Improving maternal update rates within the first hour of NICU admission.

BACKGROUND: Timely communication is essential in attaining maternal satisfaction, developing an excellent physician-patient rapport, and increasing trust. This study reports a significant improvement in maternal communication rates through the quality improvement method. METHODS: An educational module was developed, and NICU staff was presented with the slides, followed by a performance questionnaire to demonstrate understanding. The first phase was completed by obtaining feedback from mothers through a questionnaire. The first plan-do-study-act (PDSA) cycle, carried out for eight weeks looking at the rates of the maternal update provided within an hour of admission of their neonates to the NICU, was followed by the second PDSA cycle, carried out for ten weeks. The improvement was calculated using conventional statistics and a statistical process control chart. RESULTS: During the first phase of the study, thirty-six percent of the mothers were updated within an hour of admission of their neonates to the NICU. During the first PDSA cycle, we did not notice a special cause variation or process change. A significant shift, eight consecutive points above the mean, was noted on the control chart during PDSA cycle 2. The mean±SD of the weekly update rate increased significantly during PDSA cycle 2 (76.8±11) compared to PDSA cycle 1 (47.5±14), p-value = 0.0002. CONCLUSION: We improved the maternal update rates through the educational module following the QI improvement model using the PDSA cycles.

Accuracy of portable ultrasound for obstetric biometry.

OBJECTIVE: We assessed the accuracy of two portable ultrasound machines (PUM) in obtaining fetal biometry and estimating gestational age. METHODS: We analyzed data from the Fetal Age Machine Learning Initiative, an observational study of pregnant women in the United States and Zambia. Each participant underwent assessment by an experienced sonographer using both a high-specification ultrasound machine (HSUM) and a PUM (either Butterfly iQ or Clarius C3) to measure fetal biometry and calculate estimated gestational age (EGA) at each visit. Through comparison of paired PUM-HSUM scans, we estimated agreement between individual biometry measurements and aggregate gestational age estimates by reporting mean difference, along with intraclass correlation coefficient (ICC) and Bland-Altman plots, adjusting for trend. RESULTS: 881 participants contributed 1386 paired PUM-HSUM ultrasound studies between April and December 2021. PUM studies included 991 Butterfly and 395 Clarius. Gestational age at scan ranged from 7 to 38 weeks. Compared to HSUM, the Butterfly PUM had a mean difference of -0.20 days (95%CI±0.40) in the 1st trimester and -0.68 days (95%CI±0.68) in the 2nd/3rd trimesters. Also compared to HSUM, the Clarius PUM had a mean difference of 0.47 days (95%CI±0.64) in the 1st trimester and -1.67 days (95%CI±0.43) in the 2nd/3rd trimesters. ICCs were 0.989 or greater throughout. Increasing gestational age was associated with increasing error and absolute error. Both PUM devices demonstrated a modest trend toward underestimation of EGA at advancing gestational ages in 2nd/3rd trimester scans, compared to HSUM. CONCLUSION: Both the Butterfly iQ and Clarius C3 PUM devices were highly accurate in performing fetal biometry in a diverse population from the US and Zambia. This article is protected by copyright. All rights reserved.

Do Genetic Markers of Inflammation Modify the Relationship between Periodontitis and Nonalcoholic Fatty Liver Disease? Findings from the SHIP Study.

An association between periodontitis and nonalcoholic fatty liver disease (NAFLD) has been reported by experimental animal and epidemiologic studies. This study investigated whether circulating levels of serum C-reactive protein (CRP) and a weighted genetic CRP score representing markers of inflammatory burden modify the association between periodontitis and NAFLD. Data came from 2,481 participants of the Study of Health in Pomerania who attended baseline examination that occurred between 1997 and 2001. Periodontitis was defined as the percentage of sites (0%, <30%, ≥30%) with probing pocket depth (PD) ≥4 mm, and NAFLD status was determined using liver ultrasound assessment. Serum CRP levels were assayed at a central laboratory, and single-nucleotide polymorphisms previously identified through genome-wide association studies as robustly associated with serum CRP were combined into a weighted genetic CRP score (wGSCRP). Logistic regression models estimated the association between periodontitis and NAFLD within strata of serum CRP and separately within strata of the wGSCRP. The prevalence of NAFLD was 26.4% (95% confidence interval [CI], 24.6, 28.1) while 17.8% (95% CI, 16.0-19.6) had ≥30% of sites with PD ≥4 mm. Whereas the wGSCRP was not a modifier ( Pinteraction = 0.8) on the multiplicative scale, serum CRP modified the relationship between periodontitis and NAFLD ( Pinteraction = 0.01). The covariate-adjusted prevalence odds ratio of NAFLD comparing participants with ≥30% of sites with PD ≥4 mm to those with no site affected was 2.39 (95% CI, 1.32-4.31) among participants with serum CRP <1 mg/L. The corresponding estimate was 0.97 (95% CI, 0.57-1.66) for participants with serum CRP levels of 1 to 3 mg/L and 1.12 (95% CI, 0.65-1.93) for participants with serum CRP >3 mg/L. Periodontitis was positively associated with higher prevalence odds of NAFLD, and this relationship was modified by serum CRP levels.

