Impact of war on veteran life span: natural experiment involving combat versus non-combat exposed military personnel.

INTRODUCTION: There is still uncertainty around the impact of combat exposure on the life span of war veterans. Therefore we made use of a natural experiment to study the impact on veteran life span of combat versus non-combat exposure in World War II (WW2). METHODS: The combat-exposed military personnel were derived from a random (10%) sample of the military roll of the 28th (Maori) Battalion from New Zealand. One non-combat cohort was the 15th Reinforcements of this same Battalion, since the war ended before they reached the front line. The other non-combat cohort were Maori personnel who were only involved in Jayforce, which occupied Japan at the end of the WW2. Data on life span were mainly derived from an official repository of birth and death records, but supplemented with other sources, including military files. RESULTS: When comparing life spans of service veterans, there was no statistically significant reduction for the average life span of the 234 combat-exposed veterans in our sample from the 28th (Maori) Battalion (66.7 years), relative to the Maori veterans from two non-combat cohorts: the 132 personnel in the 15th Reinforcements (67.2 years) and the 147 personnel in Jayforce (66.9 years). CONCLUSIONS: Despite a very high level of wounding in the combat-exposed group (48%), there were no statistically significant reductions in life span between this group and comparable non-combat exposed veterans. This finding contrasts to life span reductions found in a similar study of New Zealand veterans of WW1.

Differential lifespan impacts on veterans by war exposure in the First World War.

INTRODUCTION: There remains uncertainty around the impact of war on the lifespan of First World War (WW1) veterans. In particular, study comparison groups do not typically consider the 'healthy soldier effect'. METHODS: We obtained lifespan data on a random sample of 857 war-exposed New Zealand WW1 veterans and compared this with lifespans of a non-war military cohort (n=1039). This comparison was possible as the non-war-cohort arrived in Europe too late to participate in the war, allowing a 'natural experiment' that avoided the 'healthy solider effect'. RESULTS: The lifespan comparisons indicated lower mean lifespan in the war-exposed veteran cohort compared with the non-war veteran cohort (69.7 vs 71.1 years; p=0.0405). This gap persisted (range: 0.8-1.1 years) but was no longer statistically significant when only considering the non-Maori ethnic grouping (nearly all European/Pakeha personnel), when excluding additional deaths in the immediate postwar period up to 31 December 1923, and when excluding participation in any other wars. This was the case in both analysis of variance and Cox proportional hazards regression adjusting for year of birth and occupational status. Within the war-exposed cohort, there were suggestive patterns of increasing lifespan with increasing occupational status and military rank (eg, 69.5, 70.0 and 70.7 mean years as group-level occupational status progressively increased). There were also stark differences in lifespan of 8.3 years between Maori (Indigenous) and non-Maori veterans (p=0.0083). CONCLUSIONS: The pattern of reduced lifespan in war-exposed versus non-war-exposed veterans was compatible with a smaller previous New Zealand study with comparable methodology. Veterans who were Maori had significantly lower lifespans than non-Maori veterans. There are a number of feasible avenues to further improve this type of work with existing data sources.

Experiencing loneliness in parenthood: a scoping review.

AIMS: Chronic loneliness is experienced by around a third of parents, but there is no comprehensive review into how, why and which parents experience loneliness. This scoping review aimed to provide insight into what is already known about parental loneliness and give directions for further applied and methodological research. METHODS: Searches for peer-reviewed articles were undertaken in six databases: PsycINFO, Medline, CINAHL, Embase, Web of Science and Scopus, during May 2019 to February 2020. We searched for English studies which examined loneliness experienced during parenthood, including studies that involved parents with children under 16 years and living at home and excluding studies on pregnancy, childbirth or postbirth hospital care. RESULTS: From 2566 studies retrieved, 133 were included for analysis. Most studies (n = 80) examined the experience of loneliness in specific groups of parents, for example, teenage parents, parents of a disabled child. Other studies examined theoretical issues (n = 6) or health and wellbeing impacts on parents (n = 16) and their offspring (n = 17). There were 14 intervention studies with parents that measured loneliness as an outcome. Insights indicate that parental loneliness may be different to loneliness experienced in other cohorts. There is evidence that parental loneliness has direct and intergenerational impacts on parent and child mental health. Some parents (e.g. with children with chronic illness or disability, immigrant or ethnic minority parents) also appear to be at increased risk of loneliness although evidence is not conclusive. CONCLUSION: This work has identified key gaps with further international, comparative and conceptual research needed.

