Validation of trichloroacetic acid exposure via drinking water during pregnancy using a urinary TCAA biomarker.

Disinfection by-product (DBP) exposure during pregnancy may be related to reduced fetal growth, but the evidence is inconclusive and improved DBP exposure assessment is required. The authors conducted a nested exposure study on a subset (n=39) of pregnant women in the Born in Bradford cohort to assess validity of TCAA exposure assessment based on tap water sampling and self-reported water-use; water-use questionnaire validity; and use of a one-time urinary TCAA biomarker. TCAA levels in urine and home tap water supply were quantified, and water use was measured via a questionnaire and 7-day diary, at 28 weeks gestation. Diary and urine measures were repeated later in pregnancy (n=14). TCAA level in home tap water supply was not correlated with urinary TCAA (0.18, P=0.29). Cold unfiltered tap water intake at home measured by questionnaire was correlated with urinary TCAA (0.44, P=0.007), but correlation was stronger still for cold unfiltered tap water intake reported over the 3 days prior to urine sampling (0.60, P<0.001). For unemployed women TCAA ingestion at home, derived from tap water sampling and self-reported water-use, correlated strongly with urinary TCAA (0.78, P<0.001), but for employed women the correlation was weak (0.31, P=0.20). Results suggest individual tap water intake is most influential in determining TCAA exposure variability in this cohort, and that TCAA ingestion at home is a valid proxy for TCAA exposure for unemployed women but less satisfactory for employed women.

Tap water use amongst pregnant women in a multi-ethnic cohort.

BACKGROUND: Studies of disinfection by-products in drinking water and measures of adverse fetal growth have often been limited by exposure assessment lacking data on individual water use, and therefore failing to reflect individual variation in DBP exposure. METHODS: Pregnant women recruited to the Born in Bradford cohort study completed a questionnaire which covers water exposure. Information was collected on water consumption, showering, bathing and swimming. Water exposure data from a subset of 39 women of the cohort are described here. RESULTS: Mean total tap water intake was 1.8 l/day, and women on average spent 146 minutes per week showering and bathing. Most tap water intake occurred at home (100% for unemployed, 71.8% for employed). Differences between age groups were observed for total tap water intake overall (p = 0.02) and at home (p = 0.01), and for bottled water intake (p = 0.05). There were differences between ethnic groups for tap water intake at home (p = 0.02) and total tap water intake at work (p = 0.02). Total tap water intake at work differed by income category (p = 0.001). Duration per shower was inversely correlated with age (Spearman's correlation -0.39, p = 0.02), and differed according to employment status (p = 0.04), ethnicity (p = 0.02) and income (p = 0.02). CONCLUSION: This study provides estimates of water exposure in pregnant women in a multi-ethnic population in the north of England and suggests differences related to age, employment, income and ethnicity. The findings are valuable to inform exposure assessment in studies assessing the relationship between DBPs and adverse birth outcomes.

How is research evidence used to support claims made in advertisements for wound care products?

AIMS AND OBJECTIVE: To investigate the amount, type and accuracy of citations use in support of product related claims from advertisements of wound care products. BACKGROUND: Although articles submitted to most medical journals are subjected to peer review, such scrutiny is often not required for the content of advertisements. DESIGN: A contents survey of advertisements from two wound care journals (Journal of Wound Care and Ostomy Wound Management) from 2002-2003 and the British Medical Journal, 2002-2003. METHODS: Data collected from advertisements included identification of product related claims made and any corresponding citations. Where journal articles were cited to support claims, the articles were obtained. Where data on file were cited, this material was requested. In each case the accuracy of claims in relation to the content of the supporting citation was assessed. RESULTS: The use of citations to support product related claims was infrequent in advertisements from wound care journals, where 35% of advertisements containing a product related claim also contained at least one citation, compared with 63% of advertisements from the British Medical Journal. Of citations that were supplied, journal articles were less common in the wound journals (40% vs. 73% in the British Medical Journal) and data on file more common (38% vs. 6% in the British Medical Journal). Where journal articles were obtained, 56% of claims in the wound care journals advertisements were not supported by the cited article, compared with 12% of claims in the British Medical Journal. CONCLUSION: The wound journals advertised predominantly medical devices. The use and accuracy of referencing in advertisements from wound care journals was poor. RELEVANCE TO CLINICAL PRACTICE: Nurses have increasing responsibilities for the prescribing of both drugs and devices, which must be accompanied by the ability to interpret marketing materials and research evidence critically. Nurse educators must ensure that nurse education generally and nurse prescriber training particularly, builds skills of information retrieval and critical appraisal.

