Acute pancreatitis in children - morbidity and outcomes at 1 year.

OBJECTIVE: To establish short-term and medium-term complications 1-year postdiagnosis, of acute pancreatitis (AP) in children aged 0-14 years. DESIGN: One-year follow-up of a prospective monthly surveillance of new cases of AP in children under 15 years through the British Paediatric Surveillance Unit (BPSU) from April 2013 to April 2014. SETTING: A monthly surveillance of >3700 consultant paediatricians and paediatric surgeons in the UK and Ireland using the BPSU. PATIENTS: Children aged 0-14 years with a new diagnosis of AP. MAIN OUTCOME MEASURES: The outcomes following AP, including the incidence of complications and comorbidity at diagnosis and at 1 year. RESULTS: Of the 94 new confirmed cases of AP identified in the UK during the study period, 90 cases (96%) were included in the 1-year follow-up. 30 patients (32%) developed further episode(s) of AP. Over one-fifth of patients developed one or more major complication. At initial admission, the most common of these was pancreatic necrosis (n=8, 9%), followed by respiratory failure (n=7, 7%). Reported complications by 1 year were pseudocyst formation (n=9, 10%), diabetes requiring insulin therapy (n=4, 4%) and maldigestion (n=1, 1%). At 1-year postdiagnosis, only 59% of children made a full recovery with no acute or chronic complications or recurrent episodes of AP. Two patients died, indicating a case fatality of ~2.0%. CONCLUSIONS: AP in childhood is associated with significant short-term and medium-term complications and comorbidities including risk of recurrence in approximately a third of cases.

Is the rate of revision of 36 mm metal-on-metal total hip arthroplasties with Pinnacle acetabular components related to the year of the initial operation? an interrupted time-series analysis using data from the National Joint Registry for England and Wales.

AIMS: The aim of this study was to determine whether the rates of revision for metal-on-metal (MoM) total hip arthroplasties (THAs) with Pinnacle components varied according to the year of the initial operation, and compare these with the rates of revision for other designs of MoM THA. PATIENTS AND METHODS: Data from the National Joint Registry for England and Wales included 36 mm MoM THAs with Pinnacle acetabular components which were undertaken between 2003 and 2012 with follow-up for at least five years (n = 10 776) and a control group of other MoM THAs (n = 13 817). The effect of the year of the primary operation on all-cause rates of revision was assessed using Cox regression and interrupted time-series analysis. RESULTS: For MoM THAs involving Pinnacle components, those undertaken between 2007 and 2012 had higher rates of revision compared with those undertaken between 2004 and 2006 (hazard ratio (HR) 2.01; 95% confidence interval (CI) 1.57 to 2.57; p < 0.001). For THAs undertaken during and after 2007, the number of revisions per 1000 implant-years at risk significantly increased by 5.20 (95% CI 0.52 to 9.89; p = 0.033) compared with those undertaken before this time. In the control group, THAs undertaken between 2007 and 2012 also had higher rates of revision (HR 1.77; 95% CI 1.49 to 2.10; p < 0.001), with revisions per 1000 implant-years for those undertaken during and after 2007 significantly increasing by 6.13 (95% CI 1.42 to 10.83; p = 0.016). CONCLUSION: The five-year revision rates were significantly increased for all primary MoM THAs undertaken from 2007 onwards. Contrary to recent reports, this finding was not specific to those involving Pinnacle acetabular components and may be explained by increased surveillance and recent lowering of the threshold for revision. Cite this article: Bone Joint J 2018;100-B:33-41.

An analysis of 30-day mortality after weekend versus weekday elective joint arthroplasty in England and Wales: a cohort study using the National Joint Registry Dataset.

