Qualitative methods are increasingly recognized as valuable, yet practitioners face difficult decisions in their choice of method and the process of analysis. The nominal group technique combines quantitative and qualitative data collection in a group setting, and avoids problems of group dynamics associated with other group methods such as brainstorming, Delphi and focus groups. Idea generation and problem solving are combined in a structured group process, which encourages and enhances the participation of group members. The stages involved in conducting a nominal group are described, and practical problems of its use in a health care setting are discussed with reference to a study of the priorities of care of diabetic patients, carers and health professionals. Some potential applications of the technique in audit and exploratory research are also outlined.
Background: Many patients with familial adenomatous polyposis (FAP) die from desmoid tumours which can arise spontaneously but often appear to be surgically induced by prophylactic colectomy. FAP results from germline adenomatous polyposis coli (APC) gene mutations and desmoids arise following biallelic APC mutation, with one change usually occurring distal to the second b-catenin binding/degradation repeat of the gene (39 to codon 1399). We have suggested that because families with germline mutations in this region already have the requisite change, they are more likely to develop desmoids. However, there are families with 59 germline mutations where desmoids are common. Patients and methods: We examined desmoid risk dependent on germline APC mutation, sex, history of abdominal surgery, and family history in FAP patients from the St Mark's Hospital Polyposis Registry. Results: Overall desmoid prevalence was 15%. Desmoids tended to cluster in susceptible individuals, irrespective of the germline APC mutation. Independent predictors of increased desmoid risk were: germline mutation distal to codon 1399; any family history of disease; and a strong family history of desmoids. A family history of multiple desmoids (.1) increased an individual's own risk of multiplicity. Females had twice the odds of developing desmoids compared with males. There was no significant interaction between any of the three explanatory variables. Conclusions: Our results indicate the influence of unknown genetic factors independent of APC in susceptibility to desmoid tumours in FAP. The data have implications in terms of clinical management of FAP patients and assessing the balance between chemoprevention and prophylactic colectomy.
Almost all patients affected by Familial Adenomatous polyposis (FAP) will develop foregut as well as hindgut polyps, and following prophylactic colectomy duodenal cancer constitutes one of the leading causes of death in screened populations. Without prophylactic colectomy, FAP patients predictably develop colorectal cancer, but the lifetime risk of upper gastrointestinal cancer is lower, estimated at approximately 5%. Management of the upper gastrointestinal cancer risk is one of the greatest challenges facing clinicians involved in the care of Polyposis families, and with improved survival following prophylactic colectomy, the burden of foregut disease (particularly duodenal adenomatosis) will increase. Until recently, the value of upper gastrointestinal surveillance in FAP populations has been contentious, but with improved understanding of the natural history coupled with developments in surgery, interventional endoscopy and medical therapy, treatment algorithms for duodenal adenomatosis in FAP are becoming clearer.
Objectives -To identify issues that patients and professionals consider important in diabetes care and differences in their priorities for care and to determine patients' and professionals'
IntroductionPeople in prison tend to experience poorer health, access to healthcare services and health outcomes than the general population. Use of video consultations (telemedicine) has been proven effective at improving the access, cost and quality of secondary care for prisoners in the USA and Australia. Implementation and use in English prison settings has been limited to date despite political drivers for change. We plan to research the implementation of a new prison-hospital telemedicine model in an English county to understand what factors drive or hinder implementation and whether the model can improve healthcare outcomes as demonstrated in other contextual settings.Methods and analysisWe will undertake a hybrid type 2 implementation effectiveness study to gather evidence on both clinical and implementation outcomes. Data collection will be guided by the theoretical constructs of Normalisation Process Theory. We will prospectively collect data through: (1) prisoner/patient focus groups, interviews and questionnaires, (2) prison healthcare, hospital and wider prison staff interviews and questionnaires, (3) routine quality improvement and service evaluation data. Up to four prisons and three hospital settings in Surrey (England) will be included in the telemedicine research, dependent on their telemedicine readiness during the study period. Prisons proposed include male and female prisoners, remand (not yet sentenced) and sentenced individuals and different security categorisations. In addition, focus groups in five telemedicine naïve prisons will provide information on patient preconceptions and concerns surrounding telemedicine.Ethics and disseminationThis study has received National Health Service Research Ethics Committee, Her Majesty’s Prison and Probation Service National Research Committee and Health Research Authority approval. Dissemination of results will take place through peer-reviewed journals, conferences and existing health and justice networks.
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