A cluster randomised controlled trial of a nutrition education intervention in the community.

BACKGROUND: Patients with enteral feeding tubes are increasingly managed in their home environment and these patients require support from a range of healthcare professionals. METHODS: A cluster randomised trial of an educational intervention was undertaken among General Practitioners and nurses both in the community and in nursing home caring for patients recently discharged to primary care. This was a short, duration (<1 h), nutrition education programme delivered in the work place soon after the patient was discharged from hospital. The primary outcome was an improvement in knowledge immediately after the intervention and the secondary outcome was knowledge at 6 months. RESULTS: Those in the intervention group had improved knowledge, which was significantly greater than those in the control group (P < 0.001), although this knowledge was not sustained at 6 months. CONCLUSIONS: A short, work-based targeted nutrition education programme is effective for improving knowledge among general practitioners and nurses both in the community and in nursing homes.

An audit of orthodontic referrals using IOTN as a comparison.

UNLABELLED: It is important that resources for orthodontic treatment within the Health Service Executive (HSE) are directed towards those children most in need of treatment. At present, children are referred using existing HSE guidelines. OBJECTIVES: To assess the level of treatment need in a sample of patients on the orthodontic waiting list in the North Eastern division of the HSE using the Index of Orthodontic Treatment Need (IOTN) as an objective comparison. Also, to compare these results with the findings of a similar audit in 2003 and to assess the effectiveness of recommendations from the 2003 audit. METHOD: Fifty models from each of two orthodontic units were selected. These were scored for the dental health component (DHC) and aesthetic component (AC) of IOTN by a calibrated examiner. RESULTS: In the 2005 audit, 100% of patients fell into DHC grades 4 or 5. These grades constitute a great need for treatment on dental health grounds. In the 2003 audit, 97% of patients fell into these two grades. The remaining 3% of children in 2003 were fostered and therefore entitled to orthodontic treatment under HSE guidelines. An average of 63.5% of patients fell into AC grades 8-10, i.e., deemed to be in great need of treatment on aesthetic grounds. CONCLUSION: The HSE screening guidelines identify patients in great need of orthodontic treatment using IOTN as an objective assessment of this need. The sensitivity of these guidelines requires assessment by measuring the level of unmet treatment need in 15-year-olds in the region. Recommendations arising from the 2003 audit relating to the filling of referral forms and the improvement of study model quality were found to have been effective.

Cryotherapy for acute ankle sprains: a randomised controlled study of two different icing protocols.

BACKGROUND: The use of cryotherapy in the management of acute soft tissue injury is largely based on anecdotal evidence. Preliminary evidence suggests that intermittent cryotherapy applications are most effective at reducing tissue temperature to optimal therapeutic levels. However, its efficacy in treating injured human subjects is not yet known. OBJECTIVE: To compare the efficacy of an intermittent cryotherapy treatment protocol with a standard cryotherapy treatment protocol in the management of acute ankle sprains. SUBJECTS: Sportsmen (n = 44) and members of the general public (n = 45) with mild/moderate acute ankle sprains. METHODS: Subjects were randomly allocated, under strictly controlled double blind conditions, to one of two treatment groups: standard ice application (n = 46) or intermittent ice application (n = 43). The mode of cryotherapy was standardised across groups and consisted of melting iced water (0 degrees C) in a standardised pack. Function, pain, and swelling were recorded at baseline and one, two, three, four, and six weeks after injury. RESULTS: Subjects treated with the intermittent protocol had significantly (p<0.05) less ankle pain on activity than those using a standard 20 minute protocol; however, one week after ankle injury, there were no significant differences between groups in terms of function, swelling, or pain at rest. CONCLUSION: Intermittent applications may enhance the therapeutic effect of ice in pain relief after acute soft tissue injury.

Total radical trapping antioxidant potential (TRAP) and exercise.

The relationship between physical activity, physical fitness and total radical trapping antioxidant potential (TRAP) was examined in the Northern Ireland Health and Activity Survey. This was a cross-sectional population study (n = 1600) using a two-stage probability sample of the population. TRAP was calculated using the sum of the individual serum antioxidant concentrations (urate, protein thiols, ascorbate, alpha tocopherol and bilirubin) multiplied by their respective stoichiometric values. Physical fitness was determined by estimation of VO2max by extrapolation from submaximal oxygen uptake, and physical activity was recorded by computer-assisted interview. Mean serum TRAP concentrations were significantly higher in males (653 +/- 8.2 mumol/l, mean +/- SEM) compared to females (564 +/- 8.0 mumol/l) (p < 0.0001). Both male and female smokers had significantly lower TRAP values than non-smokers (males p < 0.0001, females p = 0.02). In females, there was a positive relationship of TRAP with age (p < 0.001) and body mass index (p < 0.001) but a negative relationship with physical fitness (p < 0.05). The known beneficial effects of exercise and activity do not appear to be directly mediated through increased antioxidant status.

