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By T. Yespas. Barclay College. 2019.

Double-blind switch study of imipramine or sertraline treatment of antidepressant- controlled trial of once-daily venlafaxine extended release (XR) resistant chronic depression trusted glucotrol xl 10 mg. Compliance with pharmacotherapy in atric disorders purchase glucotrol xl 10 mg without prescription, third ed glucotrol xl 10mg line. Washington buy 10mg glucotrol xl with mastercard, DC: American Psychiatric mood disorders. Short-term psychotherapy of depressive managing depression refractory to selective serotonin reuptake disorders: current status and future directions. Psychiatry Inter- inhibitor treatment: a survey of clinicians. Can J Psychiatry 2000; personal Biol Proc 1994;57:115–132. Venlafaxine and bupropion depression with cognitive therapy or phenelzine: a double-blind, combination therapy in a case of treatment-resistant depression. 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Olanzapine plus domised, 12 week comparison study of the safety and efficacy fluoxetine: double-blind and open-label results in treatment- of venlafaxine and fluoxetine in moderate to severe major resistant major depressive disorder. Presented at the XI World depression in general practice. Primary Care Psychiatry 1997;3: Congress of Psychiatry, Hamburg, Germany, August 6–11, 51–58. Cognitive-behavioral ized, open-label comparison of venlafaxine and fluoxetine in treatment for depressed adolescents. A course in coping: a faxine and fluoxetine in outpatients with major depression. J cognitive-behavioral approach to the treatment of adolescent Clin Psychiatry 1998;59:352–357. The efficacy and tolerabil-´ for child and adolescent disorders. Empirically based strategies for ity of venlafaxine and paroxetine in outpatients with depressive clinical practice. Washington, DC: American Psychiatric Associ- disorder or dysthymia. Int Clin Psychopharmacol 2000;15: ation, 1996:109–135. Venlafaxine and paroxetine in treatment- depressive. A clinical psychotherapy J Psychiatry 1999;175:12–16. J Clin Psychiatry 2000;61: personal psychotherapy for depressed adolescents. Clinical outcome after chiatry 1999;60(Suppl 17):41–45. Br Med J 1998;316: sponse to fluoxetine in geriatric patients with major depression. Pharmacologic and psychotherapeutic treatments for 136. Partial response, nonre- adolescents with depression. Arch Gen Psychiatry 1997;54: sponse, and relapse with selective serotonin reuptake inhibitors 1031–1037. Paroxetine and imipra- J Clin Psychiatry 2000;61:403–408. Poor response to fluoxetine: underlying depression, and Abstracts of the 151st Annual Meeting of the American serotonergic overstimulation, or a 'therapeutic window'? J Clin Psychiatric Association, 1998; Toronto, Ontario, Canada. Child and adolescent mood disord- depressant treatment for patients with major depression who are ers—experience with serotonin-based therapies. Effects of hypericum Psychiatry Res 1995;56:295–297. Hypericum for depression: an update of the 1026–1032. Electro-acupuncture in the treat- imipramine or placebo in patients with moderate depression: ment of depressive psychosis. Int J Clin Acupuncture 1990;1: randomized multicentre study of treatment for eight weeks. Potential treatment for subthreshold and body acupuncture in major depression. J Affect Disord 2000; mild depression: A comparison of St. Placebo-controlled in the treatment of major depression in women. S-adenosyl-l-methionine (SAMe) as antidepressant: tonin-selective antidepressant therapy: differential effects on so- meta-analysis of clinical studies. Reboxetine: a dou-¨ S-adenosyl-L-methionine in speeding the onset of action of imi- ble-blind comparison with fluoxetine in major depressive disor- pramine. EPSTEIN The science of electroconvulsive therapy (ECT) has pro- schizophrenia would relieve psychosis. ECT was developed gressed rapidly over the last 20 years, providing new insights at approximately the same time as frontal leukotomy (2) into the mechanisms of action of ECT, improving both the and insulin coma therapy (3), but these treatments carried acute and long-term efficacy of the treatments, and decreas- a high morbidity, and were replaced by modern psychophar­ ing cognitive problems associated with the treatments. The indications for ECT anticonvulsant hypothesis unifies many of the scientific were established during this time, and its use in conditions findings in electroencephalography, neuroimaging, and other than mood disorders and schizophrenia diminished. This hypothesis as- depression and was one of the most significant medical ad­ sumes that ECT enhances the transmission of inhibitory vances in the twentieth century.

