakic and aphakic retinal detachment. The primary retinal reattachment rate was 84% (21 eyes). Surgical failure resulted from new/missed retinal breaks (2 eyes) and proliferative vitreoretinopathy (2 eyes). The final retinal reattachment rate with further surgery was 96% (24 eyes). There were 7 macula-on detachments which all retained their presenting visual acuity. A visual acuity of 6/18 or better was achieved by 56% of the 18 macula-off detachments. Visualisation of the peripheral retina was impaired in 17 eyes and procedures to improve visualisation were performed in 7 eyes. Retinal breaks were detected in 16 eyes at surgery that had not been identified pre-operatively. Raised intraocular pressure was the most common complication, affecting 10 eyes in the early post-operative period. Primary vitrectomy offers certain advantages in the treatment of pseudophakic and aphakic retinal detachments. A controlled study is required to determine whether primary vitrectomy achieves a better outcome than scleral buckling procedures for these retinal detachments.

Three groups of patients were reviewed 1, 2 and 3 years after extracapsular cataract extraction to assess the incidence of problems related to nylon corneal sutures and the need for suture removal. A large percentage of patients were found to have suture-related problems and required or had previously undergone suture removal. These findings are analysed. The potential risk of sight-threatening pathology associated with corneal sutures that are left in situ suggests that routine suture removal about 3 months after surgery is to be recommended.