Validation of the quality of The National Pain Database for pain management services in the United Kingdom.

Data on specialist pain management is scarce. We evaluated PainDB, a database which aggregates this information from UK pain clinics. PainDB entries for 1120 patients (2648 consultations) were compared to records at 30 pain clinics. Staff were surveyed about normal practice at 28 sites. First consultations (17 135) on the aggregated PainDB were analysed for 2003 for omissions. Those consultations included on PainDB (54.6%) showed good concurrence with written notes (88.1%), with no pattern for the missing visits. Questionnaire responses were often absent from notes (56%) and diagnosis was most frequently omitted from PainDB (12.4-18.4%). Clinic staff overestimated completeness. Despite commitment, PainDB is currently unsuitable for research or audit. As routine hospital data should provide information on activity, specific questions on severity and outcome could be answered by short-term recording of predefined variables.

A study of the association between children's access to drinking water in primary schools and their fluid intake: can water be 'cool' in school?

BACKGROUND: Water is essential for health. The 'Water is Cool in School' campaign promoted improved drinking water access in UK schools. Implementation has been patchy, and impact has not been studied. The aim of this study is to determine whether fluid intake and frequency of toilet visits are associated with children's access to drinking water in the classroom. METHODS: A total of 145 schoolchildren in Year 2 (aged 6-7 years) and 153 in Year 5 (aged 9-10 years) classes were studied in six Southampton schools. Total fluid intake and toilet visits were recorded during one school day. Schools were recruited according to drinking policy: 'prohibited access' = water prohibited in classroom; 'limited access' = water allowed in classroom but not on the desk; and 'free access' = water bottle encouraged on the desk. Data were analysed on an intention-to-treat basis. RESULTS: In total, 120 children in prohibited access, 91 in limited access and 87 in free access settings were recruited. Total fluid intake was significantly higher in Year 2 free access schools (geometric mean 293, range 104-953 mL) compared with prohibited access schools (geometric mean 189, range 0-735 mL, P=0.046), in Year 5 free access schools (geometric mean 489, range 88-1200 mL) compared with prohibited access schools (geometric mean 206, range 0-953 mL, P=0.001), and in free access versus limited access schools (geometric mean 219, range 0-812 mL, P=0.003). A total of 81% and 80% of children in prohibited and limited access schools, respectively, consumed below the minimum recommended amount of total fluid at school, compared with 46.5% in the free access schools. In total, 34.6% of children did not use the toilets at all during the school day. There was no trend observed between water access and frequency of toilet visits (median of 1 trip for each group, P=0.605). CONCLUSION: Most children have an inadequate fluid intake in school. Free access to drinking water in class is associated with improved total fluid intake. Primary schools should promote water drinking in class.

Ovalbumin-specific immunoglobulin G and subclass responses through the first 5 years of life in relation to duration of egg sensitization and the development of asthma.

BACKGROUND: Egg sensitization, particularly persistent sensitization, is a risk factor for later asthma. However, little is known about accompanying IgG and subclass responses and how they might relate to asthmatic outcome. OBJECTIVE: To characterize hen's egg ovalbumin (OVA) IgG and subclass responses through the first 5 years of life in relation to duration of egg sensitization and later asthma. SUBJECTS AND METHODS: The subjects (n=46) formed part of a larger cohort, born to atopic parents, who had been evaluated prospectively for the development of asthma. Egg sensitization was classified as transient (positive egg skin prick test at 1 year only) or persistent (positive skin test for at least 2 years). Plasma OVA IgG, IgG1 and IgG4 concentrations at birth (cord), 6 months, 1 and 5 years of age were measured by ELISA. RESULTS: The kinetics of OVA IgG and IgG1 responses, but not IgG4, differed between egg sensitized and non-egg sensitized (NES) children. Only persistently sensitized children had a rise in OVA IgG1 concentration through the first year of life, and at 1 year of age they had significantly higher OVA IgG and IgG1 than either transiently sensitized or NES children. High OVA IgG1 was associated with later asthma: at 1 year of age, OVA IgG1 greater than 14,500 U predicted asthma with a sensitivity 64% and specificity 74%. CONCLUSION: OVA IgG and subclass responses relate to the duration of egg sensitization. Measurement of OVA IgG1 concentration in infancy might offer a useful adjunct to identify those at an increased risk of asthma.

The effect of high-efficiency and standard vacuum-cleaners on mite, cat and dog allergen levels and clinical progress.