Factors that influence quality of life in rural children with asthma and their parents cheap glucotrol xl 10mg with amex. Butz A order glucotrol xl 10mg, Kub J generic 10 mg glucotrol xl free shipping, Donithan M generic glucotrol xl 10mg with visa, James NT, Thompson RE, Bellin M, et al. Influence of caregiver and provider communication on symptom days and medication use for inner-city children with asthma. Byford S, Harrington R, Torgerson D, Kerfoot M, Dyer E, Harrington V, et al. Cost-effectiveness analysis of a home-based social work intervention for children and adolescents who have deliberately poisoned themselves. Harrington R, Kerfoot M, Dyer E, McNiven F, Gill J, Harrington V, et al. Randomized trial of a home-based family intervention for children who have deliberately poisoned themselves. Byford S, Barrett B, Roberts C, Wilkinson P, Dubicka B, Kelvin R, et al. Cost-effectiveness of selective serotonin reuptake inhibitors and routine specialist care with and without cognitive- behavioural therapy in adolescents with major depression. Goodyer I, Dubicka B, Wilkinson P, Kelvin R, Roberts C, Byford S, et al. Selective serotonin reuptake inhibitors (SSRIs) and routine specialist care with and without cognitive behaviour therapy in adolescents with major depression: randomised controlled trial. Byford S, Barrett B, Roberts C, Clark A, Edwards V, Smethurst N, et al. Economic evaluation of a randomised controlled trial for anorexia nervosa in adolescents. Gowers SG, Clark A, Roberts C, Griffiths A, Edwards V, Bryan C, et al. Clinical effectiveness of treatments for anorexia nervosa in adolescents: randomised controlled trial. Gowers SG, Clark AF, Roberts C, Byford S, Barrett B, Griffiths A, et al. A randomised controlled multicentre trial of treatments for adolescent anorexia nervosa including assessment of cost-effectiveness and patient acceptability – The TOuCAN trial. Calvo A, Moreno M, Ruiz-Sancho A, Rapado-Castro M, Moreno C, Sánchez-Gutiérrez T, et al. Intervention for adolescents with early-onset psychosis and their families: a randomized controlled trial. Cano-Garcinuño A, Díaz-Vázquez C, Carvajal-Urueña I, Praena-Crespo M, Gatti-Viñoly A, García-Guerra I. Group education on asthma for children and caregivers: a randomized, controlled trial addressing effects on morbidity and quality of life. Home-based family intervention for low-income children with asthma: a randomized controlled pilot study. Chan DS, Callahan CW, Sheets SJ, Moreno CN, Malone FJ. An Internet-based store-and-forward video home telehealth system for improving asthma outcomes in children. Chan DS, Callahan CW, Hatch-Pigott VB, Lawless A, Proffitt HL, Manning NE, et al. Internet-based home monitoring and education of children with asthma is comparable to ideal office-based care: results of a 1-year asthma in-home monitoring trial. Christie D, Thompson R, Sawtell M, Allen E, Cairns J, Smith F, et al. Structured, intensive education maximising engagement, motivation and long-term change for children and young people with diabetes: a cluster randomised controlled trial with integral process and economic evaluation – the CASCADE study. A randomized controlled trial of a public health nurse-delivered asthma program to elementary schools. Clark NM, Gong M, Kaciroti N, Yu J, Wu G, Zeng Z, et al. A trial of asthma self-management in Beijing schools. Cowie RL, Underwood MF, Little CB, Mitchell I, Spier S, Ford GT. Asthma in adolescents: a randomized, controlled trial of an asthma program for adolescents and young adults with severe asthma. Domino ME, Burns BJ, Silva SG, Kratochvil CJ, Vitiello B, Reinecke MA, et al. Cost-effectiveness of treatments for adolescent depression: results from TADS. Domino ME, Foster EM, Vitiello B, Kratochvil CJ, Burns BJ, Silva SG, et al. Relative cost-effectiveness of treatments for adolescent depression: 36-week results from the TADS randomized trial. The Treatment for Adolescents with Depression Study (TADS): methods and message at 12 weeks. J Am Acad Child Adolesc Psychiatry 2006;45:1393–403. Clinical messages from the Treatment for Adolescents With Depression Study (TADS). Treatment for Adolescents with Depression Study (TADS) Team. The Treatment for Adolescents with Depression Study (TADS): demographic and clinical characteristics. Treatment for adolescents following a suicide attempt: results of a pilot trial. An economic evaluation of home care for children with newly diagnosed diabetes: results from a randomized controlled trial. Dougherty G, Schiffrin A, White D, Soderstrom L, Sufrategui M. Home-based management can achieve intensification cost-effectively in type I diabetes. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that 57 suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. Eakin MN, Rand CS, Bilderback A, Bollinger ME, Butz A, Kandasamy V, et al. Asthma in Head Start children: effects of the Breathmobile program and family communication on asthma outcomes. Edwards RT, Céilleachair A, Bywater T, Hughes DA, Hutchings J. Parenting programme for parents of children at risk of developing conduct disorder: cost effectiveness analysis. Hutchings J, Gardner F, Bywater T, Daley D, Whitaker C, Jones K, et al. Parenting intervention in Sure Start services for children at risk of developing conduct disorder: pragmatic randomised controlled trial. Espinoza-Palma T, Zamorano A, Arancibia F, Bustos MF, Silva MJ, Cardenas C, et al. Effectiveness of asthma education with and without a self-management plan in hospitalized children. Esposito-Smythers C, Spirito A, Kahler CW, Hunt J, Monti P. Treatment of co-occurring substance abuse and suicidality among adolescents: a randomized trial. Trial of an asthma education program in an inner-city pediatric emergency department.