Born in Bradford, a cohort study of babies born in Bradford, and their parents: protocol for the recruitment phase.

BACKGROUND: Bradford, one of the most deprived cities in the United Kingdom, has a wide range of public health problems associated with socioeconomic deprivation, including an infant mortality rate almost double that for England and Wales. Infant mortality is highest for babies of Pakistani origin, who comprise almost half the babies born in Bradford. The Born in Bradford cohort study aims to examine environmental, psychological and genetic factors that impact on health and development perinatally, during childhood and subsequent adult life, and those that influence their parents' health and wellbeing. This protocol outlines methods for the recruitment phase of the study. METHODS: Most Bradford women attend for antenatal care and give birth at the Bradford Royal Infirmary, which has approximately 5,800 births per year. Women are eligible for recruitment if they plan to give birth here. Babies born from March 2007 are eligible to participate, recruitment is planned to continue until 2010. Fathers of babies recruited are invited to participate. Women are usually recruited when they attend for a routine oral glucose tolerance test at 26-28 weeks gestation. Recruitment of babies is at birth. Fathers are recruited whenever possible during the antenatal period, or soon after the birth. The aim is to recruit 10,000 women, their babies, and the babies' fathers. At recruitment women have blood samples taken, are interviewed to complete a semi-structured questionnaire, weighed, and have height, arm circumference and triceps skinfold measured. Umbilical cord blood is collected at birth. Within two weeks of birth babies have their head, arm and abdominal circumference measured, along with subscapular and triceps skinfold thickness. Fathers self-complete a questionnaire at recruitment, have height and weight measured, and provide a saliva sample. Participants are allocated a unique study number. NHS numbers will be used to facilitate record linkage and access to routine data. A wide range of hospital and community sources is being accessed to provide data for the women and children. Data are checked for accuracy and consistency. CONCLUSION: Born in Bradford will increase understanding of the factors that contribute to health and wellbeing, and identify factors that influence differences in them between people of Pakistani and European origin.

Increasing the visibility of coding decisions in team-based qualitative research in nursing.

OBJECTIVES: To examine the use of the multi-rater Kappa measure of agreement (Nonparametric Statistics for the Behavioural Sciences, McGraw Hill, New York, 1988) in team based, mixed method, qualitative nursing research. DESIGN: The article presents an illustrative description of the application of the qualitative coding procedure and associated multi-rater Kappa measurement at four time points in 9 months amongst a five person health services research team. MAIN OUTCOME MEASURES: The multi-rater Kappa statistic. This is a measure of the extent to which observers achieve possible agreement beyond any agreement expected to occur by chance alone. RESULTS: Closeness to primary qualitative research data, working relationships over time, and focused research team discussion can all lead to greater agreement and convergence at the level of descriptive coding. The method of measuring agreement between groups of coders was easily applied and appeared a feasible option for similar research projects wishing to demonstrate transparency in their coding procedures. CONCLUSION: Measuring agreement beyond chance by the multi-rater Kappa statistic has some utility for research teams whose qualitative coding tasks are primarily descriptive. The method offers a standard and transparent approach for demonstrating agreement between coders and should be a feature of qualitative research reporting where appropriate.

