An assessment of introducers used for airway management.

Different introducers are available to assist with tracheal intubation. Subtle differences in the design of introducers can have a marked effect on safety and performance. The Difficult Airway Society's Airway Device Evaluation Project Team proposal states that devices should only be purchased for which there is at least a case-control study on patients assessing airway devices. However, resources are not currently available to carry out a case-control study on all introducers available on the market. This study comprised a laboratory and manikin-based investigation to identify introducers that could be suitable for clinical investigation. We included six different introducers in laboratory-based assessments (design characteristics) and manikin-based assessments involving the participation of 30 anaesthetists. Each anaesthetist attempted placement in the manikin's trachea with each of the six introducers in a random order. Outcomes included first-time insertion success rate; insertion success rate; number of attempts; time to placement; and distance placed. Each anaesthetist also completed a questionnaire. First-time insertion success rate depended significantly on the introducer used (p = 0.0016) and varied from 47% (Armstrong and P3) to 77% (Intersurgical and Frova). Median time to placement (including oesophageal placement) varied from 10 s (Eschmann and Frova) to 20 s (P3) (p = 0.0025). Median time to successful placement in the trachea varied from 9 s (Frova) to 22 s (Armstrong) (p = 0.037). We found that the Armstrong and P3 devices were not as acceptable as other introducers and, without significant improvements to their design and characteristics, the use of these devices in studies on patients is questionable. The study protocol is suitable for differentiating between different introducers and could be used as a basis for assessing other types of devices.

Electronic personal assessment questionnaire for vascular conditions (ePAQ-VAS): development and validity.

BACKGROUND: This paper describes the development and validation of an electronic personal assessment questionnaire for vascular conditions (ePAQ-VAS) that captures the symptomatology, quality of life and clinically relevant data of patients presenting to vascular services. METHODS: A two-stage survey was conducted in patients attending a tertiary vascular department. Patients completed the ePAQ-VAS remotely online, or on site using an electronic tablet. In the first stage of the survey, the responses were used to perform confirmatory factor analysis to assess the construct validity and remove redundant items. The internal reliability of disease-specific scales was investigated. In the second stage of the survey, the acceptability, known-group validity, test-retest reliability, and responsiveness of ePAQ-VAS was assessed. RESULTS: In total, 721 patients completed ePAQ-VAS. Their mean(s.d.) age was 63·5(15·7) years and 468 (64·9 per cent) were men. Some 553 patients (76·7 per cent) completed the questionnaire in clinic and the remainder completed the questionnaire online. The results of the confirmatory factor analysis confirmed the conceptual model for ePAQ-VAS structure and eliminated six items. Internal reliability was acceptable for all the scales (Cronbach's α greater than 0·7). The test-retest reliability measured by the intraclass correlation coefficient ranged from 0·65 to 0·99. The results showed that the instrument was responsive over time with the standardized response mean ranging from 0·69 to 1·60. CONCLUSION: ePAQ-VAS is a holistic data-collection process that is relevant to vascular service users and has potential to contribute to patient-focused care and the collection of aggregate data for service evaluation. A demonstration version of the final version of ePAQ can be viewed at http://demo-questionnaire.epaq.co.uk/home/project?id=VASC_1.7&page=1.

