Evaluation of swabbing methods for estimating the prevalence of bacterial carriage in the upper respiratory tract: a cross sectional study.

OBJECTIVES: Bacterial carriage in the upper respiratory tract is usually asymptomatic but can lead to respiratory tract infection (RTI), meningitis and septicaemia. We aimed to provide a baseline measure of Streptococcus pneumoniae, Moraxella catarrhalis, Pseudomonas aeruginosa, Staphylococcus aureus, Haemophilus influenzae and Neisseria meningitidis carriage within the community. Self-swabbing and healthcare professional (HCP) swabbing were compared. DESIGN: Cross-sectional study. SETTING: Individuals registered at 20 general practitioner practices within the Wessex Primary Care Research Network South West, UK. PARTICIPANTS: 10,448 individuals were invited to participate; 5394 within a self-swabbing group and 5054 within a HCP swabbing group. Self-swabbing invitees included 2405 individuals aged 0-4 years and 3349 individuals aged ≥5 years. HCP swabbing invitees included 1908 individuals aged 0-4 years and 3146 individuals aged ≥5 years. RESULTS: 1574 (15.1%) individuals participated, 1260 (23.4%, 95% CI 22.3% to 24.5%) undertaking self-swabbing and 314 (6.2%, 95% CI 5.5% to 6.9%) undertaking HCP-led swabbing. Participation was lower in young children and more deprived practice locations. Swab positivity rates were 34.8% (95% CI 32.2% to 37.4%) for self-taken nose swabs (NS), 19% (95% CI 16.8% to 21.2%) for self-taken whole mouth swabs (WMS), 25.2% (95% CI 20.4% to 30%) for nasopharyngeal swabs (NPS) and 33.4% (95% CI 28.2% to 38.6%) for HCP-taken WMS. Carriage rates of S. aureus were highest in NS (21.3%). S. pneumoniae carriage was highest in NS (11%) and NPS (7.4%). M. catarrhalis carriage was highest in HCP-taken WMS (28.8%). H. influenzae and P. aeruginosa carriage were similar between swab types. N. meningitidis was not detected in any swab. Age and recent RTI affected carriage of S. pneumoniae and H. influenzae. Participant costs were lower for self-swabbing (£41.21) versus HCP swabbing (£69.66). CONCLUSIONS: Higher participation and lower costs of self-swabbing as well as sensitivity of self-swabbing favour this method for use in large population-based respiratory carriage studies.

Shared decision-making in back pain consultations: an illusion or reality?

PURPOSE: Amid a political agenda for patient-centred healthcare, shared decision-making is reported to substantially improve patient experience, adherence to treatment and health outcomes. However, observational studies have shown that shared decision-making is rarely implemented in practice. The purpose of this study was to measure the prevalence of shared decision-making in clinical encounters involving physiotherapists and patients with back pain. METHOD: Eighty outpatient encounters (comprising 40 h of data) were observed audio-recorded, transcribed verbatim and analysed using the 12-item OPTION scale. The higher the score, the greater is the shared decision-making competency of the clinicians. RESULTS: The mean OPTION score was 24.0% (range 10.4-43.8%). CONCLUSION: Shared decision-making was under-developed in the observed back pain consultations. Clinicians' strong desire to treat acted as a barrier to shared decision-making and further work should focus on when and how it can be implemented.

Presentation, pattern, and natural course of severe symptoms, and role of antibiotics and antibiotic resistance among patients presenting with suspected uncomplicated urinary tract infection in primary care: observational study.

OBJECTIVE: To assess the natural course and the important predictors of severe symptoms in urinary tract infection and the effect of antibiotics and antibiotic resistance. DESIGN: Observational study. SETTING: Primary care. PARTICIPANTS: 839 non-pregnant adult women aged 18-70 presenting with suspected urinary tract infection. MAIN OUTCOME MEASURE: Duration and severity of symptoms. RESULTS: 684 women provided some information on symptoms; 511 had both laboratory results and complete symptom diaries. For women with infections sensitive to antibiotics, severe symptoms, rated as a moderately bad problem or worse, lasted 3.32 days on average. After adjustment for other predictors, moderately bad symptoms lasted 56% longer (incidence rate ratio 1.56, 95% confidence interval 1.22 to 1.99, P<0.001) in women with resistant infections; 62% longer (1.62, 1.13 to 2.31, P=0.008) when no antibiotics prescribed; and 33% longer (1.33, 1.14 to 1.56, P<0.001) in women with urethral syndrome. The duration of symptoms was shorter if the doctor was perceived to be positive about diagnosis and prognosis (continuous 7 point scale: 0.91, 0.84 to 0.99; P=0.021) and longer when the woman had frequent somatic symptoms (1.03, 1.01 to 1.05, P=0.002; for each symptom), a history of cystitis, urinary frequency, and more severe symptoms at baseline. CONCLUSION: Antibiotic resistance and not prescribing antibiotics are associated with a greater than 50% increase in the duration of more severe symptoms in women with uncomplicated urinary tract infection. Women with a history of cystitis, frequent somatic symptoms (high somatisation), and severe symptoms at baseline can be given realistic advice that they are likely to have severe symptoms lasting longer than three days.