The major triggers for allergic asthma are exposure to allergens of the house dust mite, Dermatophagoides pteronyssinus, and of pets. Unfortunately studies of techniques designed to reduce house dust mite and pet allergens have had mixed results. However, new so-called 'improved' products continue to appear on the market and require subjective evaluation. The homes of 60 house dust mite-allergic patients were studied to compare the effects of high-efficiency and standard vacuum-cleaners on allergen concentration. Der p 1 (house dust mite), Fel d 1 (cat) and Can f 1 (dog) allergens were measured in four separate locations in each home. Clinical analysis was by lung function, bronchodilator usage and histamine challenge techniques. There was a significant reduction in Fel d 1 (ng/m2) in dust samples from the living-room carpet (p = 0.046), bedroom carpet (p = 0.003) and mattress (p = 0.013) and living-room sofa (p = 0.005) after 12 months of using the high-efficiency cleaners, but only in the mattress sample using the standard cleaners (p = 0.014). Can f 1 (ng/g dust) was reduced in the mattress sample after using the high-efficiency vacuum-cleaners (p = 0.028), but not at other sites. Der p 1 levels were not significantly changed over this period. Clinically, patients in the high-efficiency group showed improvements in peak expiratory flow rate (PEFR) (p = 0.004), FEV1 (p = 0.026) and bronchodilator usage (p = 0.005) after 12 months. When the cat-sensitive patients were analyzed separately, improvements in histamine PC20 (p = 0.039) were also seen. Reducing Fel d 1 concentrations, in the absence of any change in Der p 1 concentrations, can produce significant improvements in the lung function of atopic, asthmatic patients. This effect was primarily achieved in those patients with cat sensitivity, but who did not possess a cat themselves.

The social impact of multiple sclerosis--a study of 305 patients and their relatives.

PURPOSE: to assess the effects of multiple sclerosis (MS) on the patients' ability to fulfil their chosen family and social roles and to examine the impact of the disease on their relatives. METHODS: a population-based survey of all known patients with MS and their relatives in Hampshire County, England, between 1986 and 1989. RESULTS: Seventy-four% of the total study population of 411 completed the study. The patients' mean age was 48.3 years (range 19-82) and the mean disease duration was 15.8 years. About 16% of patients were depressed on a mood rating scale and a similar number also exhibited symptoms of anxiety. The marital status of most patients had not changed since the onset of MS but 53% of those who were employed at the time of diagnosis gave up their jobs and the standards of living of 37% of patients and their families had declined as a direct result of the disease. The ability to continue in gainful employment or to maintain social contacts and leisure activities correlated with the course and severity of the disease and cognitive function. Most carers reported symptoms that clearly related to organic pathologies, anxiety and symptoms of depression. The occurrence of these symptoms was associated with disease severity. The professional career of 57% of relatives was also adversely affected by the patient's illness. CONCLUSIONS: MS has a profound impact on the patients' social roles and their relatives' well-being. In contrast to previous studies, a high divorce/separation rate among patients with MS was not observed. Severe disability and cognitive impairment are predictors of loss of employment, decline in the standards of living and withdrawal from social and leisure activities among patients and are strong indicators of stress among relatives.

Mechanical ventilation and high-efficiency vacuum cleaning: A combined strategy of mite and mite allergen reduction in the control of mite-sensitive asthma.

BACKGROUND: The relationship between exposure to house dust mite (HDM) allergens and prevalence of sensitization to these allergens in patients with asthma has been confirmed in many studies. Mite population growth is regulated by humidity. Reducing humidity and removing allergen by efficient vacuuming should control mite allergen and reduce symptoms. OBJECTIVE: We sought to investigate the effect of mechanical ventilation and high-efficiency vacuuming on HDM numbers and Der p 1 concentrations in the homes of mite-sensitive asthmatic subjects and to evaluate the effect of any reductions on symptoms. METHODS: The homes of 40 HDM-sensitive asthmatic subjects were randomized to receive (1) mechanical ventilation and a high-efficiency vacuum cleaner (HEVC); (2) mechanical ventilation alone; (3) an HEVC alone; and (4) no intervention. Homes and patients were monitored for 12 months. Change in absolute humidity, mite numbers, Der p 1 concentrations, lung function, bronchial hyperresponsiveness, and symptom scores were analyzed. RESULTS: Homes with mechanical ventilation achieved significantly lower humidity levels than those without (P <.001), with an associated reduction of mite numbers (P <.05) and Der p 1 concentrations (P <.001 ¿in nanograms per gram, P =.006 ¿in milligrams per square meter) in bedroom carpets and some other mite sources in the ventilated areas of the homes. The addition of a vacuum cleaner enhanced this effect. There was a trend for an improvement in histamine PC(20) (P =.085) in the patients whose homes were ventilated. CONCLUSION: The use of a mechanical ventilation system in suitable homes resulted in some reduction in numbers of HDM and Der p 1 concentrations. The addition of an HEVC slightly enhanced the effect but not sufficiently to see an improvement in symptoms.

