Good Practices for the Laboratory Performance Testing of Aqueous Oral Inhaled Products (OIPs): an Assessment from the International Pharmaceutical Aerosol Consortium on Regulation and Science (IPAC-RS).

Multiple sources must be consulted to determine the most appropriate procedures for the laboratory-based performance evaluation of aqueous oral inhaled products (OIPs) for the primary measures, dose uniformity/delivery, and aerodynamic particle (droplet) size distribution (APSD). These sources have been developed at different times, mainly in Europe and North America, during the past 25 years by diverse organizations, including pharmacopeial chapter/monograph development committees, regulatory agencies, and national and international standards bodies. As a result, there is a lack of consistency across all the recommendations, with the potential to cause confusion to those developing performance test methods. We have reviewed key methodological aspects of source guidance documents identified by a survey of the pertinent literature and evaluated the underlying evidence supporting their recommendations for the evaluation of these performance measures. We have also subsequently developed a consistent series of solutions to guide those faced with the various associated challenges when developing OIP performance testing methods for oral aqueous inhaled products.

A Systematic Review of Inequalities in the Mental Health Experiences of Black African, Black Caribbean and Black-mixed UK Populations: Implications for Action.

BACKGROUND: Measurable differences in the experience and treatment of mental health conditions have been found to exist between different racial categories of community groups. The objective of this research was to review the reported mental health of Black African-Caribbean communities in the UK, determinants of mental health, and interventions to enhance their experiences of mental health services. METHOD: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement was applied. To be included, papers must be published in a peer reviewed journal; report on adult populations (over 18) from any of Black African, Black Caribbean or Black mixed people in the UK; and assess (quantitative), or discuss (qualitative) mental health experiences, determinants of mental health, or interventions intended to enhance experiences of mental health services among the target population. The aims, inclusion criteria, data extraction, and data quality evaluation were specified in advance. Searches were conducted using EBSCO (PsychInfo; MEDLINE; CINAHL Plus; psychology and behavioural sciences collection). The search strategy included search terms relating to the aim. Risk of bias was assessed using a standard tool, records were organised using Endnote, and data were extracted and synthesised using Microsoft Excel. RESULTS: Thirty-six studies were included, of which 26 were quantitative and six reported exclusively on Black participants. Black populations were less likely to access mental health support via traditional pathways due to stigma and mistrust of mental health services. Black Africans especially, sought alternative help from community leaders, which increased the likelihood of accessing treatment at the point of crisis or breakdown, which in turn increased risk of being detained under the Mental Health Act and via the criminal justice system. DISCUSSION: Findings suggest a cycle of poor mental health, coercive treatment, stigma, and mistrust of services as experienced by Black communities. Evidence was limited by poorly defined ethnic categories, especially where Black populations were subsumed into one category. It is recommended that mental health services work collaboratively with cultural and faith communities in supporting Black people to cope with mental illness, navigate mental health pathways, and provide culturally appropriate advice. Protocol Registration Number PROSPERO CRD42021261510.

Social deprivation predicts adverse health outcomes after hospital admission with hip fracture in England.