Effectiveness of five different approaches in management of urinary tract infection: randomised controlled trial.

OBJECTIVE: To assess the impact of different management strategies in urinary tract infections. DESIGN: Randomised controlled trial. SETTING: Primary care. PARTICIPANTS: 309 non-pregnant women aged 18-70 presenting with suspected urinary tract infection. INTERVENTION: Patients were randomised to five management approaches: empirical antibiotics; empirical delayed (by 48 hours) antibiotics; or targeted antibiotics based on a symptom score (two or more of urine cloudiness, urine smell, nocturia, or dysuria), a dipstick result (nitrite or both leucocytes and blood), or a positive result on midstream urine analysis. Self help advice was controlled in each group. MAIN OUTCOME MEASURES: Symptom severity (days 2 to 4) and duration, and use of antibiotics. RESULTS: Patients had 3.5 days of moderately bad symptoms if they took antibiotics immediately. There were no significant differences in duration or severity of symptoms (mean frequency of symptoms on a 0 to 6 scale: immediate antibiotics 2.15, midstream urine 2.08, dipstick 1.74, symptom score 1.77, delayed antibiotics 2.11; likelihood ratio test for the five groups P=0.177). There were differences in antibiotic use (immediate antibiotics 97%, midstream urine 81%, dipstick 80%, symptom score 90%, delayed antibiotics 77%; P=0.011) and in sending midstream urine samples (immediate antibiotics 23%, midstream urine 89%, dipstick 36%, symptom score 33%, delayed antibiotics 15%; P<0.001). Patients who waited at least 48 hours to start taking antibiotics reconsulted less (hazard ratio 0.57 (95% confidence interval 0.36 to 0.89), P=0.014) but on average had symptoms for 37% longer than those taking immediate antibiotics (incident rate ratio 1.37 (1.11 to 1.68), P=0.003), particularly the midstream urine group (73% longer, 22% to 140%; none of the other groups had more than 22% longer duration). CONCLUSION: All management strategies achieve similar symptom control. There is no advantage in routinely sending midstream urine samples for testing, and antibiotics targeted with dipstick tests with a delayed prescription as backup, or empirical delayed prescription, can help to reduce antibiotic use. STUDY REGISTRATION: National Research Register N0484094184 ISRCTN: 03525333.

Dipsticks and diagnostic algorithms in urinary tract infection: development and validation, randomised trial, economic analysis, observational cohort and qualitative study.