Tokophobia and fear of birth: a workshop consensus statement on current issues and recommendations for future research.

Objective: To discuss and develop a statement on the current state of the evidence and opinion in Fear of Childbirth (FoC) and Tokophobia (Tocophobia), and to provide recommendations. Background: A group met in 2019 to discuss the state of clinical and academic knowledge relating to FoC/Tokophobia. Five key areas were agreed as the focus of the meeting. Methods: 12 internationally acknowledged experts, in this or a closely related area (e.g. PTSD) met to discuss their understanding of the evidence for FoC/ Tokophobia and current practice. The consensus described in this paper constitutes the expression of the general opinion of the participants and does not necessarily imply unanimity. Keys points: Work focussed on tokophobia is recent and there remains a wide range of issues, which were addressed in the workshop including complexity in defining prevalence, a theoretical lack of understanding, which creates challenge for robust assessment and the identification of risk factors. An improved aetiological and developmental understanding of the tokophobia is required to underpin appropriate, effective and evidence-based interventions. Evaluation of pathways of care and relevant interventions, should be a focus of future research. Conclusion: Significant gaps remain within the FoC/tokophobia knowledge base. Further research is necessary.

STRAWB2 (Stress and Wellbeing After Childbirth): a randomised controlled trial of targeted self-help materials to prevent post-traumatic stress disorder following childbirth.

OBJECTIVES: To test whether providing psychological self-help materials would significantly lower the incidence of post-traumatic stress disorder (PTSD) at 6-12 weeks postnatally. DESIGN: Open-label randomised controlled trial, with blinded outcome assessment. SETTING: Community midwifery services in two National Health Service (NHS) trusts in the North West. SAMPLE: A cohort of 2419 women receiving normal NHS postnatal care. METHODS: Midwives screened women for traumatic birth experience; 678 women who screened positively (28.1%) were randomly allocated to self-help with usual care (n = 336) or to usual care alone (n = 342). The self-help materials were a leaflet and online film designed to prevent the development of PTSD after trauma exposure through explaining how to manage early psychological responses. MAIN OUTCOME MEASURE: The primary outcome was a composite of diagnostic and subdiagnostic PTSD at 6-12 weeks postnatally using the gold-standard Clinician-Administered PTSD Scale (CAPS-5) interview. RESULTS: Of the 678 women correctly randomised plus the nine women randomised in error, 478 (70.5%) were followed up. Diagnostic or subdiagnostic PTSD rates at follow-up did not differ between groups who received self-help (26.7%, 65/243) or usual care alone (26.2%, 64/244) (intention-to-treat analysis: RR 1.02, 95% CI 0.68-1.53). Findings remained consistent in the per-protocol analysis (RR 1.04, 95% CI 0.85-1.27). Women viewed the materials very positively. There were no adverse effects. Health economic micro-costing indicated implementation would be very low cost. CONCLUSIONS: Many women experience a traumatic birth and risk developing PTSD, but self-help strategies without professional support are insufficient and should not be routinely introduced. TWEETABLE ABSTRACT: Self-help information alone does not reduce the number of women developing PTSD after a traumatic childbirth.

Using Google Earth to Assess Shade for Sun Protection in Urban Recreation Spaces: Methods and Results.

Shade in public spaces can lower the risk of and sun burning and skin cancer. However, existing methods of auditing shade require travel between sites, and sunny weather conditions. This study aimed to evaluate the feasibility of free computer software-Google Earth-for assessing shade in urban open spaces. A shade projection method was developed that uses Google Earth street view and aerial images to estimate shade at solar noon on the summer solstice, irrespective of the date of image capture. Three researchers used the method to separately estimate shade cover over pre-defined activity areas in a sample of 45 New Zealand urban open spaces, including 24 playgrounds, 12 beaches and 9 outdoor pools. Outcome measures included method accuracy (assessed by comparison with a subsample of field observations of 10 of the settings) and inter-rater reliability. Of the 164 activity areas identified in the 45 settings, most (83%) had no shade cover. The method identified most activity areas in playgrounds (85%) and beaches (93%) and was accurate for assessing shade over these areas (predictive values of 100%). Only 8% of activity areas at outdoor pools were identified, due to a lack of street view images. Reliability for shade cover estimates was excellent (intraclass correlation coefficient of 0.97, 95% CI 0.97-0.98). Google Earth appears to be a reasonably accurate and reliable and shade audit tool for playgrounds and beaches. The findings are relevant for programmes focused on supporting the development of healthy urban open spaces.