Sterilization and disinfection in general practice within university health services.

A postal questionnaire on 'sterilization and disinfection' was sent to all 144 nurse members of the British Association of Health Services in Higher Education (BAHSHE). Forty-nine (34%) completed valid questionnaires were returned. Despite the majority of practices performing minor surgical procedures such as cervical cytology (N= 40, 82%), ear syringing (N= 44, 90%) and wound dressing (N= 49, 100%), only 11 (22%) had access to a sterile supply department (SSD), and the definitions of sterilization and disinfection were only identified by 23 (52%) and 14 (32%) of the respondents, respectively. Forty-one (84%) respondents had a benchtop sterilizer (30 had a benchtop sterilizer, 11 a vacuum sterilizer and two had both), although there was considerable confusion on their appropriate use and maintenance. Just over half had written procedures for sterilizer use, no practice changed the sterilizer water on a daily basis as recommended by the Medical Devices Agency (MDA), few kept a sterilizer logbook and even fewer had read the MDA Device Bulletin on benchtop sterilizers. The majority of respondents voiced an interest in attending a workshop on sterilization and disinfection. We conclude that despite the location of the general practices within an academic environment, the concept of infection control is clearly not understood by university health service staff. As the implications of a failure to implement proper infection control procedures are potentially serious, the need for adequate education and training of staff is of critical importance.

Sterilization and disinfection in general practice in Northern Ireland.

In view of the recent trend towards more minor surgery being carried out in general practice we decided to conduct a postal survey to assess the level of knowledge of sterilization and disinfection and the use of benchtop sterilizers in general practice in Northern Ireland. The survey, of all 366 practices in the Province, was carried out in January/March 1998. One hundred and eleven (30%) completed questionnaires were returned. All practices performed at least one of a range of procedures requiring sterilization or disinfection, e.g., minor surgery 95%, cervical smear taking 98%, syringing of ears 98%. Only 76% of practices had a benchtop sterilizer and 39% did not have access to a sterile supply department (SSD); 32% of the latter had no desire to utilize such a service. Only 25% and 34% correctly identified the Medical Devices Agency (MDA) definitions of sterilization and disinfection respectively. The MDA Device Bulletin on benchtop sterilizers had been read by only 26% of respondents. There was an 86% interest in attending a workshop on sterilization and disinfection. The concepts and practice of sterilization and disinfection appear not to be clearly understood. We conclude that resources must be identified to provide appropriate education in this important area for primary care staff.

Physical activity, physical fitness, blood pressure, and fibrinogen in the Northern Ireland health and activity survey.

STUDY OBJECTIVE: To investigate the relationship between physical activity, physical fitness, blood pressure, and fibrinogen. DESIGN: This was a cross sectional population study using a two stage probability sample. SETTING: Northern Ireland. PARTICIPANTS: A sample of 1600 subjects aged 16-74 years from the population of Northern Ireland. MAIN OUTCOME MEASURES: Physical activity profile from computer assisted interview using the Allied Dunbar national fitness survey scales. Physical fitness using estimation of VO2 max by extrapolation from submaximal oxygen uptake while walking on a motor driven treadmill. Systolic and diastolic blood pressure measured with a Hawksley random zero sphygmomanometer. Measurement of fibrinogen using the Clauss method. MAIN RESULTS: There were significant relationships between both current and past activity and blood pressure. These were of a magnitude that would have been clinically significant, but for the fact that, with the exception of the relationship between habitual activity and diastolic pressure (p = 0.03) and past activity and systolic pressure (p = 0.03) in men, they were not sustained after adjustment for the effect of age using analysis of variance. After adjustment for other potentially confounding factors using multiple regression, there was an inverse relationship between systolic blood pressure and past activity in men, so that those with a life-time of participation compared with a life-time of inactivity had a lower systolic blood pressure of 6 mmHg (p < 0.05). There was a highly significant (p < 0.001) inverse association between both systolic and diastolic blood pressure and physical fitness (VO2 max) which was not sustained after adjustment for possible confounding factors. There were relationships between fibrinogen and highest recorded activity (p < 0.001), habitual activity (p < 0.01), and past activity (p < 0.01) in men but no significant relationship in women. The relationship between fibrinogen and activity was no longer sustained after adjustment for possible confounding factors. There was a highly significant (p < 0.001) inverse relationship with physical fitness using VO2 max. This relationship was sustained after adjustment for possible confounding factors in both men (p < 0.05) and women (p < 0.001). CONCLUSIONS: There was a relationship between physical activity, physical fitness, and blood pressure but the relationship was greatly influenced by age. A reduction of 6 mmHg in systolic blood pressure associated with past activity is of clinical significance and supports the hypothesis that physical activity is of benefit in reducing cardiovascular risk. There was a lower level of fibrinogen in those who were most active but this relationship was not significant after adjustment for possible confounding factors. There was also a lower level of fibrinogen those who were most fit (VO2 max) and this relationship persisted even after adjustment for possible confounding factors.

