Can community midwives prevent antenatal depression? An external pilot study to test the feasibility of a cluster randomized controlled universal prevention trial.

BACKGROUND: Repeated epidemiological surveys show no decline in depression although uptake of treatments has grown. Universal depression prevention interventions are effective in schools but untested rigorously in adulthood. Selective prevention programmes have poor uptake. Universal interventions may be more acceptable during routine healthcare contacts for example antenatally. One study within routine postnatal healthcare suggested risk of postnatal depression could be reduced in non-depressed women from 11% to 8% by giving health visitors psychological intervention training. Feasibility and effectiveness in other settings, most notably antenatally, is unknown. METHOD: We conducted an external pilot study using a cluster trial design consisting of recruitment and enhanced psychological training of randomly selected clusters of community midwives (CMWs), recruitment of pregnant women of all levels of risk of depression, collection of baseline and outcome data prior to childbirth, allowing time for women 'at increased risk' to complete CMW-provided psychological support sessions. RESULTS: Seventy-nine percent of eligible women approached agreed to take part. Two hundred and ninety-eight women in eight clusters participated and 186 termed 'at low risk' for depression, based on an Edinburgh Perinatal Depression Scale (EPDS) score of <12 at 12 weeks gestation, provided baseline and outcome data at 34 weeks gestation. All trial protocol procedures were shown to be feasible. Antenatal effect sizes in women 'at low risk' were similar to those previously demonstrated postnatally. Qualitative work confirmed the acceptability of the approach to CMWs and intervention group women. CONCLUSION: A fully powered trial testing universal prevention of depression in pregnancy is feasible, acceptable and worth undertaking.

Improving consultations in oncology: the development of a novel consultation aid.

BACKGROUND: The way in which patients receive bad news in a consultation can have a profound effect in terms of anxiety, depression and subsequent adjustment. Despite investment in well-researched communication skills training and availability of decision-making aids, communication problems in oncology continue to be encountered. METHODS: We conducted a mixed-methods study in a large UK Cancer Centre to develop a novel consultation aid that could be used jointly by patients and doctors. Consultations were audio-recorded and both the doctors and the patients were interviewed. We used conversation analysis to analyse the consultation encounter and interpretative phenomenological analysis to analyse the interviews. Key themes were generated to inform the design of the aid. RESULTS: A total of 16 doctors were recruited into the study along with 77 patients. Detailed analysis from 36 consultations identified key themes (including preparation, information exchange, question-asking and decision making), which were subsequently addressed in the design of the paper-based aid. CONCLUSIONS: Using detailed analysis and observation of oncology consultations, we have designed a novel consultation aid that can be used jointly by doctors and patients. It is not tumour-site specific and can potentially be utilised by new and follow-up consultations.

Prescribing in pregnancy for women with diabetes: use of potential teratogenic drugs and contraception.

AIMS: To describe contraception use and the prescription of drugs that are either not recommended in pregnancy or are potentially teratogenic by diabetes type in women of child-bearing age. METHODS: Retrospective, cross-sectional chart review undertaken in 22 general practices in Warwickshire, UK. Demographic, anthropometric, medical history, medication and contraception data were extracted from women aged 14 to 49 years with pre-existing diabetes. Independent sample t-test, Mann-Whitney test and χ(2) -test were used to test for univariable associations and multiple logistic regression was used to adjust for confounders. RESULTS: Four hundred and seventy eligible women were identified; the majority had a diagnosis of Type 2 diabetes (67%). Thirty-six per cent and 64% of women with Type 1 and Type 2 diabetes, respectively, were prescribed drugs not recommended for use in pregnancy (P < 0.001). Less than half were using concomitant contraception (P < 0.001). No significant difference of contraception use was observed between women who were and were not taking drugs not recommended for use in pregnancy (40 vs. 41%, P = 0.4). CONCLUSIONS: Use of drugs not recommended during pregnancy in women with diabetes of child-bearing age is common but is not associated with increased use of contraception. There is need to identify and overcome barriers to effective contraception use for this population group in order to facilitate optimal management of cardiovascular risk.

Validating two survey methods for identifying cases of autism spectrum disorder among adults in the community.