AIMS: To investigate whether elective joint arthroplasty performed at the weekend is associated with a different 30-day mortality versus that performed between Monday and Friday. PATIENTS AND METHODS: We examined the 30-day cumulative mortality rate (Kaplan-Meier) for all elective hip and knee arthroplasties performed in England and Wales between 1st April 2003 and 31st December 2014, comprising 118 096 episodes undertaken at the weekend and 1 233 882 episodes performed on a weekday. We used Cox proportional-hazards regression models to assess for time-dependent variation and adjusted for identified risk factors for mortality. RESULTS: The cumulative 30-day mortality for hip arthroplasty was 0.15% (95% confidence interval (CI) 0.12 to 0.19) for patients operated on at the weekend versus 0.20% (95% CI 0.19 to 0.21) for patients undergoing surgery during the normal working week. For knee arthroplasty, the cumulative 30-day mortality was 0.14% (95% CI 0.11 to 0.17) for weekend-operated patients versus 0.18% (95% CI 0.17 to 0.19) for weekday-operated patients. These differences were independent of any differences in patient age, gender, American Society of Anaesthesiologists grade, surgeon seniority, surgical and anaesthetic practices, and thromboprophylaxis choice in weekend versus weekday-operated patients. CONCLUSION: The 30-day mortality rate after elective joint arthroplasty is low. Surgery performed at the weekend is associated with lower post-operative mortality versus operations performed on a weekday. Cite this article: Bone Joint J 2017;99-B:1618-28.

Growth hormone deficiency after childhood bone marrow transplantation with total body irradiation: interaction with adiposity and age.

OBJECTIVE: Bone marrow transplantation with total body irradiation (BMT/TBI) has adverse effects on growth, growth hormone status and adiposity. We investigated the GH-IGF-I axis in relation to adiposity. DESIGN: Cross-sectional case control study. PATIENTS: BMT/TBI survivors (n = 22) and short stature control participants (n = 19), all GH-naïve or off GH treatment >3 months. MEASUREMENTS: Auxology, DEXA scans and GH-IGF-I axis investigation: (i) 12-h overnight GH profiles; (ii) insulin tolerance test (ITT); and (iii) IGF-I generation test. ANALYSIS: auto-deconvolution of GH profile data and comparison of quantitative parameters using ANOVA. RESULTS: Eighty-two percent of BMT/TBI survivors had growth hormone deficiency (GHD) using ITT. GH profile area-under-the-curve (GH-AUC) was reduced in BMT/TBI survivors vs short stature control participants [geometric mean (range) 209 (21-825) vs 428 (64-1400) mcg/l/12 h, respectively, P = 0·007]. GHD was more marked in those who had additional cranial irradiation (CRT) [ITT peak 1·4 (0·2-3·0) vs TBI only 4·1 (1·1-14·8) mcg/l, P = 0·036]. GHD was more marked at the end of growth in BMT/TBI survivors vs short stature control participants (GH-AUC 551 (64-2474) vs 1369 (192-4197) mcg/l/12 h, respectively, P = 0·011) and more prevalent (9/11 vs 1/9, respectively, P = 0·005). GH profile data were consistent with ITT results in 80% of participants. IGF-I generation tests were normal. BMT/TBI survivors still demonstrated lower GH levels after adjustment for adiposity (fat-adjusted mean difference for GH-AUC 90·9 mcg/l/12 h, P = 0·025). CONCLUSIONS: GHD was more prevalent in BMT/TBI survivors than expected for the CRT dose in TBI, worsened with time and persisted into adulthood. GHD could not be explained by adiposity. There was no evidence of GH neurosecretory dysfunction or resistance after BMT/TBI.

Cost and effectiveness of treatment options for childhood obesity.