Serological evidence of vaccination and perceptions concerning Foot-and-Mouth Disease control in cattle at the wildlife-livestock interface of the Kruger National Park, South Africa.

Communal livestock farming areas adjoining the Greater Kruger National Park Area within South Africa are part of the Foot-and-mouth disease (FMD) Protection Zone with Vaccination due to the proximity to wildlife reservoirs. FMD and its control affect the productivity of resource-poor farmers who often depend on livestock for their livelihoods. A cross-sectional study was performed with the objectives to evaluate the perceptions of farmers concerning FMD control, estimate the proportion of cattle with presumed protective antibody titres against FMD, as well as the proportion of herds with adequate herd immunity at the wildlife-livestock interface within Mpumalanga Province. One hundred and four farmers were interviewed with 73% (76/104) being cattle owners and the remainder hired cattle herders. The majority of respondents (79%, 82/104) reported a high level of satisfaction with the current animal health programmes in general. The educational level of the respondents varied by satisfaction level: the median (interquartile range; IQR) education level was standard 9 (2-12) for non-satisfied respondents, standard 3 (0-6) for little satisfied and standard 7 (2-11) for very satisfied respondents (P=0.036). Animals are not always treated at FMD inspections points, but satisfied respondents were more likely to seek veterinary assistance (P=0.001). The majority of respondents (92%, 96/104) identified the African buffalo (Syncerus caffer) as a risk factor for FMD outbreaks. Liquid-phase blocking ELISA antibody titres ≥1.6log10 were used to indicate positive serology secondary to FMD vaccination. At the time of sampling and relative to this threshold, 23% (95% confidence interval (CI): 12%-34%) of the sampled cattle had positive serology to SAT-1, 41% (95%CI: 33%-48%) to SAT-2 and 29% (95%CI: 19%-39%) to SAT-3. The median (IQR) time between the previous vaccination and sampling was 189 (168-241) days. The sampled cattle had a longer inter-vaccination interval as scheduled by state veterinary services and antibody levels were low at the time of the study. The majority of respondents expressed high satisfaction with the currently applied FMD vaccination programme, which provides an opportunity for progressive adaption of animal health programmes within the study area.

Robotic Mammosphere Assay for High-Throughput Screening in Triple-Negative Breast Cancer.

In order to identify novel treatment principles specifically affecting cancer stem cells in triple-negative breast cancer, we have developed a high-throughput screening method based on the mammosphere and anoikis resistance assays allowing us to screen compounds using a functional readout. The assay was validated against manual protocols and through the use of positive controls, such as the response to hypoxia and treatment with the known cancer stem cell-targeting compound salinomycin. Manual and robotic procedures were compared and produced similar results in cell handling, cell cultures, and counting techniques, with no statistically significant difference produced from either method. The variance between samples processed manually versus robotically was no greater than 0.012, while Levene's test of significance was 0.2, indicating no significant difference between mammosphere data produced manually or robotically. Through the screening of 989 FDA-approved drugs and a follow-up screen assessing the antineoplastic subgroup, we have identified three therapeutic compounds with the ability to modulate the breast cancer stem cell fraction in the triple-negative breast cancer cell line MDA-MB-231, highlighting their potential usage as stem cell-specific adjuvant treatments.

Eradication of Transboundary Animal Diseases: Can the Rinderpest Success Story be Repeated?

A matrix system was developed to aid in the evaluation of the technical amenability to eradication, through mass vaccination, of transboundary animal diseases (TADs). The system involved evaluation of three basic criteria - disease management efficiency, surveillance and epidemiological factors - each in turn comprised of a number of elements (17 in all). On that basis, 25 TADs that have occurred or do occur in southern Africa and for which vaccines are available, in addition to rinderpest (incorporated as a yardstick because it has been eradicated worldwide), were ranked. Cluster analysis was also applied using the same criteria to the 26 diseases, creating division into three groups. One cluster contained only diseases transmitted by arthropods (e.g. African horse sickness and Rift Valley fever) and considered difficult to eradicate because technologies for managing parasitic arthropods on a large scale are unavailable, while a second cluster contained diseases that have been widely considered to be eradicable [rinderpest, canine rabies, the Eurasian serotypes of foot and mouth disease virus (O, A, C & Asia 1) and peste des petits ruminants] as well classical swine fever, Newcastle disease and lumpy skin disease. The third cluster contained all the other TADs evaluated with the implication that these constitute TADs that would be more difficult to eradicate. However, it is acknowledged that the scores assigned in the course of this study may be biased. The point is that the system proposed offers an objective method for assessment of the technical eradicability of TADs; the rankings and groupings derived during this study are less important than the provision of a systematic approach for further development and evaluation.