ANTECEDENTES: Este artículo describe el desarrollo y la validación de un cuestionario electrónico de evaluación personal para enfermedades vasculares (ePAQ-VAS) que incluye la sintomatología, la calidad de vida y los datos clínicamente relevantes para los pacientes que son atendidos en los servicios de patología vascular. MÉTODOS: Se llevó a cabo una encuesta en dos fases entre los pacientes atendidos en un servicio de patología vascular de tercer nivel. Los pacientes completaron el cuestionario ePAQ-VAS a distancia en línea o bien en el centro hospitalario mediante una tableta electrónica. En la primera fase de la encuesta, las respuestas se utilizaron para realizar un análisis factorial de confirmación para evaluar la validez del diseño y eliminar los elementos redundantes. Se investigó la fiabilidad interna de las escalas específicas de la enfermedad. En la segunda fase de la encuesta, se evaluó la aceptabilidad, la validez de grupo conocida, la fiabilidad test-retest y la capacidad de respuesta del ePAQ-VAS. RESULTADOS: En total, 721 pacientes completaron el ePAQ-VAS, la edad media fue de 63,5 años (DE 15,7); el 64,9% eran varones (468); el 76% de los pacientes (553) completaron el cuestionario en la clínica y los pacientes restantes lo hicieron electrónicamente a distancia. Los resultados del análisis factorial de confirmación confirmaron el modelo conceptual para la estructura ePAQ-VAS y eliminaron seis ítems. La fiabilidad interna fue aceptable para todas las escalas (alfa de Cronbach > 0,7). La fiabilidad test-retest medida por el coeficiente de correlación intraclase osciló entre 0,65-0,99. Los resultados mostraron que el instrumento responde con el tiempo con una media de respuesta estandarizada que varía de 0,69 a 1,60. CONCLUSIÓN: El ePAQ-VAS es un proceso holístico de recopilación de datos que es relevante para los usuarios de servicios de patología vascular y tiene el potencial de contribuir a la atención centrada en el paciente y a la recopilación de datos agregados para la evaluación del servicio.

Cost minimization analysis of line probe assay for detection of multidrug-resistant tuberculosis in Arkhangelsk region of Russian Federation.

BACKGROUND: The development of new diagnostic tools allows for faster detection of both tuberculosis (TB) and multidrug-resistant (MDR) TB and should lead to reduced transmission by earlier initiation of anti TB therapy. The research conducted in the Arkhangelsk region of the Russian Federation in 2012-14 included economic evaluation of Line Probe Assay (LPA) implementation in MDR-TB diagnostics compared to existing culture-based diagnostics of Löwenstein Jensen (LJ) and BacTAlert. Clinical superiority of LPA was demonstrated and results were reported elsewhere. STUDY AIM: The PROVE-IT Russia study aimed to report the outcomes of the cost minimization analysis. METHODS: Costs of LPA-based diagnostic algorithm (smear positive (SSm+) and for smear negative (SSm-) culture confirmed TB patients by Bactec MGIT or LJ were compared with conventional culture-based algorithm (LJ-for SSm- and SSm+ patients and BacTAlert-for SSm+ patients). Cost minimization analysis was conducted from the healthcare system, patient and societal perspectives and included the direct and indirect costs to the healthcare system (microscopy and drug susceptibility test (DST), hospitalization, medications obtained from electronic medical records) and non-hospital direct costs (patient's travel cost, additional expenses associated with hospitalization, supplementary medicine and food) collected at the baseline and two subsequent interviews using the WHO-approved questionnaire. RESULTS: Over the period of treatment the LPA-based diagnostic corresponded to lesser direct and indirect costs comparing to the alternative algorithms. For SSm+ LPA-based diagnostics resulted in the costs 4.5 times less (808.21 US$) than LJ (3593.81 US$) and 2.5 times less than BacTAlert liquid culture (2009.61 US$). For SSm- LPA in combination with Bactec MGIT (1480.75 US$) vs LJ (1785.83 US$) showed the highest cost minimization compared to LJ (2566.09 US$). One-way sensitivity analyses of the key parameters and threshold analyses were conducted and demonstrated that the results were robust to variations in the cost of hospitalization, medications and length of stay. CONCLUSION: From the perspective of Russian Federation healthcare system, TB diagnostic algorithms incorporating LPA method proved to be both more clinically effective and less expensive due to reduction in the number of hospital days to the correct MDR-TB diagnosis and treatment initiation. LPA diagnostics comparing conventional culture diagnostic algorithm MDR-TB was a cost minimizing strategy for both patients and healthcare system.

The cost effectiveness of radon reduction programmes in domestic housing in England and Wales: the impact of improved radon mapping and housing trends.

