Differences in consumption of food items between obese and normal-weight people in India.

BACKGROUND: There is a rising prevalence of obesity in India, and diet may be a major determinant of this. We aimed to assess differences in types and quantities of food items consumed by obese and normal-weight people in India. METHODS: Cross-sectional data of 7067 factory workers and their families were used from the Indian Migration Study, conducted in four cities across northern, central and southern India. Food frequency questionnaire data were used to compare the quantities of consumption of 184 food items between 287 obese (body mass index>30 kg/m2) and 1871 normalweight (body mass index 18.50-22.99 kg/m2) individuals, using t tests and ANCOVAs. Individuals with diabetes,hypertension and cardio-vascular disease were excluded. SPSS 16.0 was used for analysis. RESULTS: After adjusting for age, sex, location and socioeconomic status, obese individuals were found to eat significantly larger quantities of 11 food items compared with normalweight individuals. These included phulkas, chapatis/parathas/naan, plain dosa, mutton/chicken pulao/biryani, chicken fried/grilled, rasam, mixed vegetable sagu, vegetable raitha, honey,beetroot and bottlegourd (p< 0.01). Consumption of plain milk was higher among normal-weight than among obese individuals (p< 0.05). Consumption of some of these food items was also found to increase by socioeconomic status, decrease by age, and be higher among men relative to women. CONCLUSION: Obese individuals were found to consume larger quantities of certain food items compared with normal weight individuals. Interventions should aim at limiting overall food consumption among obese individuals.

Costs and effectiveness of a nurse specialist anticoagulant service.

AIMS: To determine the costs and effectiveness of an anticoagulant nurse specialist service compared with a conventional consultant service based on two hospital sites in northwest Hertfordshire. METHODS: Sequential design comparing retrospectively the conduct and outcomes of a consultant service with a nurse specialist service over two six month periods. In each of the six month study periods, all new patients consecutively referred for anticoagulation over a three month period (group A) at the start of each study period and a random selection of patients who had already been attending the anticoagulant service for one year or more (group B) were included in the study. Group A patients wre followed for up to three months and group B patients for six months. The main outcome measures were costs of service provision and effectiveness. Costs included those for the use of the anticoagulant service, those related to general practitioner (GP) visits and hospitalisations, and running costs (staff time, laboratory tests, patient transport). Measures of effectiveness were the mean proportion of time patients spend in the therapeutic range, the number of drugs being taken that could interact adversely and/or inhibit haemostatic function, and patient and GP satisfaction with service provision. RESULTS: In the consultant service, for group A there were more patients aged 66-75 years (p = 0.004) and fewer patients aged more than 76 years (p = 0.001); and for group B, there were fewer patients on anticoagulation for cardiac conditions (p = 0.001), but more on anticoagulation for thromboembolic conditions (p = 0.02) than in the nurse specialist service. The clinic running costs of the nurse specialist service were 4.99 Pounds per attendance, compared with 4.75 Pounds in the consultant service. Including all other costs related to treatment, there was no statistically significant difference in cost per patient. There was no significant difference in the proportion of time patients spent in the therapeutic range between the consultant service and the nurse specialist service. In the nurse specialist service, fewer patients in group A were taking drugs that could interact adversely and/or inhibit haemostatic function (p = 0.01) and more patients were satisfied with service provision (p = 0.04) compared with the consultant service. There was no significant variation in GP satisfaction between the two services. CONCLUSION: In the provision of outpatient anticoagulation, the nurse specialist service was no more expensive than the consultant service and, using our primary outcome, at least as effective. The nurse specialist service has some clear advantages compared to the consultant service: provision of domicilliary care for housebound patients, fewer new patients taking drugs that could interact adversely and/or inhibit haemostatic function patients, it is preferred by newly referred patients to the consultant service, and it is as acceptable to their GPs.

Recurrent urinary conduit bleeding in a patient with portal hypertension: management with a transjugular intrahepatic portosystemic shunt.