Perceptions of European medical staff on the facilitators and barriers to physical closeness between parents and infants in neonatal units.

AIM: Studies have provided insights into factors that may facilitate or inhibit parent-infant closeness in neonatal units, but none have specifically focused on the perspectives of senior neonatal staff. The aim of this study was to explore perceptions and experiences of consultant neonatologists and senior nurses in five European countries with regard to these issues. METHODS: Six small group discussions and three-one-to-one interviews were conducted with 16 consultant neonatologists and senior nurses representing nine neonatal units from Estonia, Finland, Norway, Spain and Sweden. The interviews explored facilitators and barriers to parent-infant closeness and implications for policy and practice, and thematic analysis was undertaken. RESULTS: Participants highlighted how a humanising care agenda that enabled parent-infant closeness was an aspiration, but pointed out that neonatal units were at different stages in achieving this. The facilitators and barriers to physical closeness included socio-economic factors, cultural norms, the designs of neonatal units, resource issues, leadership, staff attitudes and practices and relationships between staff and parents. CONCLUSION: Various factors affected parent-infant closeness in neonatal units in European countries. There needs to be the political motivation, appropriate policy planning, legislation and resource allocation to increase measures that support closeness agendas in neonatal units.

An integrative review exploring decision-making factors influencing mental health nurses in the use of restraint.

UNLABELLED: WHAT IS KNOWN ON THE SUBJECT?: There is emerging evidence highlighting the counter therapeutic impact of the use of restraint and promoting the minimization of this practice in mental health care. Mental health nurses are often the professional group using restraint and understanding factors influencing their decision-making becomes critical. To date, there are no other published papers that have undertaken a similar broad search to review this topic. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Eight emerging themes are identified as factors influencing mental health nurses decisions-making in the use of restraint. The themes are: 'safety for all', 'restraint as a necessary intervention', 'restraint as a last resort', 'role conflict', 'maintaining control', 'staff composition', 'knowledge and perception of patient behaviours', and 'psychological impact'. 'Last resort' appears to be the mantra of acceptable restraint use, although, to date, there are no studies that specifically consider what this concept actually is. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: These findings should be considered in the evaluation of the use of restraint in mental health settings and appropriate strategies placed to support shifting towards restraint minimization. As the concept of 'last resort' is mentioned in many policies and guidelines internationally with no published understanding of what this means, research should prioritize this as a critical next step in restraint minimization efforts. INTRODUCTION: While mechanical and manual restraint as an institutional method of control within mental health settings may be perceived to seem necessary at times, there is emergent literature highlighting the potential counter-therapeutic impact of this practice for patients as well as staff. Nurses are the professional group who are most likely to use mechanical and manual restraint methods within mental health settings. In-depth insights to understand what factors influence nurses' decision-making related to restraint use are therefore warranted. AIM: To explore what influences mental health nurses' decision-making in the use of restraint. METHOD: An integrative review using Cooper's framework was undertaken. RESULTS: Eight emerging themes were identified: 'safety for all', 'restraint as a necessary intervention', 'restraint as a last resort', 'role conflict', 'maintaining control', 'staff composition', 'knowledge and perception of patient behaviours', and 'psychological impact'. These themes highlight how mental health nurses' decision-making is influenced by ethical and safety responsibilities, as well as, interpersonal and staff-related factors. CONCLUSION: Research to further understand the experience and actualization of 'last resort' in the use of restraint and to provide strategies to prevent restraint use in mental health settings are needed.

Vaccination with leptospiral outer membrane lipoprotein LipL32 reduces kidney invasion of Leptospira interrogans serovar canicola in hamsters.

The Leptospira interrogans vaccines currently available are serovar specific and require regular booster immunizations to maintain protection of the host. In addition, a hamster challenge batch potency test is necessary to evaluate these vaccines prior to market release, requiring the use of a large number of animals, which is ethically and financially undesirable. Our previous work showed that the N terminus of the outer membrane protein LipL32 was altered in Leptospira interrogans serovar Canicola vaccines that fail the hamster challenge test, suggesting that it may be involved in the protective immune response. The aim of this study was to determine if vaccination with LipL32 protein alone could provide a protective response against challenge with L. interrogans serovar Canicola to hamsters. Recombinant LipL32, purified from an Escherichia coli expression system, was assessed for protective immunity in five groups of hamsters (n = 5) following a challenge with the virulent L. interrogans serovar Canicola strain Kito as a challenge strain. However, no significant survival against the L. interrogans serovar Canicola challenge was observed compared to that of unvaccinated negative controls. Subsequent histological analysis revealed reduced amounts of L. interrogans in the kidneys from the hamsters vaccinated with recombinant LipL32 protein prior to challenge; however, no significant survival against the L. interrogans serovar Canicola challenge was observed compared to that of unvaccinated negative controls. This finding corresponded to a noticeably reduced severity of renal lesions. This study provides evidence that LipL32 is involved in the protective response against L. interrogans serovar Canicola in hamsters and is the first reported link to LipL32-induced protection against kidney invasion.