OBJECTIVES: To estimate clinical and dipstick predictors of infection and develop and test clinical scores; to compare management using clinical and dipstick scores with commonly used alternative strategies; to estimate the cost-effectiveness of each strategy; and to understand the natural history of urinary tract infection (UTI) and women's concerns about its presentation and management. DESIGN: There were six studies: (1) validation development for diagnostic clinical and dipstick scores; (2) validation of the scores developed; (3) observation of the natural history of UTI; (4) randomised controlled trial (RCT) of scores developed in study 1; (5) economic analysis of the RCT; (6) qualitative study of patients in the RCT. SETTING: Primary care. PARTICIPANTS: Women aged 17-70 with suspected UTI. INTERVENTIONS: Patients were randomised to five management approaches: empirical antibiotics; empirical delayed antibiotics; target antibiotics based on a higher symptom score; target antibiotics based on dipstick results; or target antibiotics based on a positive mid-stream specimen of urine (MSU). MAIN OUTCOME MEASURES: Antibiotic use, use of MSUs, rates of reconsultation and duration, and severity of symptoms. RESULTS: (1) 62.5% of women had confirmed UTI. Only nitrite, leucocyte esterase and blood independently predicted diagnosis of UTI. A dipstick rule--based on having nitrite or both leucocytes and blood--was moderately sensitive (77%) and specific (70%) [positive predictive value (PPV) 81%, negative predictive value (NPV) 65%]. A clinical rule--based on having two of urine cloudiness, offensive smell, reported moderately severe dysuria, moderately severe nocturia--was less sensitive (65%) (specificity 69%, PPV 77%, NPV 54%). (2) 66% of women had confirmed UTI. The predictive values of nitrite, leucocyte esterase and blood were confirmed. The dipstick rule was moderately sensitive (75%) but less specific (66%) (PPV 81%, NPV 57%). (3) Symptoms rated as moderately bad or worse lasted 3.25 days on average for infections sensitive to antibiotics; resistant infections lasted 56% longer, infections not treated with antibiotics 62% longer and symptoms associated with urethral syndrome 33% longer. Symptom duration was shorter if the doctor was perceived to be positive about prognosis, and longer with frequent somatic symptoms, previous history of cystitis, urinary frequency and more severe symptoms at baseline. (4) 66% of the MSU group had laboratory-confirmed UTI. Women suffered 3.5 days of moderately bad symptoms if they took antibiotics immediately but 4.8 days if they delayed taking antibiotics for 48 hours. Taking bicarbonate or cranberry juice had no effect. (5) The MSU group was more costly over 1 month but not over 1 year. Cost-effectiveness acceptability curves showed that for a value per day of moderately bad symptoms of over 10 pounds, the dipstick strategy is most likely to be cost-effective. (6) Fear of spread to the kidneys, blood in the urine, and the impact of symptoms on vocational and leisure activities were important triggers for seeking help. When patients are asked to delay taking antibiotics the uncomfortable and worrying journey from 'person to patient' needs to be acknowledged and the rationale behind delaying the antibiotics made clear. CONCLUSIONS: To achieve good symptom control and reduce antibiotic use clinicians should either offer a 48-hour delayed antibiotic prescription to be used at the patient's discretion or target antibiotic treatment by dipsticks (positive nitrite or positive leucocytes and blood) with the offer of a delayed prescription if dipstick results are negative.

Reading and communication skills after universal newborn screening for permanent childhood hearing impairment.

BACKGROUND: Birth in periods with universal newborn screening (UNS) for permanent childhood hearing impairment (PCHI) and early confirmation of PCHI have been associated with superior subsequent language ability in children with PCHI. However their effects on reading and communication skills have not been addressed in a population-based study. METHODS: In a follow-up study of a large birth cohort in southern England, we measured reading by direct assessment and communication skills by parent report in 120 children with bilateral moderate, severe or profound PCHI aged 5.4-11.7 years, of whom 61 had been born in periods with UNS, and in a comparison group of 63 children with normal hearing. RESULTS: Compared with birth during periods without UNS, birth during periods with UNS was associated with better reading scores (inter-group difference 0.39 SDs, 95% CI 0.02 to 0.76, p = 0.042) and communication skills scores (difference 0.51 SDs, 95% CI 0.06 to 0.95, p = 0.026). Compared with later confirmation, confirmation of PCHI by age 9 months was also associated with better reading (difference 0.51 SDs, 95% CI 0.15 to 0.87, p = 0.006) and communication skills (difference 0.56 SDs, 95% CI 0.12 to 1.00, p = 0.013). In the children with PCHI, reading, communication and language ability were highly correlated (r = 0.62-0.84, p<0.001). CONCLUSION: Birth during periods with UNS and early confirmation of PCHI predict better reading and communication abilities at primary school age. These benefits represent functional gains of sufficient magnitude to be important in children with PCHI.

Recording of vital signs in a district general hospital emergency department.

AIM: To examine and explore factors that may influence the recording of vital signs in adult patients within the initial 15 min and again within 60 min of arrival in the "resuscitation" and "major" areas of the emergency department (ED). METHODS: A retrospective analysis of recording of vital signs was performed on 400 consecutive sets of notes from adult patients presenting to the "major" or "resuscitation" areas of a district general hospital ED. The effect of staffing levels, triage category and attendances on the recording of vital signs was examined using logistic regression. The main outcome measures were the proportion of patients with all vital signs recorded within 15 min of arrival, the proportion of patients with all vital signs repeated within 60 min of arrival and the outcomes of logistic regression analysis. RESULTS: Only 223/387 patients (58%) had all vital signs recorded within 15 min of arrival and only 29/387 (7%) had all vital signs repeated at 60 min. There was a significant relationship between the failure to record vital signs and lower triage categories. There was no evidence that staffing levels or number of attendances predicted the recording of vital signs within 15 min of arrival. CONCLUSION: Recording of vital signs was poor and unrelated to staffing levels or numbers of patients attending the ED. Failure to record patients' vital signs undermines strategies to detect and manage ill patients.