In the UK, excessive levels of radon gas have been detected in domestic housing. Areas where 1% of existing homes were found to be over the Action Level of 200Bq·m(-3) were declared to be Radon Affected Areas. Building Regulations have been introduced which require that, for areas where between 3% and 10% of existing houses are above the Action Level, new homes should be built with basic radon protection using a membrane, and that, where 10% or more of existing homes exceed this level, new homes should be built with full radon protection. Initially these affected areas followed administrative boundaries, known as Counties. However, with increasing numbers of measurements of radon levels in domestic homes recorded in the national database, these areas have been successively refined into smaller units - 5km grid squares in 1999, down to 1km grid squares in 2007. One result is the identification of small areas with raised radon levels within regions where previously no problem had been identified. In addition, some parts of areas that were previously considered radon affected are now considered low, or no, risk. Our analysis suggests that the net result of improved mapping is to increase the number of affected houses. Further, the process is more complex for local builders, and inspectors, who need to work out whether radon protection in new homes is appropriate. Our group has assessed the cost-effectiveness of radon remediation programmes, and has applied this analysis to consider the cost-effectiveness of providing radon protection in both new and existing homes. This includes modelling the potential failure rate of membranes, and whether testing radon levels in new homes is appropriate. The analysis concludes that it is more cost effective to provide targeted radon protection in high radon areas, although this introduces more complexity. The paper also considers the trend in housing to a greater proportion of apartments, the regional variations in types of housing and the decreasing average number of occupants in each dwelling, and concludes that data and methods are now available to respond to the health risks of radon at a local level, in keeping with a general initiative to prioritise responses to health and social welfare issues at a more local level.

Health, economic, psychological and social impact of educating carers of patients with advanced pulmonary disease (protocol).

People with advanced pulmonary disease (APD), such as those with chronic obstructive pulmonary disease, have markedly impaired quality of life. Home Oxygen Therapy (HOT) itself is burdensome, although it often improves survival duration and quality of life in these patients. The exact burdens on informal caregivers of these patients are unknown. The central purpose of the pragmatic randomized controlled study described in this protocol is to determine the effectiveness of improving the skills and knowledge of carers of patients with APD who use HOT. Specifically we aimed to estimate the incremental impact of this carer intervention above usual care on health, economic, psychological and social domains for patient and carer dyads relative to the level of current burden. Eligible patients and their carers were recruited through three major hospitals, and randomized to an intervention or control group. The carers in the intervention group received two home-delivered education sessions based on the principles of academic detailing. Participants are currently being followed over 12 months. The primary outcome will be the proportion of patients surviving without a chronic obstructive pulmonary disease-related readmission / residential (non respite) care over 12 months. Carer secondary outcomes include perceived caregiver burden, level of expected and received social support, perceived level of mastery, self esteem, health related quality of life and disability, and ability to conduct domestic chores and household maintenance, social activities and provide service to others, and fatigue. Secondary patient outcomes include health related quality of life and disability, and current respiratory health status.

Lung-cancer reduction from smoking cessation and radon remediation: a preliminary cost-analysis in Northamptonshire, UK.