UNLABELLED: What is already known about this subject Approximately one-fifth of children in the UK are obese. There are currently few, effective interventions available in the UK. There are very little data on relative cost-effectiveness of childhood obesity interventions, which hampers the commissioning of future services. What this study adds Simple multi-component obesity interventions can be provided at relatively low cost per 0.1 body mass index standard deviation score (BMI SDS) improvement. More intensive and effective interventions incur greater cost per 0.1 BMI SDS reduction but this may be justified given the improved overall BMI SDS reduction attained. OBJECTIVE: To describe the costs and outcomes of three models of care for childhood obesity previously evaluated in two 2-arm pilot randomized trials in England. The treatments were (i) a hospital clinic (control in both trials), comprising a multidisciplinary team of consultant, dietitian and exercise specialist; (ii) a nurse-led primary care clinic replicating the service provided by the hospital and (iii) an intensive intervention using Mandometer®, a behaviour modification tool aimed at encouraging slower eating and better recognition of satiety. METHOD: Patient-level data on resources used to deliver each intervention were collected during the trials. Apart from the cost of the Mandometer® the majority of cost was staff time, dependent on discipline and grade. Outcome for both trials was body mass index standard deviation score (BMI SDS) measured at 12 months. RESULTS: Cost and outcome data were available for 143 children in total. Cost per child was £1749 (SD £243) in the Mandometer® group, £301 (£76) in the primary care group, and £263 (£88) and £209 (£81) in the hospital groups. Mean reduction in BMI SDS was 0.40 (0.35), 0.17 (0.26), 0.15 (0.25) and 0.14 (0.32), respectively. CONCLUSION: Intensive management using Mandometer® was effective but costly (£432 per 0.1 reduction in BMI SDS) compared to conventional care (range £153-£173). A total of 26% children receiving conventional care achieved a clinically meaningful reduction in BMI SDS; however, use of Mandometer® training may be justified in children not responding to conventional lifestyle interventions.

Serum levels of pigment epithelium-derived factor (PEDF) are positively associated with acanthosis nigricans in obese adolescents.

INTRODUCTION: Circulating pigment epithelium-derived factor, or serine protease inhibitor F1, is upregulated during adipogenesis, contributing to obesity-induced insulin resistance. Furthermore, pigment epithelium-derived factor is abundant in stage I melanosomes and has been reported to increase pigment granules and the appearance of mature melanosomes in retinal pigment epithelium. As acanthosis nigricans is a well-recognized clinical marker of insulin resistance, we hypothesized that increased pigment epithelium-derived factor might be associated with the generation of acanthosis nigricans. METHODS: Acanthosis nigricans, anthropometric measurements, circulating total PEDF and metabolic profiles were assessed in 28 obese adolescents in a hospital-based obesity clinic. RESULTS: Subjects with acanthosis nigricans (n = 10) showed greater plasma levels of pigment epithelium-derived factor (PEDF) than those without [geometric mean 23.55 (range 15.2-40.2) vs. 9.01 (range 5.5-18.7) µg/ml; P < 0.001]. Although pigment epithelium-derived factor was positively correlated with the homeostasis model assessment for insulin resistance (HOMA-IR) (r = 0.779, P < 0.001; 95% CI 0.573-0.892), as previously reported, for the same degree of insulin resistance, those with acanthosis nigricans exhibited a 2.1-fold (95%CI 2.0-2.3) higher level of pigment epithelium-derived factor. CONCLUSIONS: While acanthosis nigricans is undoubtedly associated with insulin resistance, its appearance is not ubiquitous in patients at any given level of HOMA-IR. The higher levels of pigment epithelium-derived factor in those with acanthosis nigricans compared with those without, with similar levels of resistance, suggest that pigment epithelium-derived factor levels are associated with acanthosis nigricans.

Normalizing eating behavior reduces body weight and improves gastrointestinal hormonal secretion in obese adolescents.

HYPOTHESIS: Retraining obese adolescents to eat more slowly will lead to beneficial changes in circulating concentrations of gastrointestinal satiety hormones. METHODS: Ghrelin and peptide tyrosine-tyrosine were measured during an oral glucose tolerance test, at baseline and at 12 months during a randomized trial assessing the clinical effectiveness of a device (Mandometer) designed to retrain eating behavior. This computerized scale provided real-time feedback during meals in the intervention arm (n = 14) to slow down the speed of eating. The control group (n = 13) received only standard care aimed at improving lifestyle behavior. The Mandometer elicited greater improvements in weight loss than standard care. RESULTS: Compared with baseline, only those using the Mandometer exhibited lower mean levels of fasting ghrelin (48.14 ± 18.47 vs. 68.45 ± 17.78 pg/ml; P = 0.002) and mean ghrelin area under the curve (72.08 ± 24.11 vs. 125.50 ± 29.72 pg/ml × min; P < 0.001) at 12 months. Absolute mean suppression in ghrelin at 60 min was enhanced (-40.50 ± 21.06 vs. -12.14 ± 19.74 pg/ml × min; P = 0.001). Peptide tyrosine-tyrosine response at 90 min remained unaltered in the standard care arm, whereas those in the Mandometer arm increased (P < 0.001): the mean 90-min response increased by 72 pg/ml [95% confidence interval (CI) 52-92 pg/ml] between baseline and 12 months. In a partial correlation analysis adjusting for change (Δ) in body mass index sd scores, Δ meal duration correlated negatively with Δ absolute suppression in ghrelin at 60 min (r = -0.58; P = 0.037; 95% CI -0.79 to -0.27) and Δ ghrelin area under the curve (r = -0.62; P = 0.025; 95% CI -0.81 to -0.31). CONCLUSIONS: Retraining obese adolescents to eat more slowly has a significant impact on the gastrointestinal hormone response to a carbohydrate load, suggesting that externally modifiable eating behaviors actually regulate the hormonal response to food.