The clinical effectiveness of static resting splints in early rheumatoid arthritis: a randomized controlled trial.

OBJECTIVE: To evaluate the effectiveness of static resting splints in early RA. METHODS: A multicentre, randomized, trial was conducted. Patients (n = 120) received either static resting splints [positioned with the wrist in neutral, MCP joint (MCPJ) and IP joint (IPJ) in a maximum of 60 degrees and 30 degrees of flexion, respectively] plus standardized occupational therapy or standardized occupational therapy alone. Change in grip strength (Ns), structural impairment (MCPJ ulnar deviation), applied dexterity (Button Board), self-report hand ability [Michigan Hand Outcomes Questionnaire (MHQ)], hand pain and morning hand stiffness were assessed at 0 and 12 months. RESULTS: Data for 56 (97%) splinted and 60 (97%) control group patients were analysed. Splint wear adherence was moderate; 24.5% 'never wore' the splints. The adjusted mean difference between groups for handgrip was -14.2 Ns (P = 0.342; 95% CI -43.7, 5.4); MCPJ ulnar deviation -1.1 degrees (P = 0.657; 95% CI = -6.2, 3.9); dexterity 0.1 s (P = 0.975; 95% CI = -6.6, 6.8) and self-report ability -3.0 on the MHQ score (P = 0.426; 95% CI -10.5, 4.5). Pain scores were unchanged in either group (P = 0.15). The occurrence of morning hand stiffness was reduced in a small group of splinted patients (P = 0.021), but the duration shortened in control patients (P = 0.010). CONCLUSIONS: There was no significant difference between the two interventions on grip strength, deformity, hand function and pain. The data favoured the control group and this study suggests that resting splints should not be used as a routine treatment of patients with early RA.

Early mortality from the time of diagnosis of Type 2 diabetes: a 5-year prospective cohort study with a local age- and sex-matched comparison cohort.

AIMS: To study patterns and predictors of early mortality in individuals with a new diagnosis of Type 2 diabetes, compared with a local age- and sex-matched comparison cohort. METHODS: A total of 736 individuals diagnosed with Type 2 diabetes between 1 May 1996 and 30 June 1998 and non-diabetic age- and sex-matched control subjects were studied. Follow-up was 5.25 years. Age- and gender-specific all-cause mortality odds ratios were calculated for the diabetic cohort compared with the non-diabetic comparator group. Mortality odds ratios were ascertained using conditional logistic regression. RESULTS: There were 147 deaths in the diabetic cohort [cardiovascular (42.2%), cancer (21.1%)]. Compared with the non-diabetic cohort, mortality odds more than doubled [odds ratio (OR) 2.47; 95% confidence interval (CI) 1.74, 3.49]. These increased odds were present in all age bands (including those aged > 75 years at diagnosis) for both cardiovascular and non-cardiovascular causes. In women, a new diagnosis of Type 2 diabetes was associated with a sevenfold increase in mortality odds in those aged 60-74 years (OR 7.00; 95% CI 2.09, 23.47). CONCLUSIONS: Type 2 diabetes is associated with a 2.5-fold increase in the odds of mortality in both men and women over the first 5 years from diagnosis. Our data strongly support the contention that the mortality risk associated with Type 2 diabetes essentially exists from, or may even predate, the time of diagnosis.

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.

Will Rogers revisited: prospective observational study of survival of 3592 patients with colorectal cancer according to number of nodes examined by pathologists.