Domestic radon levels in parts of the United Kingdom are sufficiently high as to increase the risk of lung-cancer among residents. Public health campaigns in the county of Northamptonshire, a designated radon Affected Area with 6.3% of homes having average radon levels in excess of the UK Action Level of 200 Bq m(-3), have encouraged householders to test for radon and then, if indicated to be necessary, to carry out remediation in their homes. These campaigns have been only partially successful, since to date only 40% of Northamptonshire houses have been tested, and only 15% of those householders finding raised levels have proceeded to remediate. Those who remediate have been shown to have smaller families, to be older, and to include fewer smokers than the average population, suggesting that current strategies to reduce domestic radon exposure are not reaching those most at risk. During 2004-2005, the NHS Stop-Smoking Services in Northamptonshire assisted 2847 smokers to quit to the 4-week stage, the 15% (435) of these 4-week quitters remaining quitters at 1year forming the subjects of a retrospective study considering whether smoking cessation campaigns contribute significantly to radon risk reduction. Quantitative assessment of the risk of lung-cancer among the study population, from knowledge of the individuals' age, gender, and smoking habits, together with the radon levels in their homes, demonstrates that smoking cessation programmes have significant added value in reducing the incidence of lung-cancer in radon Affected Areas, and contribute a substantially greater health benefit at a lower cost than the alternative strategy of reducing radon levels in the smokers' homes, while they remain smokers. Both radon remediation and smoking cessation programmes are very cost effective in Northamptonshire, with smoking cessation being significantly more cost effective, and these are potentially valuable programmes to drive health improvements through promotion of the uptake or environmental management for radon in the home.

A staff questionnaire study of MRSA infection on ENT and general surgical wards.

Methicillin-resistant Staphyloccocus aureus (MRSA) infection has received much attention in both the medical and non-medical press. However, it is not widely encountered on ENT wards, given the profile of short-stay, relatively well patients, although its impact seems to be increasing. We wished to explore the knowledge and attitudes towards MRSA on general surgical and ENT wards, and see if there were any significant differences between specialties, or between doctors and nurses. A 13-item questionnaire with a Likert scale response with six knowledge questions and seven attitude questions was prepared. It was completed anonymously by all nursing and medical staffs on the ENT and general surgical wards of a large District General Hospital. ENT doctors displayed the lowest knowledge and attitude scores; however, this only attained significance in terms of the knowledge of the difference between infection and colonization. Overall, nurses displayed significantly more positive attitudes towards MRSA patients than doctors, but knowledge scores were not significantly different between professions. The study suggests a lack of knowledge about and preponderance of negative attitudes towards MRSA amongst ENT doctors. The difference between colonization and infection is not well understood. Reasons for this may include the relative rarity of MRSA cases on ENT wards.

Lowering the UK domestic radon Action Level to prevent more lung cancers--is it cost-effective?

Case studies have shown that radon gas can accumulate within domestic properties at sufficiently high levels that it can cause lung cancer, and recent studies have suggested that this risk remains significant below the UK domestic Action Level of 200 Bq m(-3). Raised radon levels can be reduced by engineering measures, and it has been shown that domestic radon remediation programmes in UK Affected Areas can result in reduced risks to the population and can be cost-effective. We consider here the benefits and costs of the domestic radon remediation programme in Northamptonshire, UK, and consider the implications for that programme of reducing the UK Action Level below its present value. A radon remediation programme based on an Action Level above 200 Bq m(-3) will cost less and will target those most at risk, but will be less cost-effective and will lead to higher residual dose and greater risk of cancer in the remaining population. Reducing the Action Level below 200 Bq m(-3) will prevent more cancers, but at significantly higher cost. It will also be less cost-effective, because remediation of a significant number of houses with moderate radon levels will provide only a modest health benefit to occupants. Overall, a completed radon remediation programme of the type implemented in Northamptonshire is most cost-effective for an Action Level between 200 and 300 Bq m(-3). The implications for future health policy are discussed.

The value of Seasonal Correction Factors in assessing the health risk from domestic radon: a case study in Northamptonshire, UK.

