Changing carriage rate of Neisseria meningitidis among university students during the first week of term: cross sectional study.

OBJECTIVE: To determine the rates of, and risk factors for, meningococcal carriage and acquisition among university students. DESIGN: Repeated cross sectional study. PARTICIPANTS: 2,507 students in their first year at university. MAIN OUTCOME MEASURES: Prevalence of carriage of meningococci and risk factors for carriage and acquisition of meningococci. RESULTS: Carriage rates for meningoccoci increased rapidly in the first week of term from 6.9% on day 1, to 11.2% on day 2, to 19.0% on day 3, and to 23.1% on day 4. The average carriage rate during the first week of term in October among students living in catered halls was 13.9%. By November this had risen to 31.0% and in December it had reached 34. 2%. Independent associations for acquisition of meningococci in the autumn term were frequency of visits to a hall bar (5-7 visits: odds ratio 2.7, 95% confidence interval 1.5 to 4.8), active smoking (1.6, 1.0 to 2.6), being male (1.6, 1.2 to 2.2), visits to night clubs (1. 3, 1.0 to 1.6), and intimate kissing (1.4, 1.0 to 1.8). Lower rates of acquisition were found in female only halls (0.5, 0.3 to 0.9). The most commonly acquired meningococcal strain was C2a P1.5 (P1.2), which has been implicated in clusters of invasive meningococcal disease at other UK universities. CONCLUSIONS: Carriage rates of meningococci among university students increase rapidly in the first week of term, with further increases during the term. The rapid rate of acquisition may explain the increased risk of invasive meningococcal disease and the timing of cases and outbreaks in university students.

Management of hypertension in patients developing end-stage renal failure.

The benefits of treating hypertension include preventing or delaying the progression of chronic renal failure, and reducing the cardiovascular complications of patients with renal disease. We examined how well hypertension had been managed in all 145 patients from a single health district who started dialysis during a 3-year period. Data relating to management of hypertension, including all blood pressure readings, were obtained from their general practice and hospital case notes. The anonymized data were reviewed by two independent assessors against a set of standards based on the British Hypertension Society guidelines. There was close agreement between the assessors. Complete records were obtained in 98.5% of cases. Of the 145 patients, 107 (76.4%) were hypertensive before developing end-stage renal failure. There were departures from standards in all categories of care: 24.3% in detection/diagnosis, 29% in investigation, 22.4% in referring to a nephrologist, and 17% in follow-up. The British Hypertension Society recommended standard for diastolic blood pressure of 90 mmHg was achieved in only 45%. In 32%, the assessors independently concluded that poor blood pressure control might have affected adversely the progression of renal failure. New methods of dealing with these problems are required and possible approaches are discussed.

Effectiveness of ambulance paramedics versus ambulance technicians in managing out of hospital cardiac arrest.

OBJECTIVE: To determine the effectiveness of extended trained ambulance personnel (paramedics) for the management of out of hospital cardiac arrest. METHODS: A retrospective cohort study of patients who suffered a cardiac arrest between 1 January 1992 and 31 July 1994, and who were transported to their local accident and emergency (A&E) department. Data were collected on basic demography, operational time intervals, and ambulance crew status. Further clinical data were collected, and outcome measures included status on arrival at A&E, status on leaving A&E (hospital admission), and status on leaving hospital. The data were analysed using univariate and multivariate techniques. RESULTS: Univariate analysis showed the likelihood of arriving in A&E with a return of spontaneous circulation was more than doubled among patients attended by a paramedic crew compared with those attended by technicians (relative risk = 2.48, 95% confidence interval 1.34 to 4.60). The likelihood of successful hospital admission was also significantly increased (RR = 1.92, 95% CI 1.13 to 3.27); however, beyond this point, further survival benefits appeared to be much smaller. Similar findings were revealed using multivariate analysis. Second level modelling revealed further possible differences between paramedic and technician crews according to type of incident. Patients successfully admitted to hospital who died before discharge remained severely disabled between admission and death. CONCLUSIONS: There are marked short term survival advantages after cardiac arrest associated with paramedic care, but these probably diminish rapidly over time.