To investigate the relationship between survival in colorectal cancer patients and the number of lymph nodes examined by a pathologist, previously attributed to stage migration, we used data from a cohort of 5174 colorectal cancer patients recruited between September 1991 and August 1994, and followed-up for 5 years. We selected cases with data present on all prognostic variables, and stratified them into three groups by number of nodes examined. We made a multivariate survival comparison using a Cox regression model. In all, there were 3592 cases with data present on all prognostic variables. Patients who had >10 nodes identified had a significant survival advantage over those who had 5-10 identified, who had in turn a similar advantage over those with 0-4 identified (P<0.001). This effect was present in the whole group and at all Dukes' stages, although statistically significant only in stages B (P=0.004) and C (P=0.019). The effect remained after adjustment in a Cox regression model in which the mean number of nodes taken out by each surgical firm did not predict survival. In a sub-group with data on lymphocytic infiltration into the primary tumour a survival advantage was noted in those with prominent rather than mild infiltration (P<0.001): the former also tended to have more nodes found (P=0.015). Stage migration alone cannot explain these results, as survival advantages are noted across the whole population independent of stage. Lymphocytic infiltration into the primary tumour is prognostically important, and is associated with the number of nodes found. Reactive enlargement of lymph nodes in the mesentery may make them easier to find, reflect immune response to the tumour, and thus indirectly impact upon survival.

Impact of metabolic syndrome criteria on cardiovascular disease risk in people with newly diagnosed type 2 diabetes.

AIMS/HYPOTHESIS: We investigated the prognostic implication of metabolic syndrome according to modified National Cholesterol Education Program criteria and the implication of individual features of metabolic syndrome on cardiovascular disease (CVD) and CHD in a 5-year community-based study of people with newly diagnosed type 2 diabetes. METHODS: We entered 562 participants, aged 30-74 years, into a cross-sectional analysis and 428 participants (comprising those who were CVD-free at study entry) into a prospective analysis. In both analyses, the association of metabolic syndrome features with CVD/CHD was studied. Binary logistic regression, a Cox regression model and Fisher's exact test were used for statistical analyses. RESULTS: At diagnosis of type 2 diabetes, metabolic syndrome was independently associated with CVD (odds ratio [OR] 2.54; p=0.006) and CHD (OR 4.06; p=0.002). In the 5-year follow-up, metabolic syndrome at baseline was an independent predictor of incident CVD (hazard ratio [HR] 2.05; p=0.019). An increase in the number of individual features of the metabolic syndrome present at the time of diagnosis of type 2 diabetes was associated with a linear increase in incident CVD risk (trend p=0.044) with an almost five-fold increase when all five features were present, compared with hyperglycaemia alone (HR 4.76; p=0.042). Increasing age (HR 1.07; p<0.001), female sex (HR 0.62; p=0.032), total cholesterol (HR 1.43; p=0.01) and lipid-lowering therapy (HR 0.32; p<0.001) were also independent predictors of risk. CONCLUSIONS/INTERPRETATION: Metabolic syndrome at baseline is associated with an increased risk of incident CVD in the 5 years following diagnosis of type 2 diabetes. CVD-free survival rates declined incrementally as the presence of metabolic syndrome features increased. Thus, identifying the features of metabolic syndrome at diagnosis of type 2 diabetes is potentially a useful prognostic tool for identifying individuals at increased risk of CVD.

An evaluation of the costs, effectiveness and quality of renal replacement therapy provision in renal satellite units in England and Wales.