A new clinical trial of the effect of larval therapy.

The VenUS II trial is the first large, prospective clinical study to investigate the effect of larval therapy and hydrogel on both the bacteriology and healing of leg ulcers. This trial will compare the clinical and cost effectiveness of two types of larval therapy (loose and bagged) with a standard debridement intervention (hydrogel) in terms of effects on time to complete healing, time to debridement, wound microbiology, cost of treatment and health-related quality of life. This paper describes the aims and design of the trial, outlines the eligibility criteria for patients and discusses the nurses' role in the study. This article has not been subject to peer review.

The value of research in clinical decision-making.

This article examines the application of research-based information in clinical decision-making. In doing so it draws on the findings (and work in progress) of two research projects that seek to contribute to establishing the potential for evidence-based approaches in nursing. The authors conclude that understanding the types of decisions nurses make, their clinical uncertainties and unanswered questions is of value to both researchers, policy makers and practitioners.

Seroprevalence of cytomegalovirus, Epstein Barr virus and varicella zoster virus among pregnant women in Bradford: a cohort study.

OBJECTIVE: To estimate the seroprevalence of cytomegalovirus (CMV), Epstein Barr virus (EBV) and varicella zoster virus (VZV) among pregnant women in Bradford by ethnic group and country of birth. METHODS: A stratified random sample of 949 pregnant women enrolled in the Born in Bradford birth cohort was selected to ensure sufficient numbers of White UK born women, Asian UK born women and Asian women born in Asia. Serum samples taken at 24-28 weeks' gestation were tested for CMV IgG, EBV IgG and VZV IgG. Each woman completed a questionnaire which included socio-demographic information. RESULTS: CMV seroprevalence was 49% among the White British women, 89% among South Asian UK born women and 98% among South Asian women born in South Asia. These differences remained after adjusting for socio-demographic factors. In contrast, VZV seroprevalence was 95% among women born in the UK but significantly lower at 90% among South Asian women born in Asia. EBV seroprevalence was 94% overall and did not vary by ethnic group/country of birth. CONCLUSIONS: Although about half of White British women are at risk of primary CMV infection in pregnancy and the associated increased risk of congenital infection, most congenital CMV infections are likely to be in children born to South Asian women with non-primary infection during pregnancy. South Asian women born in South Asia are at risk of VZV infection during pregnancy which could produce congenital varicella syndrome or perinatal chickenpox. Differences in CMV and VZV seroprevalence by ethnic group and country of birth must be taken into account when universal immunisation against these viruses is contemplated.

The reliability of routine anthropometric data collected by health workers: a cross-sectional study.

BACKGROUND: Reliable data on child growth is a prerequisite for monitoring and improving child health. Despite the extensive resources invested in recording anthropometry, there has been little research into the reliability of these data. If these measurements are unreliable growth may be misreported, and health problems may go undetected. OBJECTIVES: To assess the reliability of routine infant growth data, following anthropometric training of health workers responsible for collecting these data, in Bradford, UK. To determine whether being observed by an external administrator influenced reliability. DESIGN: A test-retest design was used. PARTICIPANTS: All health workers (n=192) responsible for growth monitoring in Bradford were included in the study, of which 36.5% (n=70) had complete data. METHODS: Following training in basic anthropometry all health workers were asked to complete a test-retest study, using infants aged 0-2 years. Health workers took two recordings of weight, length, head circumference, and abdominal circumferences on five infants. A peer health worker recorded a third set of measurements on each infant. Twenty-two individuals were selected to be observed by an external administrator during data collection. Technical error of measurements (TEMs) were produced to assess intra-observer and inter-observer reliability. Differences between groups were tested to determine whether external observation influences reliability. RESULTS: None of the TEMs were excessively large, and coefficients of reliability ranged from 0.96 to 1.00. All intra-observer and inter-observer TEMs for the observed group were larger than those for the non-observed group. For example, the observed group's intra-observer TEMs for weight, length, abdominal circumference, and head circumference (46.18 g, 0.60 cm, 0.65 cm, 0.47 cm) were larger than the non-observed group's TEMS (9.14 g, 0.35 cm, 0.34 cm, 0.19 cm). TEMs for weight, abdominal circumference, and head circumference were significantly larger for the observed group, compared to the non-observed group (p<0.001). Inter-observer TEMs for length were also significantly larger for the observed group (p=0.031), whilst intra-observer TEMs for length were not significantly different between the two groups (p=0.137). CONCLUSIONS: Following training in anthropometry health workers in Bradford can, in general, reliably measure child growth. TEMs were comparable to data from other research studies and all coefficients of reliability were indicative of good quality control. Reliability measurement provides a method of quality assurance for routine data monitoring. If commissioners of health services are to be informed by these data then some form of reliability assessment should be considered, and if employed external observation is recommended to improve validity.