BACKGROUND: There are no tested methods for conducting epidemiological studies of autism spectrum disorders (ASDs) in adult general population samples. We tested the validity of the Autism Diagnostic Observation Schedule module-4 (ADOS-4) and the 20-item Autism-Spectrum Quotient (AQ-20). METHOD: Randomly sampled adults aged ≥16 years were interviewed throughout England in a general population multi-phase survey. The AQ-20 was self-completed by 7353 adults in phase 1. A random subset completed phase 2, ADOS-4 assessments (n=618); the probability of selection increased with AQ-20 score. In phase 3, informant-based Diagnostic Interview Schedule for Social and Communication Disorders (DISCO) and Autism Diagnostic Interview-Revised (ADI-R) developmental assessments were completed (n=56). Phase 1 and 2 data were presented as vignettes to six experienced clinicians (working in pairs). The probability of respondents having an ASD was compared across the three survey phases. RESULTS: There was moderate agreement between clinical consensus diagnoses and ADOS-4. A range of ADOS-4 caseness thresholds was identified by clinicians: 5+ to 13+ with greatest area under the curve (AUC) at 5+ (0.88). Modelling of the presence of ASD using 56 DISCO assessments suggested an ADOS-4 threshold in the range of 10+ to 13+ with the highest AUC at ADOS 10+ to 11+ (0.93-0.94). At ADOS 10+, the sensitivity was 1 [95% confidence interval (CI) 0.59-1.0] and the specificity 0.86 (95% CI 0.72-0.94). The AQ-20 was only a weak predictor of ADOS-4 cases. CONCLUSIONS: Clinically recommended ADOS-4 thresholds are also recommended for community cases: 7+ for subthreshold and 10+ for definite cases. Further work on adult population screening methods is needed.

Poorer graft survival in ethnic minorities: results from a multi-centre UK study of kidney transplant outcomes.

BACKGROUND: The STEPP group was established to investigate factors that affect long-term transplant outcomes including quality of life and other patient-reported outcomes between different transplant centers and patients. METHODS: Data were collected for 2,650 patients whose first renal transplant took place between 1992 and 2003 in five UK centers. Univariable and multivariable survival analyses were performed using eleven candidate explanatory variables. RESULTS: Graft survival was worse in Black (B) patients (HR B v W 1.57 95% CI 1.10, 2.24), and in South Asian (A) patients (HR A v W 1.39 95% CI 1.03, 1.85) compared to Whites (W) after adjusting for other factors including HLA mismatch, and time on dialysis. Time spent on dialysis pre-transplantation was non-linearly associated with patient, but not death-censored graft survival. Losing a functioning graft was a strong predictor of patient death. One site had both the best graft and the worst patient survival. CONCLUSIONS: Differences in patient and graft survival between ethnic groups cannot be explained by currently recognized factors. These, and the complex balance between optimum patient and graft survival which differs between sites in this study require further investigation.

Mental health problems among labour children in the Gaza Strip.

BACKGROUND: There is increasing international concern over the rising number of children involved in labour, particularly in developing countries. Despite the multitude of related risk factors, and some evidence on their social needs, there has been limited research on these children's mental health. METHODS: The aim of this study was to establish the association between labour-related variables and mental health problems among 780 children in labour (aged 9-18 years, mean 15.8) in the Gaza Strip. Measures included a demographic checklist, the Strengths and Difficulties Questionnaire, the Spence Children's Anxiety Scale and the Depression Self-rating Scale for Children. RESULTS: Children came from large families (73.2% had eight or more siblings), mainly worked to increase family income, worked an average 6.8 h per day (range 1-16), and only 37.1% had regular rest. Ratings of mental health problems were predicted by different factors, i.e. total difficulties scores by poor friendship relationships and lack of health insurance; anxiety scores by selling in the streets, working to help family, low family income and lack of health insurance; and depression scores by parents' dissatisfaction with the job and longer working hours. CONCLUSIONS: Mental health problems of children in labour are likely to be associated with socio economic determinants, as well as factors related to their under age employment. Policy, legislation and preventive programmes from statutory and voluntary agencies should adopt an integrated approach in meeting their mental health needs, by enhancing protective factors such as return to school.

Electrophysiological markers of large fibre sensory neuropathy: a study of sensory and motor conduction parameters.