OBJECTIVE: To determine if a transjugular intrahepatic portosystemic shunt can control recurrent urinary conduit bleeding in a patient with portal hypertension. METHODS: Following transjugular catheterization of the right hepatic vein, a long curve Colapinto needle was advanced through the liver parenchyma into the portal vein near its bifurcation. After a guide wire exchange, a catheter was advanced into the portal system and venogram was obtained. Following another guide wire exchange, a balloon angioplasty catheter was used to create the shunt by dilating the parenchymal tract between the hepatic and portal veins. A self-expandable stent was used to ensure patency of the shunt. RESULTS: After shunt placement, bleeding from the ileal conduit and stroma decreased significantly. A duplex ultrasound at five-month follow-up demonstrated the shunt to be completely patent. CONCLUSIONS: Based on this limited experience, it appears that the transjugular, intrahepatic, portosystemic shunt is an acceptable method to control massive, recurrent urinary conduit bleeding in patients with portal hypertension.

Provision, uptake and cost of cardiac rehabilitation programmes: improving services to under-represented groups.

OBJECTIVES: To estimate UK need for outpatient cardiac rehabilitation, current provision and identification of patient groups not receiving services. To conduct a systematic review of literature on methods to improve uptake and adherence to cardiac rehabilitation. To estimate cost implications of increasing uptake of cardiac rehabilitation. DATA SOURCES: Hospital Episode Statistics (England). Hospital Inpatient Systems (Northern Ireland). Patients Episode Database for Wales. British Association for Cardiac Rehabilitation/British Heart Foundation surveys. Cardiac rehabilitation centres. Patients from general hospitals. Electronic databases. REVIEW METHODS: The study analysed hospital discharge statistics to ascertain the population need for outpatient cardiac rehabilitation in the UK. Surveys of cardiac rehabilitation programmes were conducted to determine UK provision, uptake and audit activity, and to identify local interventions to improve uptake. Data were also examined from a trial estimating eligibility for cardiac rehabilitation and non-attendance. A systematic review of interventions to improve patient uptake, adherence and professional compliance in cardiac rehabilitation was conducted. Estimated costs of improving uptake were identified from national survey, systematic review and sampled cardiac rehabilitation programmes. RESULTS: In England, Wales and Northern Ireland nearly 146,000 patients discharged from hospital with primary diagnosis of acute myocardial infarction, unstable angina or following revascularisation were potentially eligible for cardiac rehabilitation. In England in 2000, 45-67% of these patients were referred, with 27-41% attending outpatient cardiac rehabilitation. If all discharge diagnoses of ischaemic heart disease were considered, nearly 299,000 patients would be potentially eligible and in England rates of attendance and referral would be 22-33% and 13-20% respectively. Rates of referral and attendance were similar in Wales, but somewhat lower in Northern Ireland. It was found that referral and attendance of older people and women at cardiac rehabilitation tended to be low. It was also suggested that patients from ethnic minorities and those with angina or heart failure were less likely to be referred to or join programmes. A wide range of local interventions suggested awareness of the problem of uptake. In an NHS-funded randomised controlled trial, possibly representing more optimal protocol-led care, medical and nursing staff identified 73-81% of patients with acute myocardial infarction as eligible for cardiac rehabilitation. Excluded patients tended to be older with more severe presentation of cardiac disease. Experiences of patients suggested that uptake may be improved by addressing issues of motivation and relevance of rehabilitation to future well-being, co-morbidities, site and time of programme, transport and care for dependents. Systematic review of studies supported the use of letters, pamphlets or home visits to motivate patients and the use of trained lay visitors. Self-management techniques showed some value in promoting adherence to lifestyle changes. Studies examining professional compliance found that professional support for practice nurses may have value in the coordination of postdischarge care. Average costs in 2001 of cardiac rehabilitation to the health service per patient completing a cardiac rehabilitation programme were about GBP350 (staff only) and GBP490 (total). If services were modelled on an intermediate multidisciplinary configuration with three to five key staff, approximately 13% more patients could be treated with the same budget. Depending on staffing configuration an approximate 200-790% budget increase would be required to provide cardiac rehabilitation to all potentially eligible patients. CONCLUSIONS: Provision of outpatient cardiac rehabilitation in the UK is low and little is known about the capacity of cardiac rehabilitation centres to increase this provision. There is an uncoordinated approach to audit data collection and few interventions aimed at improving the situation have been formally evaluated. Motivational communications and trained lay volunteers may improve uptake of cardiac rehabilitation, as may self-management techniques. Experience of low-cost interventions and good practice exists within rehabilitation centres, although cost information frequently is not reported. Increased provision of outpatient cardiac rehabilitation will require extra resources. Further trials are required to compare the cost-effectiveness of comprehensive multidisciplinary rehabilitation with simpler outpatient programmes, also research is needed into economic and patient preference studies of the effects of different methods of using increased funding for cardiac rehabilitation. An evaluation of a range of interventions to promote attendance in all patients and under-represented groups would also be useful. The development of standards is suggested for audit methods and for eligibility criteria, as well as regular and comprehensive data collection to estimate the need for and provision of cardiac rehabilitation. Further areas for intervention could be identified through qualitative studies, and the extension of low-cost interventions and good practice within rehabilitation centres. Regularly updated systematic reviews of relevant literature would also be useful.