Unemployment and health: the quality of social support among residents in the Trent region of England.

OBJECTIVE: To examine the quality of social support among unemployed residents in Trent, England. DESIGN: Secondary analysis of data generated by those of working age drawn from a postal lifestyle survey of the adult population of Trent region. SUBJECTS AND SETTING: Subjects were 6987 individuals (males 16-64 years and females 16-59 years of age), of whom 9.9% (689/6987) were unemployed. MAIN OUTCOME MEASURES: Responses about the quality of social support obtained from three key questions. RESULTS: Generally, the unemployed reported poorer quality of social support than employed persons (p < 0.0001) on all three key elements examined: 31% v 17% respectively had no practical support; 19% v 10% had no help with solving problems, and 21% v 10% had no emotional support. Only 57% of the unemployed had all three of these elements compared with 75% of the employed. Unemployment and lack of social support had independent and deleterious effects on perceptions of general health and mental health. Relationships remained after allowing for the possible confounding effects of age, gender, and household composition. CONCLUSIONS: There is a relationship between unemployment and poorer quality of social support which may help to explain some of the increased morbidity and mortality experienced by this group, especially that related to mental health.

Coronary heart disease: a review of the role of psychosocial stress and social support.

BACKGROUND: The role of psychosocial factors in the aetiology of coronary heart disease continues to be debated. Despite public perception of a major role for their effect, scientific opinion on their relevance remains divided. This paper reviews the literature on the influence of social support and life stress on coronary heart disease incidence and mortality. METHODS: Observational studies published in English, based on over 100 human subjects from the general population, investigating life stress or social support were considered. Fourteen studies derived from MEDLINE searches on MeSH headings: coronary disease; stress, psychological; social support; social isolation; life change events. An equivalent search of BIDS and studies referenced by papers identified using these sources was carried out. RESULTS AND CONCLUSIONS: The review concludes that both life stress and social support were found to have an influence on coronary heart disease, social support more so than stress. Both have a stronger influence on coronary heart disease mortality than on initial incidence of clinical disease. Measures of the quality of support, in particular emotion support, show the largest effects. The review highlights problems in drawing conclusions from the available literature; in particular, the inconsistency in measures used to define the psychosocial factors. Further studies are needed to investigate interrelationships between stress and social support, and a recommendation is made to adopt pragmatic measures in future studies, which if proven to have an effect, may be open to modification.

Practices and policies for influenza immunization in old people's homes in Nottingham (UK) during the 1992-1993 season: potential for improvement.

BACKGROUND: The elderly residents of nursing and old people's homes are at substantially increased risk from influenza and its complications. Annual vaccination is therefore strongly recommended by the UK Departments of Health. However, few data exist on the uptake of influenza vaccine in this setting; this was last estimated to be 45 percent in 1988-1989. A major epidemic of influenza A occurred in 1989-1990 which may have changed vaccination behaviours. METHODS: A structured interview survey was conducted in 49 old people's homes in Nottingham to determine practices and policies for influenza vaccine. The medical records of 151 randomly selected elderly residents were examined to determine vaccine uptake in the 1992-1993 season. RESULTS: Twenty-five homes (52.1 percent) claimed to operate a policy for influenza immunization but only 3 (12.0 percent) were written down and none set targets. Methods of vaccine promotion were generally weak. Accordingly, vaccine uptake was only 39.6% percent (95 percent confidence interval 33.2-46.0). CONCLUSIONS: In contrast to other high-risk groups living in the open community, no improvement in influenza vaccine uptake has occurred in nursing and old people's homes since the late 1980s. Future attempts to increase vaccine uptake in this setting should focus on developing joint policies between general practitioners and home staff to facilitate better co-ordinated programmes of vaccine promotion and administration.

Stress, social support, and stopping smoking after myocardial infarction in England.