The solution was the problem.

There are increasing numbers of adults living in the community who require enteral tube feeding. While there is significant evidence of the importance of this treatment, there are side effects which can cause difficulties for patients, their carer tabers and health professionals. Gastrointestinal complications are the most common side effects with feed formula being cited as the main culprit, often without investigating other potential causes. Many patients requiring aggressive nutrition support also require concurrent drug therapy to manage underlying disease. Drugs are often given via tubes in liquid form. These elixirs often contain large quantities of sorbitol, which will increase the osmolar concentration. There is a lack of awareness from primary health-care professionals about the difficulties that can arise when giving medications to patients receiving enteral feeding which may affect patient care and the nutritional outcomes.

Does preseason screening for cardiac disease really work?: the British perspective.

Sudden cardiac death is always a tragedy. Sudden death during sport is particularly poignant because people tend to associate sport with health and fitness. Both the public and the medical profession would like to prevent such events, and preparticipation medical screening is often promoted as one such method. When we examine the risk of death, the prevalence of at-risk conditions, the natural history of disease, and the screening methods available, it is clear that widespread screening would not be useful. Systematic preparticipation screening is not undertaken widely in the United Kingdom, but this practice has evolved and is not the result of a definite policy decision.

Ankle injuries: same joint, different sports.

Specific information on the incidence of ankle injury is not easy to establish, and studies use variable methodology and recording systems. There are problems in recording injury in many sports injury studies (23) as we often cannot calculate the relative risks without denominator data. Although we can estimate that ankle injuries make up about 10-15% of sports-related injury and that soccer and rugby are responsible for most sports-related injury in the United Kingdom, it is difficult to be more specific. Prevention and treatment strategies are also different, and taping and strapping is not widely practiced. Soccer has a particular injury pattern with some injuries particularly associated with the sport.

Physical fitness, lipids, and apolipoproteins in the Northern Ireland Health and Activity Survey.

The objective of this study was to investigate the relationship between physical fitness, lipids, and apolipoproteins in a cross-sectional study using a two-stage probability sample of the population of Northern Ireland. The main outcome measures were physical fitness using VO2max estimated by extrapolation from submaximal oxygen uptake while walking on a motor driven treadmill, and total cholesterol, HDL cholesterol, LDL cholesterol, triglycerides, HDL2 and HDL3, and Lp(a). There were no significant relationships with fitness, after adjustment for possible confounders, with the exception of a positive relationship with HDL2 in males (P < or = 0.01) and Lp(a) in females (P < or = 0.05). There was also a relationship between physical fitness and HDL:apo AI ratio in males and females after adjustment for possible confounders (P < or = 0.05). We concluded that there were few relationships between lipid parameters and physical fitness after adjustment for possible confounders. The relationship between physical fitness and Lp(a) in females suggests a benefit associated with physical fitness and the relationship between physical fitness and HDL:apo AI ratio was in keeping with improved HDL cholesterol transport.

Physical activity, lipids, apolipoproteins, and Lp(a) in the Northern Ireland Health and Activity Survey.

In a cross-sectional study using a two-stage probability sample (N = 1,600) of the population of Northern Ireland, there was an inverse association between the highest recorded recent activity and total cholesterol (P < or = 0.01), LDL (P < or = 0.01), triglyceride (P < or = 0.05) and Chol:HDL ratio (P < or = 0.001) in males, and total cholesterol (P < or = 0.001), LDL (P < or = 0.001), and triglyceride (P < or = 0.01) in females; between habitual activity and HDL (P < or = 0.05) in males and total cholesterol (P < or = 0.05) and triglyceride (P < or = 0.01) in females. There was a relationship between the highest recorded activity and apoAI (P < or = 0.01) and apoB (P < or = 0.01) in males and with apoB (P < or = 0.001) in females; between habitual activity and apoAI (P < or = 0.01) and apoAII (P < or = 0.05) in males and apoB (P < or = 0.01) in females; between past activity and Lp(a) in females (P < or = 0.05). After adjustment for possible confounding factors, total cholesterol (P < or = 0.05) and LDL (P < or = 0.05) were unexpectedly higher in males who were active throughout life. Total cholesterol (P < or = 0.05) and LDL (P < or = 0.001) were higher in females with highest recorded activity and triglycerides lower (P < or = 0.05) in those habitually active. An association between highest recorded activity and apoAI (P < or = 0.01), and past activity and apoAI:apoB ratio (P < or = 0.05) was shown in males and in females, after adjustment, and between apoB (P < or = 0.05) and highest recorded activity.