A multi-centre randomised controlled trial of minimally invasive direct coronary bypass grafting versus percutaneous transluminal coronary angioplasty with stenting for proximal stenosis of the left anterior descending coronary artery.

OBJECTIVES: To compare the clinical- and cost-effectiveness of minimally invasive direct coronary artery bypass grafting (MIDCAB) and percutaneous transluminal coronary angioplasty (PTCA) with or without stenting in patients with single-vessel disease of the left anterior descending coronary artery (LAD). DESIGN: Multi-centre randomised trial without blinding. The computer-generated sequence of randomised assignments was stratified by centre, allocated participants in blocks and was concealed using a centralised telephone facility. SETTING: Four tertiary cardiothoracic surgery centres in England. PARTICIPANTS: Patients with ischaemic heart disease with at least 50% proximal stenosis of the LAD, suitable for either PTCA or MIDCAB, and with no significant disease in another vessel. INTERVENTIONS: Patients randomised to PTCA had local anaesthetic and underwent PTCA according to the method preferred by the operator carrying out the procedure. Patients randomised to MIDCAB had general anaesthetic. The chest was opened through an 8-10-cm left anterior thoracotomy. The ribs were retracted and the left internal thoracic artery (LITA) harvested. The pericardium was opened in the line of the LAD to confirm the feasibility of operation. The distal LITA was anastomosed end-to-side to an arteriotomy in the LAD. All operators were experienced in carrying out MIDCAB. MAIN OUTCOME MEASURES: The primary outcome measure was survival free from cardiac-related events. Relevant events were death, myocardial infarction, repeat coronary revascularisation and recurrence of symptomatic angina or clinical signs of ischaemia during an exercise tolerance test at annual follow-up. Secondary outcome measures were complications, functional outcome, disease-specific and generic quality of life, health and social services resource use and their costs. RESULTS: A total of 12,828 consecutive patients undergoing an angiogram were logged at participating centres from November 1999 to December 2001. Of the 1091 patients with proximal stenosis of the LAD, 127 were eligible and consented to take part; 100 were randomised and the remaining 27 consented to follow-up. All randomised participants were included in an intention-to-treat analysis of survival free from cardiac-related events, which found a non-significant benefit from MIDCAB. Cumulative hazard rates at 12 months were estimated to be 7.1 and 9.2% for MIDCAB and PTCA, respectively. There were no important differences between MIDCAB and PTCA with respect to angina symptoms or disease-specific or generic quality of life. The total NHS procedure costs were 1648 British pounds and 946 British pounds for MIDCAB and PTCA, respectively. The costs of resources used during 1 year of follow-up were 1033 British pounds and 843 British pounds, respectively. CONCLUSIONS: The study found no evidence that MIDCAB was more effective than PTCA. The procedure costs of MIDCAB were observed to be considerably higher than those of PTCA. Given these findings, it is unlikely that MIDCAB represents a cost-effective use of resources in the reference population. Recent advances in cardiac surgery mean that surgeons now tend to carry out off-pump bypass grafting via a sternotomy instead of MIDCAB. At the same time, cardiologists are treating more patients with multi-vessel disease by PTCA. Future primary research should focus on this comparison. Other small trials of PTCA versus MIDCAB have now finished and a more conclusive answer to the original objective could be provided by a systematic review.