STUDY OBJECTIVE: To examine the effect on mortality of stopping smoking after myocardial infarction and the psychosocial factors that influence the decision to stop. DESIGN: Analysis of smokers in a large prospective study. Self completed questionnaires provided information on psychosocial factors. SETTING: Coronary care units at six English hospitals participating in a multicentre clinical trial. SUBJECTS: These comprised consenting myocardial infarction survivors who had been identified as smokers and who completed questionnaires within seven days of infarct at six hospitals participating in the Anglo-Scandinavian study of early thrombolysis. The 532 patients identified have been followed for over five and a half years. The main outcome measure was five year all cause mortality. MAIN RESULTS: Smokers who stopped within one month showed significantly reduced mortality compared with those who persisted, adjusting for other prognostic indicators (odds ratio 0.56, 95% confidence interval 0.33, 0.98). Overall, 74% stopped smoking. Being married, low life stress levels before infarct, and higher social class were associated with stopping smoking but the differentials were small. Of the clinical variables, a final diagnosis of definite myocardial infarction was associated with stopping smoking. All associations remained after multiple logistic regression. CONCLUSION: Smoking cessation can halve the smokers' odds of dying after myocardial infarction and psychosocial factors play a small but important role in the important decision to stop smoking. Health professionals should continue to stress the importance of stopping smoking to all patients as there is little evidence to support specific directing of advice to relatively "stress or "socially isolated" groups.

Do cadet force units need a dedicated medical pack?

There are over 38,000 army cadets in the United Kingdom of whom about 20,000 attend a two week annual camp each summer. In response to criticisms from the medical staff attached to cadet units about the suitability of the routinely issued medical pack, a national questionnaire survey of all serving Army Cadet Force medical personnel has been performed, along with an analysis of patient attendances at annual camp between 1989 and 1992 in one East Midlands County Force. In particular the appropriateness of the Medical Treatment Pack Training Camp Large as currently issued to cadet units has been examined. The findings suggest that, on its own, the pack is unsuitable to treat about 40% of cadets who attend for medical treatment during annual camp; medical staff on average rate its suitability for cadets as very low. Moreover, there is objective evidence that most cadet units need to obtain extra medical supplies, particularly bronchodilators, modern antibiotics and modern dressings; many do so via private purchases from civilian sources. The study highlights a situation in urgent need of review.

The influence of psychosocial factors on survival after myocardial infarction.

The prognostic importance psychosocial factors after acute myocardial infarction (AMI) is still debated. A fourfold increase in risk of mortality after AMI was reported for participants in the beta Blocker Heart Attack Trial who were described as being socially isolated and having high levels of life stress. This study was designed to determine the influence of social isolation and/or life stress on mortality after AMI in an English population. It was a follow-up study of a subset of patients recruited for the Anglo-Scandinavian Study of Early Thrombolysis (ASSET), between November 1986 and February 1988. The study group comprised 1,376 patients with suspected AMI (1,073 men and 303 women), from coronary care units in six English hospitals. Patients who were alive at 7 days and had completed a psychosocial questionnaire within seven days post-infarction were followed up for a median time of three years, the sole outcome measure being death from all causes. All deaths were notified by the National Health Service Central Registry (NHSCR). Cox's regression was used to allow for independent clinical prognostic factors such as age-group, previous documented infarct, complications in hospital, history of diabetes and history of hypertension. Socially isolated patients (in terms of lack of membership of any club or religious group or lack of contact with family and friends) were 49% more likely to die after an infarction than patients classified as not being socially isolated. While this statistic is of borderline significance it does suggest that such patients are at an increased risk of death after AMI. No associations with mortality risk were found with life-stress level, type A behaviour pattern or depression.

Information leaflets in the dermatology out-patient waiting area.

Patients' attitudes to the supply and quality of information provided about their condition were examined by questionnaire before (n = 852) and after exposure to an information leaflet campaign (n = 560) in the dermatology out-patient waiting area. A high expectation of this service was demonstrated, particularly from patients under 60 years of age with chronic diseases. A variety of information sources, other than doctors, were identified which could be improved (video-systems, specialist nurses, leaflets, posters). The campaign significantly increased the percentage of patients who derived information from the leaflet source (5.6-18.8%, P < 0.001) and it reduced a demand for leaflets (16.4-9.1%, P < 0.001). However, the campaign did not alter patients' perceived need to spend more time with a dermatologist. In order to achieve a greater impact on patient satisfaction, a combination of information sources in the out-patient department should be targeted at young adults with chronic diseases.