Following an intensive survey of domestic radon levels in the United Kingdom (UK), the former National Radiological Protection Board (NRPB), now the Radiation Protection Division of the Health Protection Agency (HPA-RPD), established a measurement protocol and promulgated Seasonal Correction Factors applicable to the country as a whole. Radon levels in the domestic built environment are assumed to vary systematically and repeatably during the year, being generally higher in winter. The Seasonal Correction Factors therefore comprise a series of numerical multipliers, which convert a 1-month or 3-month radon concentration measurement, commencing in any month of the year, to an effective annual mean radon concentration. In a recent project undertaken to assess the utility of short-term exposures in quantifying domestic radon levels, a comparative assessment of a number of integrating detector types was undertaken, with radon levels in 34 houses on common geology monitored over a 12-month period using dose-integrating track-etch detectors exposed in pairs (one upstairs, one downstairs) at 1-month and 3-month resolution. Seasonal variability of radon concentrations departed significantly from that expected on the basis of the HPA-RPD Seasonal Correction Factor set, with year-end discontinuities at both 1-month and 3-month measurement resolutions. Following this study, monitoring with electrets was continued in four properties, with weekly radon concentration data now available for a total duration in excess of three and a half years. Analysis of this data has permitted the derivation of reliable local Seasonal Correction Factors. Overall, these are significantly lower than those recommended by HPA-RPD, but are comparable with other results from the UK and from abroad, particularly those that recognise geological diversity and are consequently prepared on a regional rather than a national basis. This finding calls into question the validity of using nationally aggregated Seasonal Correction Factors, especially for shorter exposures, and the universal applicability of these corrections is discussed in detail.

The increasing prevalence of diabetes in South Australia: the relationship with population ageing and obesity.

OBJECTIVES: To use representative population surveillance data to monitor and project changes in the prevalence of diabetes for different age and body mass index (BMI) groups. STUDY DESIGN: Representative, annual, face-to-face South Australian Health Omnibus Surveys, 1991-2003 (n=3000 per year). METHODS: Trends in self-reported diabetes prevalence by age group and BMI were examined. Separate projections were made on the basis of predicted changes in population demography and diabetes prevalence. RESULTS: The age-sex standardized absolute prevalence of self-reported diabetes among people aged 15 years and over increased from 3.5% in 1991 to 6.7% in 2003. If this current trend continues, the prevalence is expected to increase to 10.5% by 2016. The prevalence of diabetes was significantly higher among those classified as obese (6.5% in 1991 to 12.2% in 2003) than those with normal BMI. The greatest relative percentage increase in prevalence between 1991 and 2003 (169%) was seen among people aged 15-39 years. Taking both age group and BMI classification into account, the greatest relative percentage increases over this time were seen among those with normal BMI aged 60 years or older (148%), and those who were obese and aged less than 60 years (139%). CONCLUSIONS: The prevalence of diabetes and obesity increased significantly between 1991 and 2003. Population ageing and an increase in diabetes prevalence in the future will further increase the burden of diabetes. Future increases in diabetes prevalence are not inevitable, however, if investments are made in public health prevention programmes, particularly those addressing obesity.

Primary closure vs second-intention treatment of skin punch biopsy sites: a randomized trial.

OBJECTIVE: To determine if healing of punch biopsy wounds by second intention is equivalent to healing with primary closure. DESIGN: Prospective, randomized, method comparison equivalence study. SETTING: Tertiary academic medical center. PARTICIPANTS: Study volunteers were recruited from the general population and enrolled between January 7, 2002, and August 20, 2002. Patients with immunodeficiency, peripheral vascular disease, or history of keloid formation and those receiving anticoagulation therapy or systemic corticosteroids were excluded. Intervention Study volunteers had two 4-mm or two 8-mm punch biopsies performed on the upper outer arms, midlateral aspect of the thighs, or upper back. One biopsy site was closed with interrupted 4-0 nylon suture, and the contralateral biopsy site was allowed to heal by second intention. MAIN OUTCOME MEASURES: At 9 months, scar appearance was evaluated blindly and independently by 3 physicians using a visual analog scale (0 indicating poor and 100 indicating best). RESULTS: Seventy-seven of 82 enrolled volunteers completed the study. Mean (SD) visual analog scale score was 57.1 (19.5) for biopsy sites allowed to heal by second intention and 58.9 (19.7) for biopsy sites that healed with primary closure. The median surface area of the biopsy scars at 9 months was 32 mm(2) for second intention and 33 mm(2) for primary closure. For the 8-mm biopsies, the volunteers preferred the appearance of the sites that healed with primary closure; however, for the 4-mm biopsies, volunteers had no significant preference for either biopsy method. Costs were lower for second intention, and complications were equivalent. CONCLUSIONS: Punch biopsy sites allowed to heal by second intention appear at least as good as biopsy sites closed primarily with suture. Although volunteers preferred suturing at larger biopsy sites, elimination of suturing of punch biopsy wounds would result in personnel efficiency and economic savings for both patients and medical institutions.