Referral of patients to an anticoagulant clinic: implications for better management.

The quality of anticoagulant treatment of ambulatory patients is affected by the content of referral letters and administrative processes. To assess these influences a method was developed to audit against the hospital standard the referral of patients to one hospital anticoagulant clinic in a prospective study of all (80) new patients referred to the clinic over eight months. Administrative information was provided by the clinic coordinator, and the referral letters were audited by the researchers. Referral letters were not received by the clinic for 10% (8/80) of patients. Among the 72 referral letters received, indication for anticoagulation and anticipated duration of treatment were specified in most (99%, 71 and 81%, 58 respectively), but only 3% (two) to 46% (33) reported other important clinical information (objective investigations, date of starting anticoagulation, current anticoagulant dose, date and result of latest international normalised ratio, whether it should be the anticoagulant clinic that was eventually to stop anticoagulation, patients' other medical problems and concurrent treatment. Twenty two per cent (16/80) of new attenders were unexpected at the anticoagulant clinic. Most patients' case notes were obtained for the appointment (61%, 47/77 beforehand and 30% 23/77 on the day), but case notes were not obtained for 9% (7/77). The authors conclude that health professionals should better appreciate the administrative and organisational influences that affect team work and quality of care. Compliance with a well documented protocol remained below the acceptable standard. The quality of the referral process may be improved by using a more comprehensive and helpful referral form, which has been drawn up, and by educating referring doctors. Measures to increase the efficiency of the administrative process include telephoning the clinic coordinator directly, direct referrals through a computerised referral system, and telephone reminders by haematology office staff to ward staff to ensure availability of the hospital notes. The effect of these changes will be assessed in a repeat audit.

Evaluation of patients' knowledge about anticoagulant treatment.

OBJECTIVE: To develop a questionnaire to evaluate patients' knowledge of anticoagulation. DESIGN: Anonymous self completed questionnaire study based on hospital anticoagulant guidelines. SETTING: Anticoagulant clinic in a 580 bed district general hospital in London. SUBJECTS: 70 consecutive patients newly referred to the anticoagulant clinic over six months. MAIN MEASURES: Information received by patients on six items of anticoagulation counselling (mode of action of warfarin, adverse effects of over or under anticoagulation, drugs to avoid, action if bleeding or bruising occurs, and alcohol consumption), the source of such information, and patients' knowledge about anticoagulation. RESULTS: Of the recruits, 36 (51%) were male; 38(54%) were aged below 46 years, 22(31%) 46-60, and 10(14%) over 75. 50 (71%) questionnaires were returned. In all, 40 respondents spoke English at home and six another language. Most patients reported being clearly advised on five of the six items, but knowledge about anticoagulation was poor. Few patients could correctly identify adverse conditions associated with poor control of anticoagulation: bleeding was identified by only 30(60%), bruising by 23(56%), and thrombosis by 18(36%). Only 26(52%) patients could identify an excessive level of alcohol consumption, and only seven (14%) could identify three or more self prescribed agents which may interfere with warfarin. CONCLUSION: The questionnaire provided a simple method of determining patients' knowledge of anticoagulation, and its results indicated that this requires improvement. IMPLICATIONS: Patients' responses suggested that advice was not always given by medical staff, and use of counselling checklists is recommended. Reinforcement of advice by non-medical counsellors and with educational guides such as posters or leaflets should be considered. Such initiatives are currently being evaluated in a repeat survey.

Systematic review of long term anticoagulation or antiplatelet treatment in patients with non-rheumatic atrial fibrillation.