International trade standards for commodities and products derived from animals: the need for a system that integrates food safety and animal disease risk management.

A case is made for greater emphasis to be placed on value chain management as an alternative to geographically based disease risk mitigation for trade in commodities and products derived from animals. The geographic approach is dependent upon achievement of freedom in countries or zones from infectious agents that cause so-called transboundary animal diseases, while value chain-based risk management depends upon mitigation of animal disease hazards potentially associated with specific commodities or products irrespective of the locality of production. This commodity-specific approach is founded on the same principles upon which international food safety standards are based, viz. hazard analysis critical control points (HACCP). Broader acceptance of a value chain approach enables animal disease risk management to be combined with food safety management by the integration of commodity-based trade and HACCP methodologies and thereby facilitates 'farm to fork' quality assurance. The latter is increasingly recognized as indispensable to food safety assurance and is therefore a pre-condition to safe trade. The biological principles upon which HACCP and commodity-based trade are based are essentially identical, potentially simplifying sanitary control in contrast to current separate international sanitary standards for food safety and animal disease risks that are difficult to reconcile. A value chain approach would not only enable more effective integration of food safety and animal disease risk management of foodstuffs derived from animals but would also ameliorate adverse environmental and associated socio-economic consequences of current sanitary standards based on the geographic distribution of animal infections. This is especially the case where vast veterinary cordon fencing systems are relied upon to separate livestock and wildlife as is the case in much of southern Africa. A value chain approach would thus be particularly beneficial to under-developed regions of the world such as southern Africa specifically and sub-Saharan Africa more generally where it would reduce incompatibility between attempts to expand and commercialize livestock production and the need to conserve the subcontinent's unparalleled wildlife and wilderness resources.

Balancing livestock production and wildlife conservation in and around southern Africa's transfrontier conservation areas.

Biodiversity conservation, of which the transfrontier conservation area movement is an integral part, and more effective livestock production/trade are pivotal to future rural development in southern Africa. For that reason, it is imperative to effectively ameliorate the obstacles that have impeded progress towards the coexistence of these two sectors for more than half a century. Transboundary animal diseases, foot and mouth disease in particular, have been and continue to be the most important of these obstacles. Fortunately, new developments in international sanitary standards applicable to trade in commodities and products derived from animals are beginning to make a solution possible. However, while progress in principle has been achieved, practical implementation remains problematic for technical reasons, exacerbated by inconsistent attitudes towards acceptance of non-traditional international trade standards. This paper describes the background to this situation, progress that has been achieved in the recent past and remaining difficulties that need to be overcome to advance towards achievement of balanced rural development in southern Africa.

Influence of NICU co-care facilities and skin-to-skin contact on maternal stress in mothers of preterm infants.

OBJECTIVE: To investigate the influence of co-care facilities and amount of skin-to-skin contact during Neonatal Intensive Care Unit (NICU) stay on maternal stress in mothers of preterm infants at two months corrected age. METHODS: A prospective cohort study that involved 300 mothers of pre-term infants was conducted in four NICUs (two with co-care facilities and two with non co-care) in Sweden. Data on duration of skin-to-skin contact per day for all days admitted to the NICU were collected using self-reports. Maternal stress was measured by the Swedish Parental Stress Questionnaire (SPSQ) at two months of infant's corrected age. RESULTS: Mothers whose infants were cared for in a NICU with co-care facilities reported significantly lower levels of stress in the dimension of 'incompetence' compared to mothers whose infants had been cared for in non co-care NICUs. The amount of skin-to-skin experienced during the neonatal stay was not significantly associated with levels of maternal stress at two months corrected age. CONCLUSION: The finding that mothers who do not experience co-care facilities experience greater levels of stress in relation to feelings of incompetence is of concern. Improvements to NICU environments are needed to ensure that mother-infant dyads are not separated.