BACKGROUND: The frequency of sural sensory nerve action potential (SNAP) abnormalities in large fibre sensory neuropathy (LFSN) is uncertain. When sural SNAPs are normal, the sural/radial amplitude ratio (SRAR) was found to improve diagnostic yield in some studies. Motor parameters have been studied rarely, but may be helpful in this setting. METHODS: The electrophysiology of 105 consecutive patients with LFSN was reviewed and compared with that of 62 controls. We determined (i) the frequency of abnormal sural SNAPs, (ii) the proportion of patients with normal sural SNAPs but reduced SRAR <0.21 and (iii) the utility of motor studies (motor nerve conduction velocity, compound muscle action potential, F-wave). RESULTS: Reduced age-adjusted sural SNAPs were present in 54.3% of all patients. In those with normal age-adjusted sural SNAPs, SRAR <0.21 offered a sensitivity of 52.1% and specificity of 83.9%, and prolonged lower limb F-wave latency >105% of the upper limit of normal (ULN) offered a sensitivity of 29.2% and specificity of 90%. Independently and in combination, both parameters significantly improved diagnostic yield. DISCUSSION: The combined use of SRAR <0.21 and/or lower limb F-wave delay >105% of the ULN may be useful in patients with LFSN and normal sural SNAPs.

Blood pressure in renal transplant recipients: are there independent predictors for achieving target blood pressure?

BACKGROUND: Post-transplant hypertension is a major modifiable risk factor for graft and patient survival. The aim of this study was to establish independent predictors for achieving systolic, diastolic and overall blood pressure target [Kidney Disease Outcome Quality Initiative (K/DOQI) target blood pressure <130/80 mm Hg] in renal-transplant recipients (RTRs) and to consider whether current management strategies are adequate to achieve this aim. METHODS: The most recent office blood pressure readings were collected for 513 RTRs at least 6 months after transplantation. In addition, demographic data, comorbidities, medications prescribed, weight, duration of transplantation, and laboratory parameters were recorded. Logistic regression analysis was used to determine whether any covariables were significant (p < 0.05) independent predictors of controlled blood pressure (<130/80 mm Hg). RESULTS: Approximately 50% of the RTRs had blood pressures <130/80. There was a marked terminal digit preference demonstrated. Subjects who were female, had diabetes, did not have heart disease or had a lower albumin:creatinine ratio had a higher probability to achieve good blood pressure control. Diabetics were more likely to be prescribed 3 or more antihypertensive agents. CONCLUSIONS: This study shows that improvements in blood pressure control can be achieved. People with diabetes were 2.1 times more likely to meet target blood pressure. Further improvements in blood pressure control may require different treatment strategies in addition to the current pharmacological approach.

Primary prevention of type-2 diabetes and heart disease: action research in secondary schools serving an ethnically diverse UK population.

BACKGROUND: Escalating rates of childhood obesity are likely to have an impact on the prevalence of coronary heart disease and type-2 diabetes. We aimed to identify barriers to healthy lifestyles and evaluate the effectiveness of an action research approach to lifestyle modification in secondary schools. METHODS: An action research partnership between schools and university researchers involved pupils aged 11-15 in five inner-city secondary schools serving a predominantly South Asian population in Leicester, UK. Data collection included baseline and follow-up diet and physical activity questionnaires. Focus groups and observational visits were used to identify barriers, assist with developing tailored interventions and review the impact of the study. RESULTS: Working with secondary schools presented challenges but a useful partnership was sustained. Qualitative feedback suggested that this had raised awareness of healthy lifestyle issues in participating schools. Barriers in pupils included low prioritization of health when making lifestyle choices. Sub-optimal diet and activity habits were identified at baseline. Overall, these persisted at follow-up, although some limited positive changes were identified. CONCLUSIONS: Using action research methods in this context is challenging but can facilitate useful data collection and may have a modest impact on lifestyle behaviours.

Flavour conditioning and alcohol: a multilevel model of individual differences.

Previous research shows that dependent drinkers respond more strongly to alcohol-related cues and suggests that alcohol cue-reactivity may be relevant to understanding dependence liability. However, a significant weakness in many studies is the fact that cue-reactivity is studied without actually conditioning subjects; responses to alcohol-related cues are simply assumed to be conditioned responses. The current report attempts to overcome this weakness by studying alcohol cue-reactivity following a flavour-conditioning procedure. A statistical model of individual differences in cue-reactivity was constructed using previous alcohol exposure, alcohol tolerance, and personality as predictor variables. Although there was no evidence for overall differences in subjective and psychophysiological responses to alcohol and soft-drink paired flavours, there were marked individual differences in responding to the different flavours. The statistical model showed that reward sensitivity (high extroversion, high neuroticism), heavier levels of drinking, and higher levels of tolerance to the intoxicating effects of alcohol were associated with lower levels of skin conductance in the presence of alcohol paired flavours.