We found social deprivation to be associated with higher mortality in the year following hip fracture among men and women aged 60 years and older in England. In those who did survive, deprivation was associated with longer hospital stays and greater risk of subsequent emergency readmission particularly for patients with dementia. INTRODUCTION: Social deprivation predicts a range of adverse health outcomes; however, its impact on outcomes following hip fracture is not established. We examined the effect of area-level social deprivation on outcomes following hospital admission for hip fracture in England. METHODS: We used English Hospital Episodes Statistics linked to the National Hip Fracture Database (April 2011-March 2015) and Office for National Statistics mortality database, to identify patients aged 60+ years admitted with hip fracture. Deprivation was measured using Index of Multiple Deprivation quintiles; Q1-least deprived; Q5-most deprived, and outcomes by mortality over 1-year, length-of-stay in NHS acute and rehabilitation hospitals ('superspell'), and emergency 30-day readmission. RESULTS: We identified 218,907 admissions with an index hip fracture (mean age 82.8 [standard deviation, SD 8.4] years; 72.6% female). Each quintile of deprivation was associated with greater mortality; age-adjusted 30-day mortality odds ratio, OR 1.30 [95% confidence interval, CI: 1.24, 1.37], p < 0.001, equating to on average 1038 fewer deaths/year among those who are least deprived (Q1 versus 2-5). Similarly, at 365 days, those most deprived had 24% higher mortality (age-sex-comorbidity-adjusted OR:1.24 [1.20, 1.28], p < 0.001; Q5 versus Q1). Among survivors, mean superspell was longer in the most versus least deprived (Q5:24.4 [SD 21.7] days, Q1:23.3 [SD 22.1], p < 0.001). Readmission was more common in those most versus least deprived (age-sex-comorbidity-adjusted OR 1.27 [1.22, 1.32], p < 0.001). CONCLUSION: Greater deprivation is associated with reduced survival at all timepoints in the year following hip fracture. Among survivors, hospital stay is increased as is readmission risk. The extent to which configuration of English hospital services, rather than patient case-mix, explains these apparent health inequalities remains to be determined.

Neuroenhancement in surgeons: benefits, risks and ethical dilemmas.

BACKGROUND: Surgeons traditionally aim to reduce mistakes in healthcare through repeated training and advancement of surgical technology. Recently, performance-enhancing interventions such as neurostimulation are emerging which may offset errors in surgical practice. METHODS: Use of transcranial direct-current stimulation (tDCS), a novel neuroenhancement technique that has been applied to surgeons to improve surgical technical performance, was reviewed. Evidence supporting tDCS improvements in motor and cognitive performance outside of the field of surgery was assessed and correlated with emerging research investigating tDCS in the surgical setting and potential applications to wider aspects of healthcare. Ethical considerations and future implications of using tDCS in surgical training and perioperatively are also discussed. RESULTS: Outside of surgery, tDCS studies demonstrate improved motor performance with regards to reaction time, task completion, strength and fatigue, while also suggesting enhanced cognitive function through multitasking, vigilance and attention assessments. In surgery, current research has demonstrated improved performance in open knot-tying, laparoscopic and robotic skills while also offsetting subjective temporal demands. However, a number of ethical issues arise from the potential application of tDCS in surgery in the form of safety, coercion, distributive justice and fairness, all of which must be considered prior to implementation. CONCLUSION: Neuroenhancement may improve motor and cognitive skills in healthcare professions with impact on patient safety. Implementation will require accurate protocols and regulations to balance benefits with the associated ethical dilemmas, and to direct safe use for clinicians and patients.

ANTECEDENTES: Los cirujanos tratan de reducir sus errores durante la atención médica mediante el entrenamiento reiterado y los avances tecnológicos. Recientemente, han surgido otras opciones para mejorar el rendimiento, como la neuroestimulación que puede subsanar los errores en la práctica quirúrgica. MÉTODOS: Se revisó la utilización de la estimulación transcraneal de corriente directa (transcranial direct-current stimulation, tDCS), una técnica de estimulación neurológica que se ha aplicado a cirujanos para mejorar su rendimiento técnico. Se revisaron las evidencias que dan soporte a la mejoría en el rendimiento motor y cognitivo tras tDCS en otros ámbitos más allá de la cirugía y se correlacionó con datos recientes obtenidos en el entorno quirúrgico y sus posibles aplicaciones a otras áreas de la atención médica. También se discuten aspectos éticos y las implicaciones que la utilización de la tDCS pudiera tener en el entrenamiento quirúrgico y perioperatorio. RESULTADOS: Al margen de la cirugía, los estudios de tDCS demuestran una mejoría en el rendimiento motor medido por el tiempo de reacción, de finalización de tareas, de fuerza y la fatiga, así como también sugieren un incremento de la función cognitiva a través de evaluaciones multitarea, de vigilancia y de atención. En cirugía, la investigación actual ha demostrado una mejoría en el rendimiento para la realización de nudos abiertos, habilidades laparoscópicas y robóticas, mientras también contrarresta las exigencias subjetivas materiales. Sin embargo, surgen aspectos éticos ante la posible aplicación de la tDCS en cirugía, como son la seguridad, la coerción, la justicia distributiva y la equidad, situaciones que deben considerarse antes de su implementación. CONCLUSIÓN: La estimulación neurológica puede mejorar las habilidades motoras y cognitivas de los profesionales sanitarios con repercusión en la seguridad del paciente. Su implementación requerirá de protocolos y regulaciones específicas para equilibrar los beneficios con los dilemas éticos asociados y garantizar su seguridad para médicos y pacientes.