Clinical efficiency in a simulated emergency and relationship to team behaviours: a multisite cross-sectional study.

OBJECTIVE: To identify specific aspects of teamworking associated with greater clinical efficiency in simulated obstetric emergencies. DESIGN: Cross-sectional secondary analysis of video recordings from the Simulation & Fire-drill Evaluation (SaFE) randomised controlled trial. SETTING: Six secondary and tertiary maternity units. SAMPLE: A total of 114 randomly selected healthcare professionals, in 19 teams of six members. METHODS: Two independent assessors, a clinician and a language communication specialist identified specific teamwork behaviours using a grid derived from the safety literature. MAIN OUTCOME MEASURES: Relationship between teamwork behaviours and the time to administration of magnesium sulfate, a validated measure of clinical efficiency, was calculated. RESULTS: More efficient teams were likely to (1) have stated (recognised and verbally declared) the emergency (eclampsia) earlier (Kendall's rank correlation coefficient τ(b) = -0.53, 95% CI from -0.74 to -0.32, P=0.004); and (2) have managed the critical task using closed-loop communication (task clearly and loudly delegated, accepted, executed and completion acknowledged) (τ(b) = 0.46, 95% CI 0.17-0.74, P=0.022). Teams that administered magnesium sulfate within the allocated time (10 minutes) had significantly fewer exits from the labour room compared with teams who did not: a median of three (IQR 2-5) versus six exits (IQR 5-6) (P=0.03, Mann-Whitney U-test). CONCLUSIONS: Using administration of an essential drug as a valid surrogate of team efficiency and patient outcome after a simulated emergency, we found that more efficient teams were more likely to exhibit certain team behaviours relating to better handover and task allocation.

Genes for prostaglandin synthesis, transport and inactivation are differentially expressed in human uterine tissues, and the prostaglandin F synthase AKR1B1 is induced in myometrial cells by inflammatory cytokines.

Prostaglandins (PGs) are important factors in the physiology of human parturition and the control of uterine contractility. We have characterized the expression of 15 genes from all stages of the PG pathway in human pregnant and non-pregnant (NP) myometrium and in other uterine tissues at delivery, and the results show patterns indicative of different capacities for PG synthesis and catabolism in each tissue. In placenta, the PG synthase expression profile favours production of PGD2, PGE2 and PGF2, with high levels of PG transporters and catabolic PG dehydrogenase suggesting rapid PG turnover. Choriodecidua is primed for PGE2, PGF2 and PGD2 production and high PG turnover, whereas amnion expresses genes for PGE2 synthesis with low levels of PG transporters and dehydrogenase. In umbilical cord, PGI2 synthase is highly expressed. In pregnant myometrium, PGI2, PGD2 and PGF2 synthases are highly expressed, whereas PG dehydrogenase is underexpressed. Myometrium from women with spontaneous or induced labour had higher expression of the PGH2 synthase PTGS2 than tissue from women not-in-labour. Myometrium from NP women had lower levels of PG synthases and higher levels of PG dehydrogenase than pregnant myometrium. Discriminant function analysis showed that expression of selected genes in myometrium could distinguish groups of women with different modes of labour from each other and from NP women. In cultured myometrial cells, there was a dose-dependent stimulatory effect of interleukin 1ß and tumour necrosis factor α on PTGS2, PTGES and AKR1B1 (PGF synthase) expression.