OBJECTIVES: To survey of the structure, processes and organisation of renal satellite units (RSUs) in England and Wales (Phase 1), and to compare the effectiveness, acceptability, accessibility and economic impact of chronic haemodialysis performed in RSUs compared to main renal units (MRUs) (Phase 2). DATA SOURCES: Phase 1: all renal satellite units in England and Wales. Phase 2: haemodialysis patients in a representative sample (based on geography, site, private--public ownership, medical input) of 12 RSUs and their MRUs. REVIEW METHODS: Phase 1 consisted of a questionnaire survey. Semi-structured interviews were held in a representative sample of 24 RSUs with the senior clinician, senior nurse and manager. Phase 2 consisted of a cross-sectional comparison of patients in these RSUs and patients in the parent MRUs deemed suitable for satellite care by senior staff. Clinical information was obtained from medical notes and unit computer systems. Generic and disease specific health-related quality of life (HRQoL) measures were used. Co-morbidity was assessed by the Wright/Khan Index, the Lister/Chandna score, the Modified Charlson Index, and the Karnofsky Performance Score. Statistical analyses compared RSU versus MRU patients and took account of the paired and clustered nature of the data. RESULTS: In Phase 1, responses were received from 74/80 (93%) of RSUs; 2600 patients were being treated in these RSUs. The interviews were generally positive about the impact of RSUs in terms of improved accessibility and a better environment for chronic haemodialysis (HD) patients, and in expanding renal replacement therapy patients (RRT) capacity. In Phase 2, some 82% of eligible patients took part, 394 patients in the 12 RSUs and 342 in the parent MRUs. The response rate was similar in both groups. There were no significant differences in clinical processes of care. Most clinical outcomes were similar, especially after pooled analysis, although a few parameters were statistically significantly different -- notably the proportion achieving Renal Association Standards for adequacy of dialysis as measured by the urea reduction ratio (URR) was higher in the RSU patients. Patient-specific quality of life did not differ except on the patient satisfaction questions from the KDQOL, which were scored higher by the RSU sample. Strength of preference for health status on and off dialysis was very similar between the groups, as were EQ-5D utilities. Major adverse events were not common in the RSU patients, although there were many hypotensive episodes on HD, a proportion of which affected the duration of the HD session. Of the costs measured, the only difference that was statistically significant was for District Nurse visits. Of particular note was that despite the MRU group having a higher proportion of patients hospitalised, this did not translate into a statistically significant budgetary impact in terms of the total cost per patient of hospitalisations or mean cost per patient per hospitalisation. CONCLUSIONS: This study has shown that RSUs are an effective alternative to MRU HD for a wide spectrum of patients. They improve geographic access for more dispersed areas and reduce patients' travel time, and are generally more acceptable to patients on several criteria. There does not seem to be an adverse impact of care in the RSUs although comparative long-term prospective data are lacking. The evidence suggests that satellite development could be successfully expanded; not all MRUs have any satellites and many have only a few. No single RSU model can be recommended but key factors would include local geography, the likely catchment population and the type of patients to be treated. There is a need for more basic budgetary information linking activity and expenditure to be available and more transparent, to perform at least an insightful top-down costing of the two care settings. Other areas suggested for further research include: a comparison of adverse events occurring in MRUs and RSUs with longer duration and larger numbers to identify more severe events, along with the more research into the scope for preventing such events, and a study into the patients deemed ineligible for satellite care. International comparisons of satellite care would also be useful.

Prognostic value of the Framingham cardiovascular risk equation and the UKPDS risk engine for coronary heart disease in newly diagnosed Type 2 diabetes: results from a United Kingdom study.

AIMS: To determine the prognostic value of the Framingham equation and the United Kingdom Prospective Diabetes Study (UKPDS) risk engine in patients with newly diagnosed Type 2 diabetes. METHODS: A community-based cohort (n=428; aged 30-74 years) free of clinically evident CVD and newly diagnosed with Type 2 diabetes were studied over a median 4.2 (sd+/-0.62) years. Predicted (using baseline variables at diagnosis) and observed proportions of primary CVD and CHD events were compared using the Framingham equations and the UKPDS risk engine (only CHD events). The discrimination (c-statistic) and calibration (HLchi2) of the risk equations were calculated. The sensitivity and specificity of the Framingham equation at a 15%, 10-year CHD risk threshold (NICE guidelines) was compared with that of the ADA lipid threshold (LDLc>or=2.6 mmol/l or triglycerides>or=4.5 mmol/l). RESULTS: The Framingham equations underestimated the overall number of cardiovascular events by 33% and coronary events by 32% and showed modest discrimination and poor calibration for CVD [c=0.673; HLchi2=32.8 (P<0.001)] and CHD risk [c=0.657; HLchi2=19.8 (P=0.011)]. Although the overall underestimate was lower and non-significant with the UKPDS risk engine for CHD (13%), its performance in terms of discrimination and calibration were similar [c=0.670; HLchi2=17.1 (P=0.029)]. The 15%, 10-year CHD risk threshold with both the Framingham and UKPDS risk engines had similar sensitivity for primary CVD as the lipid level threshold [85.7 and 89.8% vs. 93.9% (P=0.21 and 0.34)] and both had greater specificity [33.0 and 30.3% vs. 12.1% (P<0.001 and P<0.001)]. CONCLUSIONS: In people with newly diagnosed Type 2 diabetes, both the Framingham equation and UKPDS risk engine are moderately effective at identifying those at high-risk (discrimination) and are poor at quantifying risk (calibration). Nonetheless, at a population level, a 15% 10-year CHD risk threshold using either risk calculator has similar sensitivity as an approach based on a single lipid risk factor level and may have benefits in terms of cost-effectiveness given the improved specificity.

Correlation between upper limb functional ability and structural hand impairment in an early rheumatoid population.