The use of routine referral data in the development of clinical audit and management in North Lincolnshire.

As part of the national waiting list initiative, a retrospective survey of routine referrals in seven specialties to Lincoln County Hospital by general practitioners within its catchment area, during the months of January to March 1987 inclusive, was carried out, using data from the hospital's Patient Administration System and the Lincolnshire Family Practitioner Committee. These specialties were identified by managers and clinicians as those in which a significant problem of waiting times and waiting lists existed, both as perceived locally and in comparison with other districts. The total referral rate for all GPs in the study was 9.6 referrals/100 patients on their list/year, which is very close to the average of other studies published elsewhere in the country on this topic. However, the range of referral rates between practices was very wide, varying from 2.8 to 17.6. There were also wide variations within individual practices. It is therefore concluded that, taken overall, 'over-referral' by general practitioners is not the cause of any problem at Lincoln County Hospital. However, the wide variation of referral patterns has been of great interest to the general practitioners themselves. They have requested that referral rates be fed back to them routinely, in the manner of the Prescription Pricing Authority, and this will commence shortly. In addition, a working group of orthopaedic surgeons and general practitioner representatives has met to discuss the implications of the study, and the drawing up of mutually agreed referral protocols, the operation of which would be monitored jointly. The setting up of similar groups in the other specialties is under active consideration.

Postneonatal mortality in the Nottingham Health District 1985-1988.

Studies carried out in 1978 and 1981 found postneonatal mortality to be associated with poor environmental conditions. Since then, many changes have occurred to the environment. This study was designed to discover which factors are now associated with a higher risk of postneonatal death. A retrospective case-control study was carried out using 107 cases and 422 controls matched only for date of birth, to look at the effect of area of residence, social class, mother's age, and sex, birthweight, legitimacy and number of siblings. Fifty-eight per cent of the deaths were due to the sudden infant death syndrome, making this the leading cause of death. Causes previously absent from the death certificates are now appearing, particularly prematurity related deaths which now account for almost 6 per cent. The deaths were found to occur more frequently at home, in the winter, and at a peak age of 2 to 4 months. As shown previously in Nottingham, the deaths were more likely to have been male (relative risk 2.03), illegitimate (2.91), and of low birthweight (28.8). Total mortality was significantly higher in babies of mothers aged 19 or less and in babies of manual workers. Surprisingly, babies born to unemployed parents were found to have a very low relative risk of death (0.26). Mortality is still higher in the city than the suburbs and in areas of deprivation. Although still a risk factor for SIDS, high parity of the mother was found to be non-significant for postneonatal mortality in total.(ABSTRACT TRUNCATED AT 250 WORDS)

Research in an antenatal clinic--the experience of the Nottingham Mothers' Stop Smoking Project.

The Nottingham Mothers' Stop Smoking Project was extremely successful in helping women to stop smoking during pregnancy and in reinforcing non-smoking behaviour. This paper describes the experience of undertaking the action research project in the antenatal clinic from the points of view of the researchers, women and midwifery staff. The article outlines the practical problems encountered in attempting to adhere to a research protocol. The implementation of the project involving friendly encouragement, a carbon monoxide monitor and the offer of self-help groups is described within the context of the busy antenatal clinic setting. Pregnant women's experience of the project and the views of midwifery staff are also presented. The feasibility of incorporating such projects into everyday activity is discussed.

Why do pregnant women smoke?

This study aimed to record the main reasons given by pregnant women for smoking and to observe how these varied by age, education, marital status, social class and level of tobacco consumption. The study involved 498 smoking mothers who were all new antenatal clinic attenders. Data were collected by self-completed questionnaire containing closed and open response items. The participation rate was 95%. Main reasons given for smoking in pregnancy included those related to mood control (i.e. to relax, calm down, enjoyment, out of boredom) and addiction. Pregnant women were more likely to smoke to control their mood if they were older and smoked less than ten cigarettes per day. They were more likely to give addiction as their reason for smoking if they were older. Pregnant women were also more likely to smoke due to boredom if they were single, especially divorced or separated, from unskilled or semi-skilled occupational groups and if their husband or partner was unemployed. The implications of the findings for health education are discussed.