Presenting graphical information.

This article outlines the mistakes that are commonly made when data are presented graphically. Common errors when displaying data are highlighted, and preferred solutions for avoiding these mistakes are described. The preferred approaches form the requirements that authors should meet when submitting papers to the journal of Pediatric Allergy and Immunology.

The presentation of statistics.

This article outlines the statistical requirements that authors should fulfill when submitting manuscripts to Pediatric Allergy and Immunology. The requirements are based on the 'Uniform Requirements for Manuscripts Submitted to Biomedical Journals' and the CONSORT statement. Common statistical flaws that routinely arise in the medical literature are described. The use of +/-, confidence intervals and P values, correlation and regression, multiple testing and repeated measures are discussed.

Investigation of the effect of occult invasive cancer on progress towards successful cervical screening.

OBJECTIVES: To describe the effect of occult invasive disease on progress towards meeting the Health of the Nation target for reducing the incidence of cervical cancer, and to investigate the possible effect of a higher risk of cervical cancer in women born since 1940. SETTING: Southampton and South West Hampshire (SSWH), with a total female population of 218,549 in 1990, the midpoint of a study period covering 1985 to 1995. METHODS: Incidence was calculated per 100,000 women years at risk in overlapping three year periods for symptomatic and screen detected cancers. The same methods was used for cohorts of women born before and after 1940. Screen detected stage Ia1 cancers were identified as a subgroup. RESULTS: The incidence of invasive cervical cancer fell by 27.4%, from 16.8 to 12.2 per 100,000 women years at risk between 1985-87 and 1993-95, which was a significant linear trend (chi 2 = 4.494, df = 1, p = 0.034). The corresponding figures adjusted for age in a standardised European population were 16.3 and 11.5: a fall greater than required to meet the Health of the Nation target set for the year 2000. Incidence remained relatively high until screen detected cancers, more than one third of which were stage Ia1, had passed a peak in 1992. When screen detected stage Ia1 cancers were excluded, incidence fell by 41.2%, from 16.5 to 9.7 per 100,000 women years at risk: a highly significant linear trend (chi 2 = 12.391, df = 1, p < 0.001). The incidence in the first three years of the study was higher in women born between 1940 and 1954 than in those born between 1925 and 1939, though the reverse would be expected by age and the natural history of the disease. In the 1940-54 birth cohort 44% (23/52) of screen detected cancers were stage Ia1, with a peak in 1992. When these were excluded, incidence fell by 57.1%, from 31.7 to 13.6 per 100,000 women years at risk: a highly significant linear trend (chi 2 = 13.704, df = 1, p < 0.001), whereas an increase would be expected for a cohort aged from 30-45 to 40-55. In the 1925-39 cohort only 24% (8/33) of screen detected cancers were stage Ia1. When these were excluded, incidence fell by 35.3%, from 24.9 to 16.1, which was not a significant linear trend (chi 2 = 0.409, df = 1, p = 0.522). CONCLUSION: An overall decline in incidence was not achieved until prevalent occult invasive disease had been detected by improved screening. The data confirm the effectiveness of screening, particularly in a high risk cohort of women born between 1940 and 1954.

Childhood reflux and urinary infection: a follow-up of 10-41 years in 226 adults.

To ascertain the outcome of childhood vesicoureteric reflux (VUR), 226 adults (37 males), mean age 27 years, were studied after 10-35 years, extended to 41 years by postal questionnaire in 161. At presentation (mean age 5 years) all had VUR (grade III-V in 68) and urinary tract infection (UTI); there was renal scarring in 85 (acquired before referral in 11 and during follow-up in 1), hypertension in 6 and impaired renal function in 5. They were managed and followed prospectively by one paediatrician; 63% of these children remained free from UTI; VUR persisted in 63 and had resolved in 69% of 193 children managed medically. At follow-up, 61% of adults had remained free from infection; 17 adults had hypertension and/or raised plasma creatinine, 16 with scarred kidneys. Their deterioration was predictable because of scar type, blood pressure or plasma creatinine levels in childhood. No new scars developed after puberty. Renal growth rates were unaffected by initial severity or persistence of VUR. On the later questionnaire, 9 further adults, mean age 38 years, had moderate hypertension. The adults with complications were those with extensive renal scarring and/or at least borderline hypertension in childhood. Those with VUR, but no scarring, and managed carefully in childhood, did not suffer serious consequences as adults. There is a need for early recognition and treatment of children with VUR and UTI to limit scar development.