Barriers to evidence-based practice in primary care nursing--why viewing decision-making as context is helpful.

AIM: This paper reports a study examining the barriers associated with research knowledge transfer amongst primary care nurses in the context of clinical decision-making. BACKGROUND: The research literature on barriers to nurses' use of research knowledge is characterized by studies that rely primarily on self-report data, making them prone to reporting biases. Studies of the barriers to evidence-based practice often fail to examine information use and behaviour in the context of clinical decision-making. METHODS: A multi-site, mixed method, case study was carried out in 2001. Data were collected in three primary care organizations by means of interviews with 82 primary care nurses, 270 hours of non-participant observation and 122 Q-sorts. Nurses were selected using a published theoretical sampling frame. Between-methods triangulation was employed and data analysed according to the principles of constant comparison. Multiple linear regression was used to explore relationships between a number of independent demographic variables (such as length of clinical experience) and the dependent variable of nurses' perspectives on the barriers to their use of research knowledge. RESULTS: Three perspectives on barriers to research information use emerged: the need to bridge the skills and knowledge gap for successful knowledge transfer; information formats need to maximize limited opportunities for consumption; and limited access in the context of limited time for decision-making and information consumption. Demographic variables largely failed to predict allegiance to any of the perspectives identified. CONCLUSIONS: Researchers should consider using decision-making as a contextual backdrop for exploring information use and behaviour, avoid relying solely on self-reported behaviour as data, and use a variety of research methods to provide a richer picture of information-related behaviour. Practice developers need to recognize that understanding the decisions to which research knowledge is to be applied should be a characteristic of any strategy to increase research uptake by nurses.

Nurse practitioner and practice nurses' use of research information in clinical decision making: findings from an exploratory study.

BACKGROUND: There is a lack of evidence regarding the kinds of decisions made by primary care nurses and the information sources they use in clinical decision making. OBJECTIVE: To describe the decisions made by nurses working in general practice and the sources of information they use to underpin those decisions. METHODS: Qualitative methods (interviews, observation, documentary analysis) were used to collect data on the clinical decision making and information seeking behaviour of a purposive sample of 29 practice nurses and four nurse practitioners from general practices in the North of England. Data were collected November 2001-September 2002. RESULTS: A seven-fold typology captured the types of decisions the nurses made on a daily basis concerning assessment, diagnosis, intervention, referral, communication, service delivery and organization (SDO) and information seeking. Faced with clinical uncertainty, the majority of the nurses in the study relied on personal experience, or obtained advice and information from GP or other colleagues. These 'human sources' of information were overwhelmingly preferred to text or on-line resources. Despite encounters with evidence-based resources through continuing professional development, the nurses rarely used them to seek answers to routine clinical questions. CONCLUSION: The decisions of the nurses in the study were mainly concerned with undifferentiated diagnosis and treatment, in the context of acute conditions and chronic disease management. 'Human sources' of information were preferred to any other; however, we do not know whether information obtained from colleagues is based on research.