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Internalizing symptoms appear to remain fairly sta- GAD/OAD is a frequently co-occurring disorder generic glucotrol xl 10mg visa. Among boys buy glucotrol xl 10mg lowest price, internalizing symptoms those with a primary diagnosis of OAD purchase glucotrol xl 10mg otc, there is often an are not only predictive of later internalizing symptoms but additional diagnosis of separation anxiety disorder (37% to also of subsequent externalizing problems (15) buy 10mg glucotrol xl amex. Although 44%), social phobia (4% to 57%), simple phobia (9% to there may be high rates of recovery associated with a particu- 43%) or a depressive disorder (1% to 69%) (24). There are lar anxiety disorder, children who recover are at increased a number of potential reasons for the high rates of comor- risk of developing other psychiatric diagnoses, most com- bidity, including true covariation of distinct disorders, the monly other anxiety disorders or depressive disorders (16). Among young children, the disorder often and course. For children in general, compulsions alone are more common than obsessions alone (26). The most common compulsions Generalized Anxiety Disorder (GAD) include washing/cleaning, repeating/redoing, and checking, GAD is characterized by excessive anxiety or worry, which and the most common obsessions include germs/contami- is difficult to control and is accompanied by symptoms of nants and fear of harm to the self or to another (26). The GAD diagnosis symptoms change over time in 90% of children (4). Mean age of onset is approxi- about future events, personal safety, and social evaluation, mately 10 years. Information about the course of OCD is and often present with multiple somatic complaints, such variable and may be best described as chronic but fluctuat- as headaches and stomachaches (19). During the 2- to 7-year follow- was used previously. Prevalence estimates of OAD tended up period, the patients on average received two different to be quite variable, 2% to 19% (19), and often very high, modalities of treatment (medication, behavioral therapy, partially because functional impairment was not necessary other individual therapy, and family therapy), with 96% for the diagnosis (20). Recent estimates of the prevalence having had additional psychopharmacologic treatment and of GAD are in the range of 2. In spite of ongoing to be more prevalent in older children and in girls (19). Of Information about course is not yet available for the the 11% who were symptom-free, only three (of 54) patients GAD diagnosis, but some extrapolation from OAD is possi- had no symptoms and were not on current medications. Other estimates of be interpreted with caution because it is based on a single, continued OCD at follow-up (1. The Posttraumatic Stress Disorder (PTSD) most common co-occurring conditions include other anxi- To meet the criteria for a diagnosis of PTSD, a person must ety disorders (38%), tic disorders (24% to 30%), mood have been exposed to a traumatic event and as a result is disorders (26% to 29%), and specific developmental disabil- exhibiting symptoms of reexperiencing, numbing/avoid- ities (24%) (26). A recent confirmatory factor analytic history of tic disorder and current affective disorder at base- study supported the presence of these three basic clusters line were associated with poorer outcome. PTSD presentations that are specific to chil- Agoraphobia) (PD) dren include reenactment of the trauma in play, physical attempts (e. Diagnosis of PTSD depends on exposure to a traumatic Young children tend to articulate their panic-related fears stressor. Each year, 6% to 7% of Americans are exposed to in a different way than do adolescents or adults by virtue traumatic events (36), but the incidence is much greater in of their developmental level; they are more likely to express certain subpopulations. For example, studies of urban youth concerns about sudden somatic symptoms and less likely to report exposure rates of up to 75% (37). Not everyone who describe fears of dying, losing control, or going crazy (4). Estimates PD is uncommonly reported in children, to the point vary tremendously depending on the type of trauma and that there has been some debate as to whether it exists before the elapsed time between the event and assessment. Evidence of the existence of PD in children comes et al. There is no epidemiologic study to date, related events, 8. Overall, it appears that exposed children may be the predominance of somatic symptoms in presentation. PD appears to be tically important factors are whether the trauma involves a two to three times more common in females (29). Hayward single occurrence or is repeated, and whether it involves et al. Although the evidence is not entirely consistent, it