The practical use of electrets in a public health radon remediation campaign.

As part of a long-term assessment of domestic radon in Northamptonshire, England, a batch of 50 commercially available electrets was deployed for nearly 1,000 exposures, individual exposure periods ranging from one to eight weeks. Responsivity was comparable with that of recently-calibrated Durridge RAD-7 continuously-monitoring equipment. Voltage history analysis indicated mean voltage decay during manufacturers' QA assessment of 0.059+/-0.026 Vday(-1), increasing to 0.114+/-0.073 Vday(-1) during storage to first use and to 0.204+/-0.49 Vday(-1) during inter-deployment storage. At a representative elevated radon concentration of 500 Bqm(-3), the resulting perturbation is 3% over a 7-day deployment; at the typical mean Northamptonshire level of 80 Bqm(-3) it approaches 22%. Each electret can be used for up to 25 measurements, which makes the technology attractive for organisational use. It is not suited for deployment by individual householders.

Analysis of the individual health benefits accruing from a domestic radon remediation programme.

Although radon can be present within buildings at sufficient levels to pose a health risk, levels can be reduced relatively easily. Recent studies on a group of radon-remediated homes, based on assessment of collective population-average risk coefficients, have estimated the benefits and cost effectiveness accruing from remediation and have confirmed that domestic remediation in UK radon Affected Areas would result in significantly reduced cancer risks to the population in those areas. Although the population-average approach used hitherto has applied occupancy and lung-cancer risk factors, these are potentially misleading in assessing discrete populations. The study reported here uses the recently developed European Community Radon Software (ECRS) to quantify individual risks in a sample of householders who remediated their homes following indications that radon levels exceeded the action level. The study proceeds from population-averaged to 'individual risk' evaluation, successfully comparing individual and collective risk assessments, and demonstrates that those who remediate are not representative of the general population. Health benefits accruing from remediation are three times lower than expected, largely because remediators are older, live in smaller households, and smoke less than the population average, leading to the conclusion that the current strategy employed in the UK is failing to target those most at risk.

Assessment of health risks to skin and lung of elevated radon levels in abandoned mines.

Radon, together with its progeny, is present in high levels in some underground sites. Radon is known to increase the risk of lung cancer, while increased levels of radon decay products on the skin surface have been implicated in skin cancer induction and at sufficient levels might cause deterministic effects such as erythema. Although radon levels in working mines are controlled, radon in abandoned mines can reach very high levels, which would result in an occupant exceeding recommended annual exposure limits in less than 2 h in some mines. The relative importance of dose limits for the lung, skin cancer, and deterministic effects is discussed in the light of practical experience.

The costs and benefits of radon remediation programmes in existing homes: case study of action level selection.

Radon gas can be present within buildings at sufficiently high levels that it becomes a health risk. Such levels can be reduced, and so radon remediation programmes in the home in UK Affected Areas should result in reduced risks to the population. This paper considers the benefits and costs of the domestic radon remediation programme in Northamptonshire, UK, and considers the implications of the choice of Action Level, in view of the adoption of different levels in many countries. A programme with a higher Action Level will cost less, and target those most at risk, but will be less cost effective. In addition, a higher Action Level leaves a higher residual dose and risk to the remaining population. Such doses are higher than and inconsistent with the radiation dose limits for the general public in the EU Basic Standards Directive.

The costs of radon mitigation in domestic properties.