Concordance between tuberculin skin test and interferon-γ assay and interferon-γ response to mitogen in pediatric tuberculosis contacts.

There is paucity of data on the usefulness of Interferon (IFN)-γ release assays in the diagnosis of latent tuberculosis infection (LTBI) in children. The aim of this study was to evaluate the concordance between tuberculin skin test (TST) and QuantiFERON®-TB Gold in-tube (QFT-GIT) test, when used in contact screening to diagnose LTBI in asymptomatic children. We also aimed to determine if there is any correlation between age and the IFN-γ response to the mitogen. Children assessed at Leicester Royal Infirmary and Glenfield hospital (Leicester, United Kingdom) as part of tuberculosis contact screening were studied. Two hundred and eighty three children (mean [SD] age 5.3 [4.1] years, 148 males) underwent clinical examination, chest radiograph, TST, and QFT-GIT test. In this group, there was good agreement (κ = 0.70 [95%CI = 0.57-0.83], P < 0.0001) between TST and QFT-GIT. Of the 18 children in this group with an indeterminate QFT-GIT test result, all except one were < 5-years-old. To study the correlation between age and the IFN-γ response to the mitogen, results of 282 children who had QFT-GIT test as part of tuberculosis contact screening during the study period were analyzed. A significant correlation was observed between age and the IFN-γ response to the mitogen (r = 0.47, P < 0.001). Whilst our study re-emphasizes the good overall concordance between TST and QFT-GIT, the high rate of indeterminate results and the low IFN-γ response to the mitogen seen in young children raise some concerns about the performance of IGRAs in this group.

Post-discharge surveillance to identify colorectal surgical site infection rates and related costs.

A growing number of surveillance studies have highlighted concerns with relying only on data from inpatients. Without post-discharge surveillance (PDS) data, the rate and burden of surgical site infections (SSIs) are underestimated. PDS data for colorectal surgery in the UK remains to be published. This is an important specialty to study since it is considered to have the highest SSI rate and is among the most expensive to treat. This study of colorectal SSI used a 30 day surveillance programme with telephone interviews and home visits. Each additional healthcare resource used by patients with SSI was documented and costed. Of the 105 patients who met the inclusion criteria and completed the 30 day follow-up, 29 (27%) developed SSI, of which 12 were diagnosed after discharge. The mean number of days to presentation of SSI was 13. Multivariable logistic analysis identified body mass index as the only significant risk factor. The additional cost of treating each infected patient was pound sterling 10,523, although 15% of these additional costs were met by primary care. The 5 month surveillance programme cost pound sterling 5,200 to run. An analysis of the surveillance nurse's workload showed that the nurse could be replaced by a healthcare assistant. PDS to detect SSI after colorectal surgery is necessary to provide complete data with accurate additional costs.

An investigation of medication adherence to 5-aminosalicylic acid therapy in patients with ulcerative colitis, using self-report and urinary drug excretion measurements.

BACKGROUND: Non-adherence to 5-aminosalicylic acid (5-ASA) medication can limit the established benefits of this therapy in ulcerative colitis (UC). AIM: To determine rates and predictors of non-adherence to 5-ASA therapy in UC patients. METHODS: Medication adherence was assessed using self-report data and urinary drug excretion measurements. Participants completed a study-specific questionnaire and two validated questionnaires: Beliefs about Medicine Questionnaire (BMQ)-Specific and Satisfaction with Information about Medicines Scale. RESULTS: A total of 169 participants provided self-report adherence data; 151 also provided urine samples. Adherence rates were 111/151 (68%) according to self-report and 90/151 (60%) according to urine analysis, but the two measures were not correlated (chi(2) = 0.12, P = 0.725). Logistic regression identified a significant association between self-reported non-adherence and younger age [odds ratio (OR) for increased age 0.954, 95% confidence interval (CI) 0.932-0.976] and also doubts about personal need for medication (OR for BMQ - Specific Necessity scores 0.578, 95% CI 0.366-0.913). For non-adherence based on urine analysis, only South Asian ethnicity was independently associated with non-adherence (OR 2.940, 95% CI 1.303-6.638). CONCLUSIONS: Our observations confirm the difficulty of accurately assessing medication adherence. Nonmodifiable (younger age, South Asian ethnicity) and potentially modifiable (medication beliefs) predictors of non-adherence were identified.