of panic attacks and sexual development in girls and found appears that a single exposure is less likely to lead to long- a positive relationship. There were no reported panic attacks term symptomatology (36). Additional disorders may be integrally In the one study of the course of early PD, 30% contin- related to the trauma, such as fears about safety of the self ued to have PD and 30% had another psychiatric disorder or loved ones or grief about loss (35). Other psychopathol- 3 to 4 years later, but the generalizablity of this result is ogy may also be a function of other factors, such as a dis- rupted or disorganized childhood or engagement in risky questionable because of the small size of the study popula- behaviors, which increase the risk for both psychopathology tion (ten) (16). Retrospective reports suggest that earlier and traumatic exposure (38). Available information suggests that there is a high rate of comorbidity in adolescents with SAD is the only current anxiety disorder that is uniquely PD, particularly with affective disorders; again, this should diagnosed in children and adolescents. The hallmark feature 862 Neuropsychopharmacology: The Fifth Generation of Progress of this disorder is excessive concern about separation from Social Phobia attachment figures. This is frequently manifested as distress Social phobia involves 'marked and persistent fear of one at separation and excessive worry that harm will befall the or more performance or social situations in which the person attachment figure or that some negative event will lead to is exposed to unfamiliar people or to possible scrutiny by separation (18). These children frequently avoid going to others' (18). The anxious response in such situations is school, fear being left alone or sleeping alone, and exhibit associated with cognitions involving concerns about being a panic-like physiologic response to separation (32). Childhood social phobia is asso- Prevalence estimates for SAD are 2. The onset of SAD is usually Although there are fewgood epidemiologic studies of early and associated with a major stressor (4). Of nine chil- social phobia in childhood, data from community studies dren with SAD followed by Cantwell and Baker (23), only in adolescents suggest that it is quite common (1% to 2%), one was still diagnosable 4 to 5 years later; this was the with a noticeable jump in prevalence rates sometime be- highest rate of recovery of any of the disorders that they tween ages 12 to 13 and ages 14 to 17 (44). However, with SAD, although 25% had developed another disorder, when social phobia is present in adolescence, it is a strong most commonly depressive, 3 to 4 years later. SAD fre- predictor of social phobia in adulthood (17). These data, quently co-occurs with other disorders, most often other taken together, suggest that social phobia in childhood may anxiety disorders (OAD, 23% to 33%; specific phobias, be a more transitory phenomenon than social phobia in 12. If these findings are confirmed in future stud- disorder (approximately one-third) (32). Evidence that has been cited in support of this idea includes the symptomatic similarity between a panic attack and the response to separation in a child with SAD; the ANXIETY AND STRESS DISORDERS IN frequency of a history of SAD in panic patients; the cluster- YOUNG TO MIDDLE-AGE ADULTS ing of SAD, PD, and depressive disorders in families; and Epidemiology the similarities in effective pharmacologic treatments for the two conditions (39–41). Documented cases of panic epi- Several epidemiologic studies have documented the high sodes unrelated to separation, however, argue against this rate of anxiety disorders among adults in the general popula- hypothesis (29). In reports from the Epidemiologic Catchment Area factor for the later development of PD, at least among (ECA) Study, anxiety disorders were found to occur as a females (4). More recently, the National Comorbidity Survey (NCS) found that 24. The two studies used somewhat different A specific phobia is diagnosed if a child consistently displays sampling methods, and different diagnostic interviews, significant and excessive fear in response to a specific object probably therein explaining at least some of the variance in or situation (18). The most common fears among children rates between studies (47). The prevalence of this disorder is in the range of 0. Comorbidity among the anxiety, mood, and substance use Unlike the other anxiety disorders reviewed here, chil- disorders is extensive (47). For example, two-thirds of per- dren with specific phobias remain a fairly distinct group. In a clinical sample of 85 patients were least likely to show onset of a different disorder within with major depression, 29% met criteria for a current anxi- the follow-up period. What is particularly noteworthy about this relationship Chapter 60: Anxiety and Stress Disorders: Course over the Lifetime 863 is the temporal sequencing of disorders. Certain anxiety dis- also provide persuasive evidence of the seriousness of anxiety orders, social phobia in particular (which has a median onset disorders (52,63,64). The annual cost of anxiety disorders of between 13 and 15 years of age), almost inevitably begin in the United States was estimated at $42.