Assessment of natural regeneration of mangrove with reference to edaphic factors and water in Southern Gulf of Kachchh, Gujarat, India.

The study was carried out to determine the natural regeneration of four species of mangroves along with estimation of physico-chemical characteristics of sediment and water from seven sites of mangroves in the southern Gulf of Kachchh. Spatial variation of different parameters of water and sediment investigated were: water-pH (7.87-8.04); Salinity (37.07-39.42 ppt); Nitrate (1.21-2.71 ppm); Nitrite (0.03-0.08 ppm); Phosphate (0.39-0.95 ppm) and sediment-pH (7.39-7.61); Bulk density (0.36-0.54 g/cc); Particle density (1.19-1.68 g/cc); Organic carbon (0.77-1.05%); and Organic matter (1.06-1.71%). The density (recruit/sq. m) of natural recruitment of four mangrove species was in order of Avicennia marina > Ceriops tagal > Aegiceras corniculatum > Rhizophora mucronata. Cluster analysis grouped seven sites in three major clusters i.e. Group A (Poshitra & Khijadiya - 91% similarity); Group B (Dedeka-Mundeka, Kalubhar & Pirotan- 94% similarity) and Group C (Sikka & Jodiya- 93% similarity) whereas Non-metric multidimensional scaling showed formation of two groups (Coastal and Islands) depending on the environmental conditions and mangrove natural regeneration. Principal component analysis showed the number of parameters such as salinity, texture and organic carbon which affects the natural regeneration of mangrove species in the study area.

Dental Public Health in Action: Understanding oral health care needs and oral health-related quality of life in vulnerable adults in Plymouth.

This paper aims to provide a snapshot analysis of the oral health status of vulnerable adults in Plymouth; and to demonstrate the extent to which oral disease impacts on their normal functioning through the implementation of the Oral Health Impact Profile (OHIP). It is acknowledged that gaining a representative sample of a transient population such as people who are homeless, or individuals affected by problematic use of drugs and/or alcohol is difficult. An opportunity was identified to collect data within the Community Engagement Team's (CET) programme of activity within the Peninsula Dental Social Enterprise. The CET works alongside local organisations to enable dental students from Peninsula School of Dentistry to undertake outreach programmes in a variety of settings. A study was designed which aimed to analyse the oral health status of vulnerable adults accessing three day-support services in Plymouth, and to understand the extent to which oral disease impacts on their normal functioning through the OHIP-14. For all impact domains, the 44 patients in this study reported a greater impact than that found in the Adult Dental Health Survey. The most commonly reported impact domains were physical pain and psychological discomfort. The sample was divided into high and low oral health-related quality of life impact groups, and those participants in the high impact group had significantly greater median D3MFT scores, i.e. higher levels of decay experience. This survey highlights how these vulnerable groups are characterised by a high prevalence of poor oral health, ill-health, deprivation and social exclusion.

Cost analysis of osteoradionecrosis.

OBJECTIVE: Osteoradionecrosis is a significant complication of head and neck cancer treatment, and its most severe form (grade III) necessitates radical surgery. This study aimed to compare the cost of free-flap reconstructive surgery for grade III osteoradionecrosis and similar non-osteoradionecrosis cases in order to assess the cost burden of osteoradionecrosis treatment. METHODS: All patients who underwent free-flap reconstructive surgery for osteoradionecrosis between July 2004 and July 2010 at Auckland City Hospital (19 patients) were identified, and relevant data were collected retrospectively. These patients were matched in terms of age and sex with patients who underwent free-flap reconstructive surgery. RESULTS: The treatment cost was 44 per cent higher in osteoradionecrosis patients when compared to non-osteoradionecrosis patients. CONCLUSION: The significant financial burden on the health system, and the growing evidence for the effectiveness of pentoxifylline, tocopherol and clodronate, should prompt us to explore this alternative treatment further.