OBJECTIVE: To explore the relationship in individuals with early rheumatoid arthritis (RA) between self-report upper limb function, therapist-assessed upper limb function and therapist-assessed measures of structural impairment (handgrip, active hand motion and metacarpophalangeal (MCP) joint ulnar deviation). DESIGN: Thirty-six patients with early RA were recruited across seven outpatient occupational therapy departments. OUTCOME MEASURES: Upper limb functional activity and ability was measured using the Disability of the Arm, Shoulder and Hand (DASH) questionnaire and the Grip Ability Test (GAT). Upper limb impairment was assessed by bilateral power handgrip using the MIE Digital Grip Analyser, goniometry measures of bilateral metacarpophalangeal (MCP) joint ulnar deviation and bilateral active motion of the wrist. RESULTS: Strong correlations (> 0.7) were seen between the self-report DASH questionnaire and the therapist-rated GAT assessment. Bilateral power handgrips were also strongly correlated with both functional assessments. Dominant ulnar deviation at the MCP joints demonstrated a weak correlation (0.3-0.4) with both self-report and therapist-rated functional ability and a weak to moderate. (0.1-0.5) correlation on the nondominant side. CONCLUSION: In this early RA population handgrip strength is an accurate indicator of upper limb ability. Ulnar deviation at the MCP joints shows only a weak to moderate association with upper limb functional activity and ability. Although the DASH and the GAT were strongly correlated, the DASH was a more discriminating measure than the GAT in assessing upper limb ability in this sample population.

Geographical variation in breast cancer survival rates for women diagnosed in England between 1992 and 1994.

The 5-year relative survival rates of women diagnosed with breast cancer between 1992 and 1994 were compared among the 99 Health Authorities (1999 boundaries) of England. Substantial variation, with evidence of geographical clustering was observed. Part of this variation was explained by differences in deprivation between Health Authorities, in particular by the percentage of class IV and V households. British Journal of Cancer (2004) 90, 2153-2156. doi:10.1038/sj.bjc.6601812 www.bjcancer.com Published online 27 April 2004

Laboratory markers predict bone loss in Crohn's disease: relationship to blood mononuclear cell function and nutritional status.

BACKGROUND: Crohn's disease is associated with reduced bone density. The power of simple markers of systemic inflammation to identify higher rates of bone loss, in Crohn's disease, is uncertain. This relationship and the role of circulating (peripheral blood) mononuclear cells were investigated in a case-control study. METHODS: Urinary deoxypyridinoline/creatinine and serum osteocalcin concentrations were compared in male and premenopausal females with "active" Crohn's disease (C-reactive protein > or = 10 and/or erythrocyte sedimentation rate > or = 20) (n = 22) and controls with "quiescent" Crohn's disease (C-reactive protein < 10 and erythrocyte sedimentation rate < 20) (n = 21). No patients were receiving corticosteroid therapy. Production of tumour necrosis factor-alpha, interferon-gamma and prostaglandin E(2) by peripheral blood mononuclear cells were measured. RESULTS: Active Crohn's disease was associated with a higher deoxypyridinoline/creatinine (P = 0.02) and deoxypyridinoline/creatinine:osteocalcin ratio (P =0.01) compared with quiescent Crohn's disease, but similar osteocalcin (P = 0.24). These were not explained by vitamin D status, dietary intake or nutritional status. However, production of interferon-gamma by concanavalin A-stimulated peripheral blood mononuclear cells was lower in active Crohn's disease (P = 0.02) and correlated negatively with the deoxypyridinoline/creatinine:osteocalcin ratio (r = -0.40, P = 0.004). CONCLUSION: In Crohn's disease, raised C-reactive protein and erythrocyte sedimentation rate may indicate higher rates of bone loss and, if persistent, the need to assess bone mass even where disease symptoms are mild. This may be partly explained by altered production of interferon-gamma by peripheral blood mononuclear cells.

Serum ovalbumin-specific immunoglobulin G responses during pregnancy reflect maternal intake of dietary egg and relate to the development of allergy in early infancy.