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The Patient Centred Assessment Method versus other tools or interventions to promote holistic assessment We believe that we have already made strong arguments that nurse use of depression screening tools has been ineffective and may have led to underdetection of mental health issues in patients with LTCs generic 10mg glucotrol xl with visa. However buy glucotrol xl 10mg without a prescription, as with the existence of the INTERMED purchase glucotrol xl 10mg without prescription, there are some other tools that may be considered as promoting holistic assessment best 10mg glucotrol xl, and it is important to reflect on the PCAM in relation to these other tools. We found reference to the use of the Family Nurse Partnership Tool55 among adults with learning disability and, although it includes attention to social circumstances, it also includes using a battery of other mental health assessment tools that we did not find appropriate for PNs. We are not aware that this approach has either been specifically designed for use in primary care or tested for use in primary care, whereas the PCAM tool has been specifically designed for use in primary care. None of these was deemed appropriate for the purpose of PN assessment of biopsychosocial needs in primary care settings. The HNA has not been fully evaluated in any clinical trials and has not been developed for use in primary care by patients with LTCs. This initiative has been rolled out in NHS England and now also in Scotland. Figure 10 is a composite of models used to describe the HoC. It requires enthusiastic clinical leadership supported by administrators and policy-makers. It is an approach that aligns with locality working and with health and social integration. However, it is not clear what this means for practitioners at the level of the consultation and face-to-face interactions, other than that these should encompass patient-centred co-ordinated care. The HoC relies on many parts of the system (of health and social care professionals) working together, and it is less clear how non-medical support (formal and informal) will be included and accessed within the consultation to support patient self-management and address other identified needs. The Links Worker Programme61 in Scotland is a Scottish Government-funded programme aiming to mitigate the impact of the social determinants of health in people who live in areas of high socioeconomic deprivation. Its basis is the inclusion of a new specialist role, the community links worker, in primary care teams. They undertake some of the signposting and community referral tasks that the PCAM was asking of primary care nurses, but can go further in facilitating access for patients to these suggested signposting or referral options. Similarly to the goals of nurse use of the PCAM Organisational processes and arrangements Empowered, Multidisciplinary activated and health and social engaged Person-centred care care team individuals and planning carers Additional non-medical support (formal and informal) FIGURE 10 A composite version of the HoC model. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 73 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. DISCUSSION with patients, the rationale for links workers is that, if individuals feel supported in their lives, then they are more likely to respond to information on ways to improve their health and to live well. If these people were to be successfully supported sooner rather than later, then there is a potential that their risk of developing LTCs would be reduced, or further complications delayed or prevented if they have already contracted long-term illness(es). The PCAM is probably most similar to the Links Worker model in its aims. The Links Worker Programme commenced during the PCAM study and its evaluation is still under way. Therefore, the evidence base for the Links Worker Programme is still unclear. However, there is still a need in primary care for nurses (and GPs) who see the majority of patients with LTCs to be able to feel confident in determining whether or not patients have any problems that could be dealt with by the links worker. The completion of the PCAM tool in annual reviews could act as a facilitator for referral to those in links worker-type roles, who could then facilitate access to community-based resources. The two initiatives are more compatible than incompatible, and could strengthen the identification of needs and communication between the primary care team and the links worker. It is also unclear who will fund, and whether or not they will fund, the continuation of the links worker roles in Scotland, and these are not available across the UK. Therefore, the PCAM may still be the best method available for the promotion of biopsychosocial assessment in primary care and, with the development of a locally derived resource pack, could also be the best-available method for facilitating access to a broader range of psychosocial supports. In conclusion, we believe that the PCAM is uniquely developed for primary care and we are not aware of directly comparable assessment tools that have been prepared for and tested in primary care. The PCAM provides a comprehensive and practical approach via the three components of training, the PCAM tool and the resource toolkit. Other