More to teamwork than knowledge, skill and attitude.

OBJECTIVE: To assess whether team performance in simulated eclampsia is related to the knowledge, skills and attitudes of individual team members. DESIGN: Cross-sectional analysis of data from the Simulation and Fire Drill Evaluation randomised controlled trial. SETTING: Six secondary and tertiary maternity units in south-west England. PARTICIPANTS: One hundred and fourteen maternity professionals in 19 teams of six members; one senior and one junior obstetrician; two senior and two junior midwives. METHODS: We validated a team performance ranking scheme with respect to magnesium administration (Magnesium Administration Rank, MAR) by expert consensus (face validity) and correlation with clinical measures (construct validity). We tested for correlation between MAR and measures of knowledge, skills and attitudes. MAIN OUTCOME MEASURES: Correlation between team performance (MAR) and scores in validated multiple-choice questionnaires (MCQs) (knowledge), a measure of individual manual skill to manage an obstetric emergency (skill) and scores in a widely used teamwork/safety attitude questionnaire (attitude). RESULTS: There was no relationship between team performance and cumulative individual MCQs, skill or teamwork/safety attitude scores. CONCLUSIONS: The knowledge, manual skills and attitudes of the individuals comprising each team, measured by established methods, did not correlate in this study with the team's clinical efficiency in the management of simulated eclampsia. The inference is that unidentified characteristic(s) play a crucial part in the efficiency of teams managing emergencies. Any emphasis of training programmes to promote individual knowledge, skills and attitudes alone may have to be re-examined. This highlights a need to understand what makes a team efficient in dealing with clinical emergencies.

The effect on visual function of Hydroview intraocular lens opacification: a cross-sectional study.

PURPOSE: Hydroview intraocular lenses (IOLs) have been associated with symptomatic opacification of the optic necessitating IOL exchange. Glare and misty vision have been noted as common presenting symptoms. This study's purpose was to investigate the impact of IOL opacification on objective measurements of visual function, including glare, and on vision-related quality of life. METHODS: All patients who underwent Hydroview IOL implantation at Bristol Eye Hospital between December 2000 and the end of February 2001 were invited for assessment along with patients found to have Hydroview IOL opacification in routine ophthalmic clinics. Glare, visual acuity, contrast sensitivity, visual field, and colour vision were assessed. Vision-related quality of life and subject's symptoms were determined by questionnaire. IOL opacification was assessed by slit lamp bio-microscopy and anterior segment photography. RESULTS: Data from 129 patients were analysed. Fifty subjects had opacified IOLs and 79 clear IOLs. Subjects with opacified IOLs showed dramatically higher levels of glare (adjusted mean difference of 0.63 log units 95% CI, 0.45-0.82; P<0.001) with only mildly reduced visual acuity (adjusted mean difference of 0.09 logMAR units 95% CI, 0.03-0.15; P=0.002). Opacification was associated with poorer contrast sensitivity (P<0.001), visual field (P<0.001), and with lower vision-related quality of life (P<0.001). CONCLUSIONS: This study highlights the significant impact IOL opacification has on visual performance and experience, in particular glare and consequent impact on quality of life. The study shows that to quantify accurately the effect of IOL opacification on vision glare must be assessed.

Carbetocin versus oxytocin for the prevention of postpartum haemorrhage following caesarean section: the results of a double-blind randomised trial.

OBJECTIVE: To compare the effectiveness of carbetocin and oxytocin when they are administered after caesarean section for prevention of postpartum haemorrhage (PPH). STUDY DESIGN: Double-blind randomised single centre study (1:1 ratio). SETTING: Teaching hospital in Bristol, UK with 6000 deliveries per annum. POPULATION: Women at term undergoing elective or emergency caesarean section under regional anaesthesia, excluding women with placenta praevia, multiple gestation and placental abruption. METHODS: Women were randomised to receive either carbetocin 100 microg or oxytocin 5 IU intravenously after the delivery of the baby. Perioperative care was otherwise normal and use of additional oxytocics was at the discretion of the operating obstetrician. Analysis was by intention to treat. PRIMARY OUTCOME MEASURE: The proportion of women in each arm of the trial that needed additional pharmacological oxytocic interventions. RESULTS: Significantly more women needed additional oxytocics in the oxytocin group (45.5% versus 33.5%, Relative risk 0.74, 95% CI 0.57-0.95). The majority of women had oxytocin infusions. There were no significant differences in the secondary outcomes, including major PPH, blood transfusions and fall in haemoglobin. CONCLUSIONS: Carbetocin is associated with a reduced use of additional oxytocics. It is unclear whether this may reduce rates of PPH and blood transfusions.