Efficacy of antiglaucoma fixed combination therapy versus unfixed components in reducing intraocular pressure: a systematic review.

AIM: To evaluate the efficacy of the fixed combination ocular hypotensive therapies compared with their non-fixed components used concomitantly for lowering intraocular pressure (IOP) in glaucoma and ocular hypertension. METHODS: A systematic review of the literature, up to May 2007, without limits on year or language of publication was performed. Seven randomised controlled trials (n = 2,083 eyes) were identified. Assessment of methodological quality was made using standardised criteria. Results were pooled quantitatively using meta-analysis methods, and statistical analysis was performed using STATA software. The difference in mean intraocular pressure (mm Hg) from baseline between the fixed combination and non-fixed component therapies was compared. Non-inferiority in terms of efficacy was set at an upper confidence limit of < or =1.5 mm Hg for all time points (hour (Hr)0, Hr2 and Hr8) and evaluated at 12 weeks. Safety was evaluated from data on adverse events as reported in the included studies. RESULTS: Of the 679 abstracts identified, seven randomised controlled trials met the selection criteria. The quality scores of included studies were high (mean of 29.4, maximum score 30). The mean differences (95% CI) and p values at 12 weeks were as follows: 0.200 mm Hg, (CI -0.106 to 0.507), p = 0.20 for Hr0, 0.393 mm Hg (CI 0.038 to 0.747), p = 0.03 for Hr2 and 0.501 mm Hg (CI 0.156 to 0.846), p = 0.004 for Hr8. Although both Hr2 and Hr8 showed statistical significance favouring the non-fixed combinations, the non-inferiority measure < or =1.5 mm Hg upper confidence limit was not exceeded. CONCLUSIONS: Fixed combination therapies are equally safe and effective at lowering IOP as their non-fixed components administered concomitantly.

Comparison of accuracy of lag screw placement in cephalocondylic nails and sliding hip screw plate fixation for extracapsular fractures of the neck of femur.

This study compared the accuracy of lag screw placement between extracapsular femoral fractures fixed with sliding hip screw plate systems and those fixed with cephalocondylic nails. It involved 75 retrospective radiographs of fractures fixed with either a cephalocondylic nail (32) or a sliding hip screw plate system (43). Postoperative anteroposterior and lateral radiographs of the hip were scanned using a digital X-ray scanner and measured using computer software. Measurements were conducted by two independent observers, and the radiographs were calibrated to correct for magnification. Accuracy of lag screw placement was determined by "tip apex distance," described by Baumgaertner et al., and by the ratio method described by Parker. The mean tip apex distance was 24.0 mm in sliding hip screw plate systems and 21.1 mm in cephalocondylic nails. This was found to be statistically significant. Lag screw placement through cephalocondylic nails is more accurate and therefore has less chance of cut-out compared with sliding hip screw plate systems. There was no statistically significant difference using Parker's ratio method because this method quantifies the direction of the screw rather than the depth of penetration.

Multiple variable interval schedule behaviour in humans: effects of ethanol, mood, and reinforcer size on responding maintained by monetary reinforcement.

Ethanol is an effective reinforcer but, in common with other drugs of abuse, it may derive some of its reinforcing properties from the effects it has on behaviour maintained by other reinforcers. However, any assessment of ethanol's hypothesized effect on behaviour maintained by other reinforcers must take into account the fact that ethanol may have multiple mechanisms of action. In order to address this problem the experiments reported herein used a procedure based upon Herrnstein's Matching Law which allowed joint assessment of subjects' motor capacity and reinforcer sensitivity. The effect of ethanol (0, 0.3, and 0.6 g/kg) on motor capacity and reinforcer sensitivity was assessed by studying behaviour maintained by monetary reinforcement. In the first experiment the procedure was validated by showing that the behaviour of subjects was sensitive to changes in reinforcer value and in the second experiment 0.6 g/kg ethanol reduced motor capacity but did not affect reinforcer sensitivity. As a secondary hypothesis we also studied the effect of mood on reinforcer sensitivity and motor capacity. It was found that lower mood scores (lower hedonic tone) were associated with reduced reinforcer sensitivity and that male subjects showed higher motor capacity than females. However, there was also a mood by sex interaction, which indicated that higher motor capacity in males was only found in the presence of lower mood scores. The results are discussed in relation to the mechanisms of ethanol's dopaminergic effects, interactions between ethanol and other drugs of abuse, and the changes in reinforcer sensitivity which are thought to occur in depression.