initiatives like HoC lack an easily understood and easy-to-use practical tool. The use of the PCAM by primary care nurses as a decision aid for referral to links-type roles in primary care would work really well. Links-type roles could also make use of the PCAM itself. The PCAM could serve as a systematic way of recording needs and actions to be shared across the primary care team (GPs, nurses, links or other social care roles). Patient and public involvement One of the key benefits of including PPI in clinical trials and on trial design is that they are likely to make studies more feasible, at least in terms of patient recruitment. Research has shown that trials with higher levels of PPI are four times more likely to recruit to target. These can help to identify necessary adjustments to improve recruitment and retention. The PPI partners in this study did indeed help to shape the recruitment strategy for patients, which was to opt in to either a focus group study or involved opting in to completing questionnaires and a possible interview. The outcomes needed to include measures of physical health, mental health and social needs. We also required information on actions undertaken by nurses (advice, referrals, signposting) and on whether or not patients had taken up this advice, referral or signposting to services. The complexity of the study design, and its attempt to gather multiple outcomes at both the nurse level and the patient level, was not lost on our PPI members, as we worked together to gather the required knowledge in the most efficient manner. This was probably helped by the degree of knowledge of research that our PPI members had and their enthusiasm for the study. They contributed to the many discussions throughout the study on how to address this and were reassured that the team had tried all possible avenues within the time scale available to achieve practice recruitment and retention. In reflecting on our PPI as a team, we thought it best to allow our PPI members to write their own contributions to this. We asked them to reflect on their experience of working with us and whether or not we could have done anything differently to enable their participation in the study. Their responses are included in the following two subsections. My experience and comments on the Patient Centred Assessment Method process; by patient representative 1 As a patient representative I appreciate the requirement and desirability for academia to be sometimes balanced by a lay point of view and if not present the journey from concept to publication may not be as comprehensive as it could be. I sit as a patient representative (I prefer the term representative patient) on several committees and research groups so feel qualified to state that my experience with this feasibility study was one of the best in terms of support, inclusiveness, consideration and birthday cakes. The panel made an effort to explain any terms or acronyms I or my fellow PR [patient representative] were unfamiliar with and always listened to our viewpoints and took the time to solicit our thoughts. As to the actual content of the study I share the disappointment on the paucity of the total numbers of patients and practices involved but strongly believe that this holistic approach will show many benefits. My particular thanks must go to Professor Maxwell, Dr Carina Hibberd and Ms Nadine Dougall. My experience and comments on the Patient Centred Assessment Method process; by patient representative 2 As a sufferer from a sluggish (not to say absent) NHS protocol in dealing with anxiety issues caused by the diagnosis of a cardiac problem, I joined the Living Better Project Steering Committee which was an RCGP-led study aiming to improve the care of people with LTCs in primary care, hoping for procedural improvement. Unfortunately the results of the research resulting from the Living Better project did not translate into the hoped for improved protocol to establish a route to identify co-lateral problems which frequently resulted alongside a chronic disease diagnosis. But, in PCAM, I saw an opportunity to introduce a method to improve this situation within the existing structure. Encouraged to be involved from the start in discussing the initial documentation and to join the Steering Committee by the key researchers it has been a pleasure to be involved with and to follow the development of this ambitious project. Always encouraged to participate fully in committee discussions and to contribute ideas throughout, and to feel free to criticise, my lay colleague and I were kept involved in all of the developing problems by the project leaders as well as in the successes. Our involvement in the discussion of the final report has also been thorough. The infectious enthusiasm of the researchers and their stoicism when things were difficult have been singular. There is no doubt in my mind that, in PCAM, there is the germ of an idea which will become part of NHS protocol in the years to come. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals 75 provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK. DISCUSSION Strengths and limitations The strength of this study is that it was designed as a feasibility study that has fully tested practice, nurse and patient recruitment and retention.

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