A cautionary note about estimating effects of secondary exposures in cohort studies.

Cohort studies are often enriched for a primary exposure of interest to improve cost-effectiveness, which presents analytical challenges not commonly discussed in epidemiology. In this paper, we use causal diagrams to represent exposure-enriched cohort studies, illustrate a scenario wherein the risk ratio for the effect of a secondary exposure on an outcome is biased, and propose an analytical method for correcting for such bias. In our motivating example, maternal smoking (Z) is a cause of fetal growth restriction (X), which subsequently affects preterm birth (Y) (i.e., Z → X → Y); strong positive associations exist between both Z, X and X, Y; and enrichment for X increases its prevalence from 10% to 50%. In the X-enriched cohort, unadjusted and X-adjusted analyses lead to bias in the risk ratio for the total effect of Z on Y. After application of inverse probability weights, the bias is corrected, with a small loss of efficiency in comparison with a same-sized study without X-enrichment. With increasing interest in conducting secondary analyses to reduce research costs, caution should be employed when analyzing studies that have already been enriched, intentionally or unintentionally, for a primary exposure of interest. Causal diagrams can help identify scenarios in which secondary analyses may be biased. Inverse probability weights can be used to remove the bias.

Prostate involvement during sexually transmitted infections as measured by prostate-specific antigen concentration.

BACKGROUND: We investigated prostate involvement during sexually transmitted infections by measuring serum prostate-specific antigen (PSA) as a marker of prostate infection, inflammation, and/or cell damage in young, male US military members. METHODS: We measured PSA before and during infection for 299 chlamydia, 112 gonorrhoea, and 59 non-chlamydial, non-gonococcal urethritis (NCNGU) cases, and 256 controls. RESULTS: Chlamydia and gonorrhoea, but not NCNGU, cases were more likely to have a large rise (40%) in PSA than controls (33.6%, 19.1%, and 8.2% vs 8.8%, P<0.0001, 0.021, and 0.92, respectively). CONCLUSION: Chlamydia and gonorrhoea may infect the prostate of some infected men.

Uncertain outcomes: adjusting for misclassification in antimalarial efficacy studies.

Evaluation of antimalarial efficacy is difficult because recurrent parasitaemia can be due to recrudescence or re-infection. PCR is used to differentiate between recrudescences and re-infections by comparing parasite allelic variants before and after treatment. However, PCR-corrected results are susceptible to misclassification: false positives, due to re-infection by the same variant present in the patient before treatment; and false negatives, due to variants that are present but too infrequent to be detected in the pre-treatment PCR, but are then detectable post-treatment. This paper aimed to explore factors affecting the probability of false positives and proposes a Monte Carlo uncertainty analysis to account for both types of misclassification. Higher levels of transmission intensity, increased multiplicity of infection, and limited allelic variation resulted in more false recrudescences. The uncertainty analysis exploits characteristics of study data to minimize bias in the estimate of efficacy and can be applied to areas of different transmission intensity.

Endorsement by the primary care practitioner consistently improves participation in screening for colorectal cancer: a longitudinal analysis.

OBJECTIVES: To investigate the effect of general practice (GP) and general practitioner (GPR) endorsement for faecal occult blood test (FOBT)-based screening on maintenance of participation in screening over four successive screening rounds. SETTING: South Australian residents aged > or = 50 years. METHODS: Random selection of four groups (n = 600 per group): one from the Commonwealth electoral roll (ER) and three from the combined patient lists of two collaborating GPs (GP1, GP2, GP3). Subjects were mailed offers to screen using a faecal immunochemical test over four successive rounds, spaced approximately 18 months apart. The GP1 and ER groups were invited to screen without any endorsement from a GPR or medical practice; GP2 invitees received an invitation indicating support for screening from their medical practice; and GP3 invitations were printed on practice letterhead and were signed by a GPR. RESULTS: Multivariate analyses indicated that initial participation as well as re-participation over four successive rounds was significantly enhanced in the GP2 (39%, 42%, 45% and 44%) and GP3 groups (42%, 47%, 48% and 49%) relative to the ER group (33%, 37%, 40% and 36%). The analyses also indicated that 60-69 year olds were most likely to participate in all rounds (relative risk [RR] 1.49, 1.39, 1.43 and 1.25), and men were generally less likely to participate than women in all screening rounds (RR 0.86, 0.84, 0.80 and 0.83). CONCLUSIONS: Associating a GPR or medical practice of recent contact with an invitation to screen achieves better participation and re-participation than does an invitation from a centralized screening unit. Furthermore, enhanced participation can be achieved by practice endorsement alone without requiring actual GPR involvement.