Socio-economic & household risk factors of malaria in tribal areas of Madhya Pradesh, central India.

BACKGROUND & OBJECTIVES: Malaria is a major public health problem in many States of the country, particularly, in Madhya Pradesh where both Plasmodium vivax and P. falciparum are endemic. Although many studies have been conducted to investigate risk factors for malaria, but only a few have examined household and socio-economic risk factors. The present study was, therefore, undertaken to explore the relationship of different socio-demographic, socio-economic and behavioural risk factors with malaria prevalence in tribal areas of Madhya Pradesh, India. METHODS: This study was undertaken in all 62 villages of Bargi Primary Health Centre from May 2005 to June 2008. These villages comprised 7117 households with an average family size of five members. Fortnightly fever surveys were conducted in all villages to assess prevalence of malaria infection in the community. The distinct univariate and multivariate logistic regression models were fitted on the data set. RESULTS: The important socio-demographic risk factors like age of household head, social group, occupation and family size; socio-economic factors like type of walls of house, place of drinking water source, irrigated land, cash crop; and behavioural variables like place of sleeping, use of bed nets, etc. were found significantly associated with malaria in univariate analyses. In multivariate analyses only social groups, family size, type of walls of house, and place of sleeping had strong significant association with prevalence of malaria. INTERPRETATION & CONCLUSIONS: The study shows that in tribal areas where people are living in poor quality of houses with no proper use of preventive measures, malaria is firmly established. We conclude that community based interventions which bring improvement in standard of living, access to healthcare facilities and health awareness, will have a significant impact on malaria prevention in these areas.

Soft tissue ossification and condylar cartilage degeneration following TMJ disc perforation in a rabbit pilot study.

OBJECTIVE: There are limited clinical treatments for temporomandibular joint (TMJ) pathologies, including degenerative disease, disc perforation and heterotopic ossification (HO). One barrier hindering the development of new therapies is that animal models recapitulating TMJ diseases are poorly established. The objective of this study was to develop an animal model for TMJ cartilage degeneration and disc pathology, including disc perforation and soft tissue HO. METHODS: New Zealand white rabbits (n = 9 rabbits) underwent unilateral TMJ disc perforation surgery and sham surgery on the contralateral side. A 2.5 mm defect was created using a punch biopsy in rabbit TMJ disc. The TMJ condyles and discs were evaluated macroscopically and histologically after 4, 8 and 12 weeks. Condyles were blindly scored by four independent observers using OARSI recommendations for macroscopic and histopathological scoring of osteoarthritis (OA) in rabbit tissues. RESULTS: Histological evidence of TMJ condylar cartilage degeneration was apparent in experimental condyles following disc perforation relative to sham controls after 4 and 8 weeks, including surface fissures and loss of Safranin O staining. At 12 weeks, OARSI scores indicated experimental condylar cartilage erosion into the subchondral bone. Most strikingly, HO occurred within the TMJ disc upon perforation injury in six rabbits after 8 and 12 weeks. CONCLUSION: We report for the first time a rabbit TMJ injury model that demonstrates condylar cartilage degeneration and disc ossification, which is indispensible for testing the efficacy of potential TMJ therapies.

Assessment of endothelial glycocalyx disruption in term parturients receiving a fluid bolus before spinal anesthesia: a prospective observational study.