Fetal peripheral blood mononuclear cell proliferative responses to mitogenic and allergenic stimuli during gestation.

Blood samples were obtained from fetuses and premature babies (n = 51) (15-34 weeks gestation) to determine at what stage the fetal immune system was able to produce a positive proliferative response to common allergens. Peripheral blood mononuclear cells (PBMC) were stimulated with the mitogen, phytohaemagglutinin (PHA), and the allergens, house dust mite, cat fur, birch tree pollen, beta-lactoglobulin, ovalbumin and bee venom (mellitin). Results were expressed as ratios of stimulated to unstimulated 3H thymidine incorporation, and as percent positive responders. There was an increase in proliferation ratio which correlated with increasing gestational age for PHA (p < 0.0001), cat fur (p = 0.042), birch pollen (p = 0.022) and beta-lactoglobulin (p = 0.006). The point in gestation when cells from some individuals began responding to the allergens with a ratio of 2.0 was at approximately 22 weeks. PBMC proliferative response ratios were higher from samples from babies > 22 weeks gestation compared to < 22 weeks for the mitogen and all allergens, except mellitin. There was also a greater proportion of positive responders from samples > 22 weeks compared to < 22 weeks for the mitogen and all allergens, except mellitin. Maternal exposure to birch pollen, which has a discrete season, was assessed to determine whether exposure had occurred at 22 weeks gestation or beyond. Results showed a higher proliferative response in infant cells stimulated with birch pollen (p = 0.005) and higher proportion of positive responders (p = 0.01) in the group of babies whose mothers had been exposed to birch pollen beyond 22 weeks, compared to those whose mothers had not been so exposed. These results suggest that in utero fetal exposure to an allergen from around 22 weeks gestation may result in primary sensitisation to that allergen, leading to positive proliferative responses, at birth.

Peripheral blood mononuclear cell proliferative responses in the first year of life in babies born to allergic parents.

BACKGROUND: Raised peripheral blood mononuclear cells (PBMCs) proliferative responses to food allergens have been demonstrated in children with established atopic dermatitis. OBJECTIVE: In this report we investigate the PBMC proliferative responses to inhalant and food allergens from babies at birth, 6 months and 1 year of age, born to atopic and non-atopic parents. METHODS: PBMCs, separated by density gradient centrifugation, were cultured for 6 days with autologous plasma and a range of allergens (house dust mite [HDM], cat, grass pollen, tree pollen, betalactoglobulin and ovalbumin). Proliferative responses were measured by the uptake of [3H] thymidine added for the final 18 h of culture. RESULTS: At birth, infants born to atopic parents who developed allergic disease by 1 year of age had significantly more positive responses (stimulation index > or = 2 with a value of > or = 1000 cpm above background) to HDM (P = 0.0097), betalactoglobulin (P = 0.0166) and ovalbumin (P = 0.0035) than newborns who did not develop allergy. Infants who developed allergy also had significantly more positive responses to HDM (P = 0.03) and ovalbumin (P = 0.0057) than babies, born to non-atopic parents, who did not develop allergies. At 6 months of age a significant fall in response to HDM (P = 0.003) and cat fur extract (P = 0.006) was seen in infants who developed allergic disease by 1 year of age. A similar pattern was seen for proliferative responses to betalactoglobulin and ovalbumin (P = 0.0006, P = 0.004). Conversely, proliferations to grass and tree pollen extracts increased at 6 months (P = 0.04, P = NS) and 1 year (P = NS, P = 0.01) compared with birth which was significant for infants who did not develop allergic disease. CONCLUSION: Proliferative responses to seasonal allergens increased over the first year of life whilst those to perennial allergens, both inhalant and food, fell. This suggests either the induction of a systemic immune tolerance by perennial exposure to antigens or movement of sensitized cells to target organs where allergen exposure occurs. This process may be independent of the development allergic disease.

Invasive cervical cancer in Southampton and South West Hampshire: effect of introducing a comprehensive screening programme.

A study of invasive cervical cancer in Southampton and South West Hampshire is reported, covering three consecutive three year periods during which the screening coverage increased from an estimated 60% to a recorded 87% of eligible women aged 20-64. From the first to the third periods of the study in that age group registrations of fully invasive squamous cell carcinoma (stage lb and above) fell from 64 to 30 (53%), which was largely counteracted by an increase in microinvasive squamous cell carcinoma (linear trend: P<0.0001). In the same age group registrations of adenocarcinoma rose slightly, which resulted from an increase in the number diagnosed at a depth of invasion of less than 3 mm. There were no significant changes in the numbers of stage III and IV cancers or among cancers in women aged 65 and over. A strong inverse association was found between stage of both histological types of cancer and their likelihood of being screen detected rather than symptomatic: 91% of screen detected cancers were diagnosed at stage I compared with 38% of symptomatic cancers. There was a slight downward trend in the incidence of cancer per 100,000 total female population across the three periods of the study with a significant trend towards low stage disease, which is likely to reduce mortality in years to come. The trend towards screen detected cancers and cancers of less than 3 mm depth of invasion is presented as a positive outcome to be expected in early rounds of increasing the screening coverage.