Efficacy of dexmedetomidine compared with midazolam for sedation in adult intensive care patients: a systematic review.

Patients in Intensive Care Unit (ICU) often require sedatives which commonly include midazolam and the more recently developed α2-receptor agonist, dexmedetomidine. It was our aim to compare the sedative and clinical effectiveness of dexmedetomidine vs midazolam in adults admitted to ICU, using an objective appraisal of randomized control trials. Medline, Embase, SCOPUS, Web of Knowledge, Cinhal, the United States National Library of Medicine, and the Cochrane Database of Systematic Reviews were searched using keywords: 'dexmedetomidine', 'midazolam', and 'intensive care'. These were limited to human studies and adults (>18 yr old). Six randomized controlled trials were found and were critically appraised using a standardized appraisal method. Two papers described the time spent by each intervention group within a specified target sedation range and both found no statistically significant difference between midazolam and dexmedetomidine (P=0.18 and P=0.15). A third paper found no statistically significant difference in the length of time that patients were sedated within a target zone (P=0.445). Two additional pilot studies did not report P values as they were insufficiently statistically powered. A final paper found that, of the eight occasions measured, patients on dexmedetomidine were more often within the target sedation range than patients on midazolam. The sedative benefits of dexmedetomidine vs midazolam remain inconclusive. While some secondary outcomes showed clinical effectiveness of dexmedetomidine, more research is needed to validate the findings of these studies.

Using a venous thromboembolism checklist significantly improves VTE prevention: a junior doctor led intervention.

AIMS: Given that venous thromboembolic disease is a significant cause of morbidity and mortality, the aim of this study was to increase the rate of VTE risk assessment performed by junior doctors in the acute setting. We also wanted to increase the rates of prescription of thromboembolic preventative measures in those patients whom the assessment identified as being high risk. METHODS: A survey of all patients admitted to three medical wards over a 3-week period was performed to determine whether VTE risk assessment had been performed, and whether prescription of prophylactic measures had been carried out where appropriate. A prompt sheet was subsequently attached to the drug card, and the survey repeated to assess impact on risk assessment and prescription rates. RESULTS: Use of the prompt sheet significantly increased the percentage of patients being appropriately prescribed VTE prophylaxis. CONCLUSIONS/MESSAGE FOR THE CLINIC: Most physicans are aware of the risk of VTE to inpatients, but because of human factors throughout the daily ward activities, VTE assessment can be missed. A simple intervention such as a VTE assessment prompt sheet on the front of the drug card can significantly improve VTE assessment and therefore patient safety.

Responders to insulin therapy at 18 months in adults with newly diagnosed diabetes: which insulin regimen?

OBJECTIVES: To describe baseline characteristics of responders to insulin therapy (HbA(1c) targets < 58 mmol/mol, 7.5%) at 18 months among adults with newly diagnosed diabetes. METHODS: A retrospective UK study derived from 479 general practices electronic dataset. We included all adults (age > 18 years) with newly diagnosed diabetes who required insulin therapy within 6 months of diagnosis. The data comprised insulin regimen (long-acting only; premixed insulin only; basal bolus insulin regimen), gender, Townsend quintile, baseline and an 18-month measurement of clinical and biochemical variables. Multiple imputations were undertaken and logistic regression used to assess the effect of covariates. RESULTS: A total of 1492 patients (aged 19-93 years) were analysed. Means (SD) baseline HbA(1c) and BMI were 10.3% (2.6%) and 29.6 (7.0%), respectively. Following multiple imputation for missing data, logistic regression analysis indicated important covariates to achieve HbA(1c) targets were baseline HbA(1c), lipid lowering therapy, gender and age. Including all covariates, those treated with premixed insulin were 47% more likely to achieve target HbA(1c) at 18 months than those treated with a basal-bolus regimes (adjusted OR 1.47; 95% CI 1.12-1.92, P = 0.006)) and 32% more likely than those treated with long-acting insulin was (adjusted OR 1.32; 95% CI 1.01-1.74, P = 0.044). Those with a higher baseline HbA(1c) level, on lipid-lowering therapy, women and younger patients had a lower response rate. Mean weight gain (SD) was 2.4 kg (8.5 kg) and was not influenced by treatment regimen. CONCLUSION: The use of premixed insulin regimen among newly diagnosed patients with diabetes appears to be most effective in reaching HbA(1c) target values, independent of other confounders. The appropriate choice of insulin regimen at initiation should therefore take into account various metabolic and psychosocial factors.