BACKGROUND: Fluid bolus administration is a standard treatment for hypotension. However, the effectiveness of the traditional prophylactic bolus in parturients undergoing spinal anesthesia for cesarean delivery has been questioned. One potential mechanism for the failure of a prophylactic fluid bolus to prevent hypotension is hypervolemia-induced destruction of the endothelial glycocalyx, a structure that plays a vital role in regulating intravascular fluid shifts. METHODS: Thirty healthy parturients undergoing elective cesarean delivery under spinal anesthesia were recruited. Known endothelial glycocalyx biomarkers, heparan sulfate and syndecan-1 along with atrial natriuretic peptide, were measured before and after a 750-mL crystalloid fluid bolus. Cardiac performance parameters, cardiac index and systemic vascular resistance, were monitored during the fluid bolus using thoracic-impedance cardiography. RESULTS: A significant increase in both heparan sulfate 96 ng/mg (P=0.0098) and syndecan-1 2.4 ng/mg (P=0.045) were observed after the fluid bolus. There was a non-significant increase in atrial natriuretic peptide 0.6 pg/mg (P=0.293). Cardiac parameters showed a small but significant change; over an average of 15 min, cardiac index increased by 0.1L/min/m2 (P=0.0005) and systemic vascular resistance decreased by 30.7 dyn.s/cm5 (P=0.0025). CONCLUSIONS: A prophylactic fluid bolus in parturients undergoing spinal anesthesia for cesarean delivery disrupts the endothelial glycocalyx, as noted by a statistically significant increase in post-bolus heparan sulfate and syndecan-1 levels. Although studied in the past, atrial natriuretic peptide could not explain this disruption. Our fluid bolus did not have a clinically relevant effect on cardiac performance.

The 2012 International Union against Sexually Transmitted Infections European Collaborative Clinical Group report on the diagnosis and management of Neisseria gonorrhoeae infections in Europe.

The European Collaborative Clinical Group (ECCG) was inaugurated at the 26th International Union against Sexually Transmitted Infections (IUSTI) Congress in Riga, Latvia 2011. The ECCG is a network of over 100 sexually transmitted infection specialists who have come together to conduct questionnaire-based research across the European region. It is expected that this work will focus and direct guideline development. A central core group of the ECCG has also been established who are responsible for identifying suitable survey questions that will be carried out but only after approval by the full ECCG Board. The ECCG aims to conduct a maximum of two projects per year which will be presented at the annual regional congresses and published as appropriate.

Does the '2012 IUSTI ECCG report on the diagnosis and management of Neisseria gonorrhoeae infections in Europe' depict the situation in Europe?

Gonorrhoea is a major public health concern globally. Of particular grave concern is that resistance to the third generation cephalosporins has been identified during recent years. This paper summarises and discusses the results of the '2012 IUSTI European Collaborative Clinical Group (ECCG) report on the diagnosis and management of Neisseria gonorrhoeae infections in Europe'. Although high quality care was reported in many settings, in several other countries the testing, diagnostics, antimicrobial treatment and follow-up of gonorrhoea patients need to be optimized. This, together with increased access to and use of antimicrobial susceptibility testing, is crucial in controlling the emergent spread of cephalosporin-resistant and multidrug-resistant gonorrhoea.

Pain, motor and gait assessment of murine osteoarthritis in a cruciate ligament transection model.

OBJECTIVE: The major complaint of Osteoarthritis (OA) patients is pain. However, due to the nature of clinical studies and the limitation of animal studies, few studies have linked function impairment and behavioral changes in OA animal models to cartilage loss and histopathology. Our objective was to study surrogate markers of functional impairment in relation to cartilage loss and pathological changes in a post-traumatic mouse model of OA. METHOD: We performed a battery of functional analyses in a mouse model of OA generated by cruciate ligament transection (CLT). The changes in functional analyses were linked to histological changes graded by OARSI standards, histological grading of synovitis, and volumetric changes of the articular cartilage and osteophytes quantified by phase contrast micro-computed tomography (µCT). RESULTS: OA generated by CLT led to decreased time on rotarod, delayed response on hotplate analysis, and altered gait starting from 4 weeks after surgery. Activity in open field analysis did not change at 4, 8, or 12 weeks after CLT. The magnitude of behavioral changes was directly correlated with higher OARSI histological scores of OA, synovitis in the knee joints, cartilage volume loss, and osteophyte formation. CONCLUSION: Our findings link functional analyses to histological grading, synovitis, comprehensive three-dimensional assessment of cartilage volume and osteophyte formation. This serves as a reference for a mouse model in predicting outcomes of OA treatment.