The paper examines the costs of mitigating radon levels in domestic properties using data from the radon-affected county of Northamptonshire in the United Kingdom. Cost-effectiveness of mitigation is measured in terms of the total costs per lung cancers saved per year by mitigation expenditures. The results obtained match those reported in published theoretical estimates for proposed national mitigation programmes. Mitigation in domestic properties is shown to be more effective in reducing lung cancers than a mitigation programme designed for National Health Service workplaces in Northamptonshire, when all householders discovering radon levels above 300 Bequerels per cubic metre (Bq m(-3)) are assumed to implement mitigation strategies. In the United Kingdom, however, as elsewhere, only a small percentage of those finding raised radon levels proceed to mitigation. This reduces the effectiveness of mitigation programmes in domestic properties to levels matching those in the National Health Service workplaces. The paper confirms findings in studies from Europe and the United States that a significant proportion of householders with radon levels between 200 and 300 Bq m(-3) do not implement remedial work. The paper concludes with a range of policy proposals based on the results obtained.

An analysis of UK waste minimization clubs: key requirements for future cost effective developments.

The UK waste strategy is based upon use of the best practicable environmental option (BPEO), by those making waste management decisions. BPEO is supported by the use of the waste hierarchy, with its range of preferable options for dealing with waste, and the proximity principle, where waste is treated/disposed of as close to its point of origin as possible. The national waste strategy emphasizes the key role of waste minimization and encourages industry, commerce and the public to move towards sustainable waste management practice for economic and environmental reasons. Waste minimization clubs have been used, since the early 1990s, to demonstrate to industry/commerce that reducing waste production can lead to significant financial savings. There have been around 75 such clubs in the UK and they receive support from a wide range of agencies, including the Environmental Technology Best Practice Program. The early Demonstration Clubs had significant savings to cost ratios, e.g. Aire and Calder at 8.4, but had very high costs, e.g. Aire and Calder at 400,000 pounds. It is acknowledged that the number of clubs will have to be approximately doubled in the next few years so as to have an adequate coverage of the UK. There are at present, marked regional variations in club development and cognizance needs to be taken, by facilitators, of the need for extensive coverage of the UK. Future clubs will probably have to operate in a financially constrained climate and they need to be designed to deliver significant savings and waste reduction at low cost. To aid future club design, final reports of all projects should report in a standard manner so that cost benefit analysis can be used to inform facilitators about the most effective club type. rights reserved.

Effects of altitude versus economic status on birth weight and body shape at birth.

The compelling evidence linking small size at birth with later cardiovascular disease has renewed and amplified a clinical and scientific interest in the determinants of fetal growth. Although the effects of maternal nutrition on fetal growth have been extensively studied, comparatively little is known about the effects of maternofetal hypoxia. This study tested the hypothesis that in highland regions, high altitude rather than maternal economic status is associated with reduced and altered fetal growth by investigating the effects of high altitude versus economic status on birth weight and body shape at birth in Bolivia. Bolivia is geographically and socioeconomically unique. It contains several highland (>3500 m above sea level) and lowland (<500 m) cities that are inhabited by very economically divergent populations. Birth weight, body length, and head circumference were compared between a high- (n = 100) and low- (n = 100) income region of La Paz (3649 m; largest high-altitude city) and a high- (n = 100) and low- (n = 100) income region of Santa Cruz (437 m; largest low-altitude city). In addition, the frequency distribution across the continuum of birth weights was plotted for babies born from high- and low-income families in La Paz and Santa Cruz. Mean birth weights were lower in babies from La Paz than in babies from Santa Cruz in both high- and low-income groups. The cumulative frequency curve across all compiled birth weights was shifted to the left in babies from La Paz compared with those from Santa Cruz, regardless of economic status. The frequency of low birth weight (<2500 g) was higher in babies from La Paz than from Santa Cruz in both high- and low-income groups. In addition, at high altitude but not at low altitude, high income was associated with an increase in the head circumference:birth weight ratio. These findings suggest that high altitude rather than economic status is associated with low birth weight and altered body shape at birth in babies from Bolivia.