Vitamin E and exercise in the Northern Ireland population.

Serum vitamin E, vitamin E/cholesterol and physical activity and fitness were examined in a representative cross section (n = 1600) of the Northern Ireland population as part of the Northern Ireland health and activity survey. Serum vitamin E levels were measured by high-performance liquid chromatography, cholesterol by an enzymatic method, physical activity profile was recorded by computer assisted interview and physical fitness was determined by estimation of VO2 max. The levels of serum vitamin E and vitamin E/cholesterol ratio in the Northern Irish population were similar or higher than in other populations with lower incidences of coronary heart disease. The assessment of activity showed that 75% of the population fell below recommended activity levels likely to confer a cardioprotective effect. A significant relationship (P = 0.01) was found in males between serum vitamin E levels and lifetime participation in physical activity. Otherwise no relationship was found between serum vitamin E or vitamin E/cholesterol ratio and physical activity or fitness in the population.

READER: an acronym to aid critical reading by general practitioners.

READER represents a sequence of steps in the assessment of general practice literature. An article may be judged on the first four steps: r for relevance, e for education, a for applicability, d for discrimination. The next step, e, involves the evaluation of the article using a scoring system. Finally the reader decides what to do with the article, as illustrated by r for reaction.

Disseminated intravascular coagulation complicating systemic juvenile chronic arthritis ("Still's disease").

Two children suffering from systemic juvenile chronic arthritis (JCA) complicated by acute disseminated intravascular coagulation (DIC) are described. One had a fatal outcome with acute renal failure and cerebral haemorrhage; the other recovered. Early recognition and treatment of the underlying cause - usually an infection - as well as replacement of clotting factors are important in management.

Are sports medicine journals relevant and applicable to practitioners and athletes?

OBJECTIVE: To examine the evidence base of sports medicine research and assess how relevant and applicable it is to everyday practice. METHODS: Original research articles, short reports, and case reports published in four major sport and exercise medicine journals were studied and classified according to the main topic of study and type of subjects used. RESULTS: The most common topic was sports science, and very few studies related to the treatment of injuries and medical conditions. The majority of published articles used healthy subjects sampled from the sedentary population, and few studies have been carried out on injured participants. CONCLUSIONS: There is a dearth of studies addressing diagnostic and treatment interventions in the sports medicine literature. The evidence base for sports medicine must continue to increase in terms of volume and quality.

Sport and exercise medicine: building the foundations of a new discipline.

New disciplines emerge as medicine evolves. But, to be recognised as a clinical discipline we must be prepared to measure ourselves against established criteria; there should be consensus on the core content of the discipline and an identifiable body of knowledge to allow us to deal with common clinical problems. At this developmental stage in our evolution we have general agreement on what defines sport and exercise medicine but, as most of our clinical skills developed empirically, research is relatively underdeveloped. The volume and quality of this research does not yet reflect a vibrant research culture. The validity of our clinical method is supported by research evaluating the sensitivity and specificity of clinical tests but the evidence supporting other areas of clinical practice is uncertain. Some aspects of prevention have become integrated into clinical practice without sufficient evidence and, screening has been introduced without critical evaluation. To ensure the future success of our discipline and achieve recognition of its value in the wider medical community, we must nurture an evaluative culture and ensure that clinical practice is built on firm foundations of research evidence.

Ascorbate and exercise in the Northern Ireland population.

The relationship between physical activity, physical fitness and serum ascorbate was examined in the Northern Ireland Health and Activity Survey. This was a cross sectional population study (n = 1600), using a two stage probability sample, of the population of N. Ireland. Physical activity profile was recorded by computer assisted interview and physical fitness was determined by estimation of VO2 max by extrapolation from submaximal oxygen uptake. Serum ascorbate was measured using a colorimetric reaction of 2,4 dinitrophenylhydrazine with dehydroascorbate. Mean serum ascorbate was greater in females than males (p < 0.001), and was lower in smokers than non-smokers in both males (p = 0.01) and females (p < 0.001). There was no statistically significant relationship between serum ascorbate and age, social class, body mass index, physical activity or physical fitness in males but there was a relationship with age (p < 0.01) and physical fitness (p < 0.05) in females.

The integration of evidence based medicine and personal care in family practice.

Evidence based medicine is seductive in its simplicity and few would argue with the philosophical concept. The reality of its application in primary care is rather different. It is difficult to find evidence supporting many clinical management decisions, it may be difficult to interpret evidence when it is available, and it may be difficult to apply this evidence in the consultation. Clinical decisions may be influenced at many levels through health policy, audit, protocols, and guidelines, but the individual doctor patient relationship remains at the core of general practice. Developing a culture of evidence based medicine in general practice must integrate quantitative and qualitative research, epidemiology and psychology and the skills of public health and family medicine.