Reduced mortality compared with national averages following phacoemulsification cataract surgery: a retrospective observational study.

BACKGROUND: Higher or equal rates of mortality are associated with cataract surgery compared with the general population. Cataract surgery has advanced, and the clinical characteristics of the patient undergoing cataract surgery have changed. AIMS: To reinvestigate survival following cataract surgery. METHOD: Survival data were gathered up to the end of 2006 on 933 consecutive patients who underwent cataract surgery between December 2000 and February 2001. These data were compared with national and regional mortality figures, and standardised mortality ratios (SMR) were calculated. RESULTS: After adjusting for age and sex, there was a statistically significant reduced mortality compared with national (SMR = 0.88 (95% CI 0.79 to 0.99)) and regional figures (SMR = 0.87 (95% CI 0.78 to 0.98)). CONCLUSION: All previous studies found decreased survival among cataract surgery cohorts. These data differ from data at earlier times, as cataract surgery seems to be associated with increased survival. This illustrates the need for continual re-evaluation of accepted medical knowledge in the light of changes in practice and population demographics.

Overnight variations in cortisol, interleukin 6, tumour necrosis factor alpha and other cytokines in people with rheumatoid arthritis.

OBJECTIVE: To investigate overnight variations in absolute values and patterns of cytokines including interleukin 6 (IL6) and tumour necrosis factor alpha (TNFalpha) in rheumatoid arthritis (RA), and to relate any changes to those occurring in blood cortisol. METHODS: A total of 16 people (8 female) with active RA and who had received no recent glucocorticoids were admitted overnight. Blood samples were obtained at 13 time points between 21.00 and 10.00. RESULTS: The geometric mean IL6 concentration rose significantly from 35 pg/ml at 22:00 to 64 pg/ml at 07:15 (repeated measures analysis of variance (ANOVA), p<0.001). The geometric mean cortisol concentration rose significantly overnight from 57 ng/ml at 01:00 to 229 ng/ml at 07:15 (repeated measures ANOVA, p<0.001). Neither TNFalpha nor the other cytokines measured changed significantly. Using cubic regression modelling IL6 began to rise before cortisol (range 0.01 to 4.83 h) in eight participants and after cortisol (range 1.11 to 5.14 h) in three participants. In a random coefficient model including data from all participants, the estimated mean IL6 value began to rise 3.05 h before the estimated mean cortisol value, with the IL6 peak occurring 0.70 h before the cortisol peak. CONCLUSION: The mean IL6 and cortisol concentrations showed a significant overnight variation. Neither TNFalpha nor the other cytokines measured changed significantly. In a random coefficient model IL6 began to rise approximately 3 h, and reached a peak about 40 min, before cortisol. These studies confirm that there are abnormalities in plasma cortisol and IL6 concentrations and dynamics. The data also link the overnight rise in IL6 to the circadian variation in symptoms.

Safety and effectiveness of diclofenac sodium in assisted reproduction treatment: a randomized prospective double-blind study.