Prevalence of oral diseases and oral-health-related quality of life in people with severe mental illness undertaking community-based psychiatric care.

OBJECTIVES: To describe the prevalence of oral diseases and their impact on oral-health-related quality of life in people with severe mental illness undertaking community-based psychiatric care. METHODS: A survey was conducted at eight outpatient psychiatric care clinics in Tower Hamlets, London, UK. One hundred and twelve consecutive patients with mental illness were invited to participate in this study. They were clinically examined and asked to complete the oral health impact profile (OHIP) questionnaire. RESULTS: The response rate was 79% (n = 89); 57 (64%) males and 58 persons over 45 years of age (65%) participated in this survey. Overall OHIP score was 25.4 (95% CI 23.3, 27.4), 70 (78%) were smokers and 45 (51%) had been to the dentist in the last two years. Forty-seven (53%) respondents had caries in at least one tooth, 60 (67%) had 21 teeth and more, and 14 (16%) used dentures. Advanced periodontal treatment was indicated in 42 (55%) of patients and 52.8% (n = 47) patients reported current pain. CONCLUSION: Overall, this survey found that oral health has a great impact on patients with severe mental illness being treated in the community setting and their oral health is poorer than the national adult general population. Future research should consider the causes that relate to the poorer oral health in this population and potential health promotion mechanisms in this population to encourage an upstream approach to health.

An investigation into the numbers of dentists from 19 European Economic Area (EEA) member states currently registered to work in the United Kingdom and key differences between the practise of dentistry in the UK and their member states of origin.

The aim of this short communication is to highlight the numbers of non-UK EEA qualified dentists currently registered with the General Dental Council (GDC) and to present a brief overview of the systems for the provision of oral healthcare in the non-UK EEA member states identifying differences in practise. The relevant data were gathered for the National Clinical Assessment Service (NCAS) as part of a wider project. It was found that at 31 December 2010, 28% of dentists registered with the GDC had not qualified in the UK. Of these more than 6,300 were European Economic Area (EEA) dentists with non-UK qualifications. The nature of their practise varied widely from member state to member state. The implications of these findings are discussed briefly.

The use of an exclusion-based risk-assessment model for venous thrombosis improves uptake of appropriate thromboprophylaxis in hospitalized medical patients.

BACKGROUND: Venous thromboembolism is a common condition in hospitalized medical patients. Numerous studies have demonstrated that low molecular weight heparin significantly reduces this risk but, despite this, the use of thromboprophylaxis remains poor. AIM: To evaluate the use of an exclusion based risk-assessment model (RAM) for venous thrombosis in improving the uptake of appropriate thromboprophylaxis in hospitalized medical patients. DESIGN: A survey with a subsequent audit cycle of three separate audits over 36 months. METHODS: 497 hospitalized patients with acute medical conditions on general medical wards were audited at a secondary care centre in London, UK. The survey and subsequent audits were performed by reviewing the notes and medication charts of medical patients, prior to the launch of the RAM and at 12, 28 and 36 months following its introduction. RESULTS: Prior to launching the RAM, 49% of hospitalized medical patients received appropriate thromboprophylaxis. This did not change 12 months after the RAM was introduced but increased significantly to 71% following formal education of the health care professionals involved in thromboprophylaxis prescription. This improvement was maintained as demonstrated by a subsequent audit 8 months later (75.9%). CONCLUSION: The introduction of a simple exclusion-based RAM for venous thrombosis in medical patients significantly improved delivery of thromboprophylaxis. The successful uptake of the RAM appears to have been dependent on direct education of those health carers involved in its use. A similar exclusion-based model used nationally could have a significant impact on the burden of VTE currently experienced in the UK.

Removal of lead and zinc ions from water by low cost adsorbents.