A comparative study between the use of analgesia/anaesthesia and of episiotomy in women delivered under consultant supervision or general practitioner care.

A retrospective cohort study based on obstetric records was performed, to compare the use of analgesia/anaesthesia during labour by consultants and general practitioners. The episiotomy rates for the two groups were also compared. 111 general practitioner patients were identified and these were matched with 111 consultant patients. No difference was found between the two groups for duration of stages I or II. The rates for episiotomy, 1 degree or 2 degrees tear or intact perineum were the same in each group. Women delivered under consultant supervision used more entonox than women delivered under general practitioner care, but this was counterbalanced by an increased use of pethidine in the latter group. No difference was found between the two groups with regard to the use of epidurals. There was an increased use of local anaesthetic by general practitioners. This was due to general practitioners preferring to use local anaesthetic for suturing after an epidural had worn off, whereas hospital doctors preferred to top-up the epidural to provide anaesthesia for suturing. This study supports the view that women delivered under the care of their own general practitioner in a hospital obstetric unit fare no worse than similar women delivered under consultant supervision. The former group have the advantage of continuity of care from their general practitioner.

Abdominal pain of unknown aetiology in pregnancy.

The outcome of 140 pregnancies complicated by unexplained abdominal pain was compared with that in a comparison group of 280 women who gave birth at the same time. The two groups were comparable for maternal age and parity but the study group contained a significantly higher proportion of smokers, unmarried women, and women whose partners were unemployed (P less than 0.001). All the pregnancies resulted in livebirths. There were no statistically significant differences in birthweight, gestational age at delivery or mode of delivery between the two groups.

Improved primary care does not prevent the admission of children to hospital.

In Nottingham Health District a study has been carried out whose aims were: (1) to compare acute paediatric medical admissions in 1985 with those in 1975 and to relate any differences to changes in services; (2) to measure the numbers of preventable admissions, working on the hypothesis that this would give an indication of the performance of community services. A structured questionnaire was completed with parents, and information obtained from notes of all children admitted with acute medical problems during October 1985. Results were compared with a similar study undertaken in 1975 by Wynne and Hull1 on children from the same catchment area. Further information for all health districts in Trent Region was obtained from Hospital Activity Analysis data relating to these 10 years. There has been a 100% increase in children's admissions in Nottingham, with similar increases throughout Trent Region. Apart from ingestions, there are increases in every diagnostic category, with a 6-fold increase in the admission rate for lower respiratory tract problems, mostly asthma and wheeze. Only 9% were classified as 'social admissions'. The idea of certain admissions being preventable is not a useful concept. Improvements in primary care have not been accompanied by a fall in hospital admissions.

Nottingham mothers stop smoking project -- baseline survey of smoking in pregnancy.

In the largest survey of smoking in pregnancy to date in the United Kingdom, 3882 women attending the two antenatal clinics in Nottingham during July and August 1986, were asked about their smoking habits. Thirty-seven per cent of pregnant women were smoking and only one in four of these was successful at stopping at some point during pregnancy. However, 55 per cent of the mothers who smoked at the start of pregnancy claimed to smoke less during pregnancy. No change was reported in the habits of one-quarter of the mothers who smoked during pregnancy and this proportion may represent an 'irreducible minimum'. Mothers were more likely to continue to smoke if younger (14-20 years), single, living with a partner who smoked, who left school at 16 years and were from manual working families. Those who succeeded in giving up smoking during pregnancy were more likely to be from professional and managerial families. Antenatal booklets about the dangers of smoking were the source of information cited most frequently. Half of the smoking mothers claimed not to have received advice from their family practitioners about the hazards of smoking nor information about how to give up the habit. Even fewer received such advice from hospital doctors, or midwives. This represents a major challenge to professional training in health education.