Relation between the incidence of invasive cervical cancer and the screening interval: is a five year interval too long?

OBJECTIVE: To examine the incidence of invasive cervical cancer per 100,000 women years at risk and relative risk according to screening history among eligible women aged 25-69 in Southampton and South West Hampshire during the three years after completion of the first round of comprehensive screening. RESULTS: There was a significantly higher incidence of invasive cervical cancer in women who had not been screened during the preceding 0.5-5.5 years than in those who had been screened (relative risk (RR) 2.6; 95% confidence interval (CI) 1.6 to 4.3). Among the latter group of women (with interval cancers) there was a significantly higher incidence in those with a long interval of 3.5-5.5 years since their most recent smear than in those with a short interval of 0.5-3.5 years (RR 2.2; 95% CI 1.3 to 3.8). Among women with non-interval cancers, there was a significantly higher incidence among those who had no cytology record than among those who had been screened but were overdue for a smear (RR 3.0; 95% CI 1.2 to 7.3). When screen detected cancers were excluded from the figures the relative risks for all the comparative groups described above were greater, though the 95% confidence limits were wider because the numbers were smaller. The most pronounced difference in incidence was between symptomatic cancers in women with a short screening interval (5.8 per 100,000 women years at risk) and in women with no cytology record (71.3 per 100,000 years at risk). Most cancers were interval cancers (76%) because of the high screening coverage: 89.2% of eligible women aged 25-69 had been screened during the preceding 0.5-5.5 years. The overall incidence per 100000 women years at risk approached that of interval cancers, and was nearer to that observed in the short than the long interval because 74.7% of women had been screened within 3.5 years. CONCLUSION: The results confirm the effectiveness of screening but suggest that a five year screening interval may be too long, at least during the early rounds of screening.

A controlled neuropsychological study of HIV-seropositive and HIV-seronegative adolescent haemophiliacs.

Sixty-four males with haemophilia were assessed with a series of neuropsychological tests and a structured interview for psychiatric symptoms. Thirty-one had been infected with human immunodeficiency virus (HIV) before the age of 18 and were in various stages of the disease at the time of testing and 33 were HIV negative. Sixteen male control subjects were recruited to match in age with the haemophilia group. The HIV-seropositive group were older than the HIV-negative group due to the cohort effect of the time of infection. Contrary to predictions from the known effects of HIV on the central nervous system the HIV-seropositive group performed better on many of the tests than the HIV-seronegative group. In some but not all of the tests this may have been an age effect. There was very little psychiatric morbidity, consistent with the view that high levels of psychological support provided by the haemophilia units can alleviate the effects of the illness on emotions and behaviour. These findings form a baseline for a 2-year follow-up study which is in progress.

Identifying correct bacteriological vocabulary: software to look up RKC codes and statements.

A program has been written to help identify the correct RKC codes (Rogosa, Krichevsky and Colwell, 1986) for describing microbiological attributes. Terms, which may be complete words, parts of words, or numbers, can be typed into the computer. A search is made of the set of about 13,800 RKC codes and statements that describe them. Statements that contain the search terms are displayed in a scrolling window so that the required statement(s) can be identified. A list of selected RKC statements can be built up in a second window for subsequent use by other software packages. The program called RKCLIST runs under the MS-DOS operating system. The software routines used to create RKCLIST have been written so that they can be incorporated into other software packages that make use of the RKC coding scheme.

A bacterial identification teaching exercise revisited.

Bacterial Identification, first described by Bryant (1986), is a program that provides a novel way of enhancing the teaching of systematic bacteriology and numerical identification procedures. A student is assigned an unknown isolate from a list of bacteria. The student's objective is to identify the unknown isolate using the least number of tests from the set of tests available. Simultaneously the computer tries to identify the unknown using optimised and random selection of tests. A student can compare their progress against that of the computer. The program has been improved and the data matrix on which it was based has been revised by the addition of 14 more species, an additional test and by updating the original probability matrix. The program, Bacterial Identification, is available as 'freeware' and has been placed with organisations that distribute such software.