Insufficient information is available on the safety and efficacy of the potent analgesic diclofenac sodium administered following oocyte retrieval. The present study aims to address this issue. A randomized prospective double-blind study of 381 assisted conception cycles was performed. Patients included were <40 years old with early follicular FSH <10 IU/l and no medical contraindications to receiving non-steroidal anti-inflammatory drugs. Patients were randomized to either receive diclofenac sodium suppository 100 mg (Voltarol) at the end of oocyte retrieval or nothing. Effect of diclofenac sodium on outcome was assessed. A total of 187 IVF/intracytoplasmic sperm injection cycles were randomized to receive diclofenac sodium at the end of oocyte retrieval and 194 cycles did not receive diclofenac sodium. The number reaching embryo transfer in the two groups was 185 and 190 respectively. The implantation and pregnancy rates per embryo transfer were 25.3% and 38.9% in the Voltarol group and 21.6% and 32.6% in the group randomized not to receive Voltarol. Use of diclofenac sodium did not significantly compromise the implantation and pregnancy rates. Patients randomized to receive diclofenac sodium had statistically significantly reduced pain scores prior to discharge (P = 0.030). Administration of diclofenac sodium for analgesia following oocyte retrieval did not compromise treatment outcome.

Elevated glucose concentrations during an oral glucose tolerance test are associated with the presence of metabolic syndrome in childhood obesity.

AIMS: To investigate whether changes in glucose concentrations during an OGTT in obese children reflect the presence of peripheral insulin resistance and/or cardiovascular risk factors more closely than single measurements of fasting plasma glucose (FPG). METHODS: One hundred and twenty-two obese children attending our Paediatric Obesity Service underwent formal OGTTs, following the measurement of blood pressure and fasting levels of insulin, glucose and lipid profiles in the majority. Fasting insulin was used as a surrogate measure of insulin sensitivity. Three different child-specific definitions for metabolic syndrome were used to identify clustering of cardiovascular risk factors in 65 of these children. RESULTS: In the whole group, 10.7% had IGT but changes in glucose during the OGTT were not influenced by age, sex, pubertal status or raw (or age- and sex-adjusted) body mass index (BMI). During the OGTT, FPG, glucose at 60 min and area under the glucose curve correlated highly with fasting insulin. Children with metabolic syndrome (defined using any of three definitions) had comparable FPG levels to those without metabolic syndrome, but they demonstrated significantly elevated glucose levels at 60 min. On sub-group analysis, obese children with normal carbohydrate metabolism were significantly more likely to have a 1 h glucose level > or = 7.8 mmol/l if they had metabolic syndrome (P = 0.026). CONCLUSIONS: These data suggest that an elevated 1 h post-load glucose measurement is seen in obese children who have a coexistent clustering of cardiovascular risk factors.

Patient-actor perception of care: a comparison of obstetric emergency training using manikins and patient-actors.

OBJECTIVE: To explore the effect of training on patient-actor perception of care during simulated obstetric emergencies. METHOD: A subanalysis from a prospective randomised controlled trial in six UK hospitals and the Bristol Medical Simulation Centre, UK. Midwives and doctors working in participating hospitals were eligible for inclusion. 140 participants (22 junior and 23 senior doctors, 47 junior and 48 senior midwives) were randomised to one of four obstetric emergency training interventions: 1-day course at local hospitals; 1-day course at simulation centre; 2-day course with teamwork training at local hospitals; and 2-day course with teamwork training at simulation centre. Local training used patient-actors and low-fidelity part-task trainers whereas simulation centre training used full-bodied computerised manikins and high-fidelity part-task trainers. Three weeks before and after the training, the participants managed three simulated obstetric emergencies. Patient-actors scored their care after each simulation using a patient-actor perception score (communication, safety, respect). RESULTS: The following numbers of scores were awarded: 139 and 132 participant and 46 and 48 team scenarios, before and after training, respectively. There was a significant improvement in all scores in all scenarios after the training (p = 0.017 to >0.001). Perception of safety and communication during postpartum haemorrhage was significantly improved following training with patient-actors compared with training with manikins (safety p = 0.048, communication p = 0.035). Teamwork training offered no additional benefit to patient-actors' perception of their care. CONCLUSIONS: All multiprofessional training improved patient-actor perception of care. Training using a patient-actor may be better at improving perception of safety and communication than training with a computerised manikin simulator.

Change in knowledge of midwives and obstetricians following obstetric emergency training: a randomised controlled trial of local hospital, simulation centre and teamwork training.