OBJECTIVE: To examine the benefits and risks of long term anticoagulation (warfarin) compared with antiplatelet treatment (aspirin/indobufen) [corrected] in patients with non-rheumatic atrial fibrillation. METHODS: Meta-analysis of randomised controlled trials from Cochrane library, Medline, Embase, Cinhal, and Sigle from 1966 to December 1999. Odds ratios (95% confidence intervals) calculated to estimate treatment effects. OUTCOME MEASURES: Fatal and non-fatal cardiovascular events, reductions of which were classified as benefits. Fatal and major non-fatal bleeding events classified as risks. RESULTS: No trials were found from before 1989. There were five randomised controlled trials published between 1989-99. There were no significant differences in mortality between the two treatment options (fixed effects model: odd ratio 0.74 (95% confidence interval 0.39 to 1.40) for stroke deaths; 0.86 (0.63 to 1.17) for vascular deaths). There was a borderline significant difference in non-fatal stroke in favour of anticoagulation (0.68 (0.46 to 0.99)); and 0.75 (0.50 to 1.13) after exclusion of one trial with weak methodological design. A random effects model showed no significant difference in combined fatal and non-fatal events (odds ratio 0.79 (0.61 to 1.02)). There were more major bleeding events among patients on anticoagulation than on antiplatelet treatment (odds ratio 1.45 (0.93 to 2.27)). One trial was stopped prematurely after a significant difference in favour of anticoagulation was observed. The only trial to show a significant difference in effect (favouring anticoagulation) was methodologically weaker in design than the others. CONCLUSIONS: The heterogeneity between the trials and the limited data result in considerable uncertainty about the value of long term anticoagulation compared with antiplatelet treatment. The risks of bleeding and the higher cost of anticoagulation make it an even less convincing treatment option.

Setting up a nurse-led anticoagulant clinic.

People on anticoagulation therapy need regular monitoring. With appropriate training, nurse specialists can improve patient care in anticoagulant clinics.

Prevalence and level of Listeria monocytogenes and other Listeria species in retail pre-packaged mixed vegetable salads in the UK.

As part of the European Commission (EC) co-ordinated programme for 2005, a study of pre-packaged ready-to-eat (RTE) mixed salads containing meat or seafood ingredients from retail premises was undertaken in the UK to determine the frequency and level of Listeria monocytogenes in these products. Almost all (99.8%; 2682/2686) samples were of satisfactory/acceptable microbiological quality. Two (0.1%) samples exceeded EC legal food safety criteria due to the presence of L. monocytogenes in excess of 100 cfu g(-1) (1.7 x 10(2), 9.9 x 10(2)cfu g(-1)) while another two (0.1%) were unsatisfactory due to L. welshimeri levels over 100 cfu g(-1) (1.2 x 10(3), 6.0 x 10(3) cfu g(-1)). Overall contamination of Listeria spp. and L. monocytogenes found in samples of mixed salads in the UK was 10.8% and 4.8%, respectively. Almost twice as many salad samples with meat ingredients were contaminated with Listeria spp. and L. monocytogenes (14.7% and 6.0%, respectively) compared to samples with seafood ingredients (7.4% and 3.8%, respectively). Pre-packaged mixed salads were contaminated with Listeria spp. and L. monocytogenes more frequently when: collected from sandwich shops; not packaged on the premises; stored or displayed above 8 degrees C. This study demonstrates that the control of L. monocytogenes in food manufacturing and at retail sale is essential in order to minimize the potential for this bacterium to be present in mixed salads at the point of consumption at levels hazardous to health.

Controlled clinical trial of two weight reducing diets in a NHS hospital dietetic outpatient clinic: a pilot study.

BACKGROUND: Outpatient dietary weight reduction for obesity is unsatisfactory. The objective of this study was to compare the efficacy of an energy prescription diet with usual care (a healthy eating diet) in adult overweight patients referred to a NHS hospital dietetic outpatient clinic, in terms of weight change over 12 weeks. METHODS: Controlled clinical trial (systematic allocation). RESULTS: Of the 53 patients who attended their first appointment, 27 completed the trial. Mean weight loss (kg) after 12 weeks was 4.2 (sd 3.8) on the energy prescription diet (n = 16) and 6.0 (sd 2.8) on the healthy eating diet (n = 11). CONCLUSIONS: Patients on a weight reducing diet based on energy prescription or healthy eating lost, on average, clinically significant amounts of body weight by 12 weeks. Mean weight loss was greater by about 50% in the healthy eating group and supports the development of a larger trial to estimate true effect.

Left femoral vein approach for the percutaneous placement of the Bird's Nest Filter.

The Bird's Nest Filter femoral catheter set has proven to be too short in some patients to permit placement in close proximity to the renal veins via the left femoral vein approach. The use of the longer, but otherwise identical Bird's Nest Filter jugular catheter set via the left femoral vein eliminates this problem.