In this study, activated carbon, kaolin, bentonite, blast furnace slag and fly ash were used as adsorbent with a particle size between 100 mesh and 200 mesh to remove the lead and zinc ions from water. The concentration of the solutions prepared was in the range of 50-100 mg/L for lead and zinc for single and binary systems which are diluted as required for batch experiments. The effect of contact time, pH and adsorbent dosage on removal of lead and zinc by adsorption was investigated. The equilibrium time was found to be 30 min for activated carbon and 3h for kaolin, bentonite, blast furnace slag and fly ash. The most effective pH value for lead and zinc removal was 6 for activated carbon. pH value did not effect lead and zinc removal significantly for other adsorbents. Adsorbent doses were varied from 5 g/L to 20 g/L for both lead and zinc solutions. An increase in adsorbent doses increases the percent removal of lead and zinc. A series of isotherm studies was undertaken and the data evaluated for compliance was found to match with the Langmuir and Freundlich isotherm models. To investigate the adsorption mechanism, the kinetic models were tested, and it follows second order kinetics. Kinetic studies reveals that blast furnace slag was not effective for lead and zinc removal. The bentonite and fly ash were effective for lead and zinc removal.

Measuring access: how accurate are patient-reported waiting times?

INTRODUCTION: A national audit of waiting times in England's genitourinary medicine clinics measures patient access. Data are collected by patient questionnaires, which rely upon patients' recollection of first contact with health services, often several days previously. The aim of this study was to assess the accuracy of patient-reported waiting times. METHODS: Data on true waiting times were collected at the time of patient booking over a three-week period and compared with patient-reported data collected upon clinic attendance. Factors contributing to patient inaccuracy were explored. RESULTS: Of 341 patients providing initial data, 255 attended; 207 as appointments and 48 'walk-in'. The accuracy of patient-reported waiting times overall was 52% (133/255). 85% of patients (216/255) correctly identified themselves as seen within or outside of 48 hours. 17% of patients (17/103) seen within 48 hours reported a longer waiting period, whereas 20% of patients (22/108) reporting waits under 48 hours were seen outside that period. Men were more likely to overestimate their waiting time (10.4% versus 3.1% p<0.02). The sensitivity of patient-completed questionnaires as a tool for assessing waiting times of less than 48 hours was 83.5%. The specificity and positive predictive value were 85.5% and 79.6%, respectively. CONCLUSION: The overall accuracy of patient reported waiting times was poor. Although nearly one in six patients misclassified themselves as being seen within or outside of 48 hours, given the under and overreporting rates observed, the overall impact on Health Protection Agency waiting time data is likely to be limited.

The association of life course socio-economic position with diagnosis, treatment, control and survival of women with diabetes: findings from the British Women's Heart and Health Study.

OBJECTIVES: To examine the association of socio-economic position (SEP) with the diagnosis, treatment and control of diabetes, and with survival in women with and without Type 2 diabetes. METHODS: Prospective cohort study of 4277 women from 23 centres in Great Britain, aged 60-79 years at baseline. RESULTS: Of the 4277 women, 220 (5.1%) were known to have Type 2 diabetes and a similar number [n = 188 (4.4%)] had undiagnosed diabetes based on a single fasting glucose level > or = 7.0 mmol/l. Neither childhood nor adult SEP was associated with being correctly diagnosed amongst the 408 women with either diagnosed or undiagnosed diabetes. In both women with and without diabetes, SEP was associated with more adverse levels of fasting insulin, triglycerides, high-density lipoprotein cholesterol and body mass index, but was not associated with glycated haemoglobin in either group. Over the follow-up period, 395 women died. The hazard ratio for all-cause mortality per additional indicator of adverse SEP in adulthood in women with diabetes [1.40 (1.05, 1.85)] was similar to that in women without diabetes [1.26 (1.12, 1.41], P for difference in the two estimates = 0.70). Childhood SEP was not associated with survival. CONCLUSION/INTERPRETATION: A considerable number of older women with Type 2 diabetes are not diagnosed, but SEP is not related to being correctly diagnosed. The marked socio-economic gradient for all-cause mortality is the same for women with and without diabetes and is not fully explained by conventional risk factors.