OBJECTIVES: To explore the effect of obstetric emergency training on knowledge. Furthermore, to assess if acquisition of knowledge is influenced by the training setting or teamwork training. DESIGN: A prospective randomised controlled trial. SETTING: Training was completed in six hospitals in the South West of England, UK and at the Bristol Medical Simulation Centre, UK. POPULATION: Midwives and obstetric doctors working for the participating hospitals were eligible for inclusion in the study. A total of 140 participants (22 junior and 23 senior doctors, 47 junior and 48 senior midwives) were studied. METHODS: Participants were randomised to one of four obstetric emergency training interventions: (1) 1-day course at local hospital, (2) 1-day course at simulation centre, (3) 2-day course with teamwork training at local hospital and (4) 2-day course with teamwork training at simulation centre. MAIN OUTCOME MEASURES: Change in knowledge was assessed by a 185 question Multiple-Choice Questionnaire (MCQ) completed up to 3 weeks before and 3 weeks after the training intervention. RESULTS: There was a significant increase in knowledge following training; mean MCQ score increased by 20.6 points (95% CI 18.1-23.1, P < 0.001). Overall, 123/133 (92.5%) participants increased their MCQ score. There was no significant effect on the MCQ score of either the location of training (two-way analysis of variants P = 0.785) or the inclusion of teamwork training (P = 0.965). CONCLUSIONS: Practical, multiprofessional, obstetric emergency training increased midwives' and doctors' knowledge of obstetric emergency management. Furthermore, neither the location of training, in a simulation centre or in local hospitals, nor the inclusion of teamwork training made any significant difference to the acquisition of knowledge in obstetric emergencies.

Use of clinical risk factors to identify postmenopausal women with vertebral fractures.

INTRODUCTION AND HYPOTHESIS: Previous studies have been unable to identify risk factors for prevalent vertebral fractures (VF), which are suitable for use in selection strategies intended to target high-risk sub-groups for diagnostic assessment. However, these studies generally consisted of large epidemiology surveys based on questionnaires and were only able to evaluate a limited number of risk factors. Here, we investigated whether a stronger relationship exists with prevalent VF when conventional risk factors are combined with additional information obtained from detailed one-to-one assessment. METHODS: Women aged 65-75 registered at four geographically distinct GP practices were invited to participate (n=1,518), of whom 540 attended for assessment as follows: a questionnaire asking about risk factors for osteoporosis such as height loss compared to age 25 and history of non-vertebral fracture (NVF), the get-up-and-go test, Margolis back pain score, measurement of wall-tragus and rib-pelvis distances, and BMD as measured by the distal forearm BMD. A lateral thoraco-lumbar spine X-ray was obtained, which was subsequently scored for the presence of significant vertebral deformities. RESULTS: Of the 509 subjects who underwent spinal radiographs, 37 (7.3%) were found to have one or more VF. Following logistic regression analysis, the four most predictive clinical risk factors for prevalent VF were: height loss (P=0.006), past NVF (P=0.004), history of back pain (P=0.075) and age (P=0.05). BMD was also significantly associated with prevalent VF (P=0.002), but its inclusion did not affect associations with other variables. Factors elicited from detailed one-to-one assessment were not related to the risk of one or more prevalent VFs. The area under ROC curves derived from these regressions, which suggested that models for prevalent VF had modest predictive accuracy, were as follows: 0.68 (BMD), 0.74 (four clinical risk factors above) and 0.78 (clinical risk factors + BMD). Analyses were repeated in relation to the subgroup of 13 patients with two or more VFs, which revealed that in this instance, the Margolis back pain score and rib-pelvis distance were associated with the presence of multiple VFs (P=0.022 and 0.026, respectively). Moreover, the predictive value as reflected by the ROC curve area was improved: 0.80 (BMD), 0.88 (the four most predictive clinical risk factors consisting of the height loss, past NVF, Margolis back pain score and rib-pelvis distance) and 0.91 (clinical risk factors + BMD). CONCLUSIONS: Evaluation of additional risk factors from detailed one-to-one assessment does not improve the predictive value of risk factors for one or more prevalent vertebral deformities in postmenopausal women. However, the use of factors such as the Margolis back pain score and rib-pelvis distance may be helpful in identifying postmenopausal women at high risk of multiple prevalent VFs.