BACKGROUND: The value of allergen elimination diets during pregnancy for primary prevention of infant allergy has been questioned. However, dietary compliance may influence effectiveness. OBJECTIVES: To monitor egg intake during a randomized controlled trial of egg avoidance throughout pregnancy and lactation by serial measurements of serum ovalbumin (OVA) IgG concentration in conjunction with dietary diary record and also, to analyse specific IgG concentrations at birth in relation to infant allergic outcome. METHODS: Pregnant women, with personal or partner atopy, were randomized to complete dietary egg exclusion or an unmodified healthy diet before 20 weeks gestation. The infants were evaluated for atopy at 6 months of age. Serum food-specific IgG concentrations were determined by ELISA in maternal samples collected at study recruitment and during labour, and in infant samples at birth (umbilical cord). RESULTS: Serum-specific IgG to OVA, but not the unrelated allergen, cow's milk beta-lactoglobulin, decreased over pregnancy in egg-avoiding women only (P<0.001). Cord OVA IgG concentration correlated with maternal IgG at delivery (r=0.944; P<0.001), and for infants born to atopic women, cord concentration was higher than that of their mother's (P<0.001). Infants with the lowest and highest cord IgG concentrations were the least likely, and those with mid-range concentrations were the most likely, to be atopic by 6 months of age (P=0.008). CONCLUSION: Serum OVA IgG concentration reflects egg consumption, thereby indicating dietary allergen doses to which the developing immune system might be exposed. Trans-placental maternal IgG must be considered among early life factors that regulate infant atopic programming.

Essential fatty acid status in paediatric Crohn's disease: relationship with disease activity and nutritional status.

BACKGROUND: Active paediatric Crohn's disease is associated with nutritional deficiencies and altered nutrient intake. The availability of essential fatty acids (linoleic and alpha-linolenic acids) or their derivatives (arachidonic and eicosapentaenoic acids) may alter in plasma and cell membrane phospholipid in protein-energy malnutrition in children and in Crohn's disease in adults. AIM: To investigate the relationship of fatty acid phospholipid profiles with disease activity and nutritional status in paediatric Crohn's disease. METHODS: The fatty acid (proportionate) composition of plasma and erythrocyte phosphatidylcholine was determined in 30 patients (10.3-17.0 years) stratified into active and quiescent Crohn's disease (paediatric Crohn's disease activity index) and high and low body mass (body mass index centile). RESULTS: In plasma phosphatidylcholine, active disease activity was associated with a lower level of alpha-linolenic acid compared with that in quiescent disease (P < 0.05). A body mass index below the 50th centile was associated with active Crohn's disease, low linoleic and alpha-linolenic acids and high arachidonic acid (P < 0.05) in plasma phosphatidylcholine, and low alpha-linolenic acid in erythrocyte phosphatidylcholine. These findings could not be explained through differences in habitual dietary fat intake. CONCLUSION: In paediatric Crohn's disease, a low body mass index centile and high disease activity are associated with altered profiles of essential fatty acids and their derivatives, which may reflect altered metabolic demand.

Inequalities in survival from colorectal cancer: a comparison of the impact of deprivation, treatment, and host factors on observed and cause specific survival.

OBJECTIVE: To investigate whether socioeconomic deprivation is associated with cause specific and all cause survival for colorectal cancer and to what extent this is independent of significant prognostic factors. DESIGN: Prospective cohort. SETTING: The former Wessex Health Region, South West England. PARTICIPANTS: All patients resident in Wessex registered with a diagnosis of colorectal cancer over three years (n=5176). Survival analysis was carried out on those patients with compete data for all factors and a positive survival time (n=4419). OUTCOMES: Death from colorectal cancer and all cause over five year follow up from initial diagnosis. MAIN RESULTS: Deprivation was significantly associated with survival for both outcomes in univariate analysis; the unadjusted hazard ratio for dying from colorectal cancer (most deprived compared with most affluent) was 1.12 (95% CI 1.00 to 1.25) and for all cause was 1.18 (1.07 to 1.30). Significant prognostic factors for both outcomes were age, specialisation of surgeon, Dukes's stage, and emergency compared with elective surgery. Comorbidity and gender were only associated with all cause survival. After adjustment for prognostic factors, the effect of deprivation on both cause specific and all cause mortality was reduced, and it was non-significant for colorectal cancer. However, the most deprived group had consistently worse survival than the most affluent. CONCLUSIONS: Factors associated with survival with colorectal cancer depend on the outcome measure. Socioeconomic deprivation is adversely associated with survival in patients with colorectal cancer. This is strongest for non-colorectal cancer death, partly reflecting higher comorbidity, but it is there for colorectal cancer though not statistically significant. Conclusive evidence of the inequalities by socioeconomic status and underlying reasons needs to come from studies using individual based measures of socioeconomic status and more detail on treatment and host related factors.