Retinal microvascular abnormalities and cognitive decline: the ARIC 14-year follow-up study.

BACKGROUND: Because retinal and cerebral arterioles share similar pathologic processes, retinal microvascular changes are expected to be markers of cerebral small vessel disease (SVD). To better understand the role of SVD in cognitive function, we investigated the relationship between retinal microvascular abnormalities and longitudinal changes in cognitive function in a community-based study. METHODS: A total of 803 participants underwent 4 cognitive assessments between 1990-1992 and 2004-2006, using the Word Fluency (WF) test, Digit Symbol Substitution (DSS), and Delayed Word Recall as well as retinal photography in 1993-1995. Covariate adjusted random effects linear models for repeated measures were used to determine the associations of cognitive change with specific retinal vascular abnormalities. RESULTS: Individuals with retinopathy showed declines in executive function and psychomotor speed, with 1) an average decline in WF of -1.64 words per decade (95% confidence interval [CI] -3.3, -0.02) compared to no decline in those without retinopathy +0.06 (95% CI -0.6, 0.8) and 2) a higher frequency of rapid decliners on the DSS test. CONCLUSION: Signs of retinal vascular changes, as markers of the cerebral microvasculature, are associated with declines in executive function and psychomotor speed, adding to the growing evidence for the role of microvascular disease in cognitive decline in the elderly.

An advance notification letter increases participation in colorectal cancer screening.

OBJECTIVES: To determine the impact of novel invitation strategies on population participation in faecal immunochemical test (FIT)-based colorectal cancer (CRC) screening. SETTING: A community screening programme in Adelaide, South Australia. METHODS: In total, 2400 people aged 50-74 years were randomly allocated to one of four CRC screening invitation strategies: (a) CONTROL: standard invitation-to-screen letter explaining risk of CRC and the concept, value and method of screening; (b) Risk: invitation with additional messages related to CRC risk; (c) Advocacy: invitation with additional messages related to advocacy for screening from previous screening programme participants and (d) Advance Notification: first, a letter introducing CONTROL letter messages followed by the standard invitation-to-screen. Invitations included an FIT kit. Programme participation rates were determined for each strategy relative to control. Associations between participation and sociodemographic variables were explored. RESULTS: At 12 weeks after invitation, participation was: CONTROL: 237/600 (39.5%); Risk: 242/600 (40.3%); Advocacy: 216/600 (36.0%) and Advance Notification: 290/600 (48.3%). Participation was significantly greater than CONTROL only in the Advance Notification group (Relative risk [RR] 1.23, 95% confidence interval [CI] 1.06-1.43). This effect was apparent as early as two weeks from date of offer; Advance Notification: 151/600 (25.2%) versus CONTROL: 109/600 (18.2%, RR 1.38, 95% CI 1.11-1.73). CONCLUSIONS: Advance notification significantly increased screening participation. The effect may be due to a population shift in readiness to undertake screening, and is consistent with the Transtheoretical Model of behaviour change. Risk or lay advocacy strategies did not improve screening participation. Organized screening programmes should consider using advance notification letters to improve programme participation.

Effect of tuberculosis on the survival of women infected with human immunodeficiency virus.

Evidence regarding the effect of tuberculosis (TB) disease on progression of human immunodeficiency virus (HIV) disease is inconclusive. The authors estimated the effect of time-varying incident TB on time to acquired immunodeficiency syndrome (AIDS)-related mortality using a joint marginal structural Cox model. Between 1995 and 2002, 1,412 HIV type 1 (HIV-1)-infected women enrolled in the Women's Interagency HIV Study were followed for a median of 6 years. Twenty-nine women incurred incident TB, and 222 died of AIDS-related causes. Accounting for age, CD4 cell count, HIV-1 RNA level, serum albumin level, and non-TB AIDS at study entry, as well as for time-varying CD4 cell count, CD4 cell count nadir, HIV-1 RNA level, peak HIV-1 RNA level, serum albumin level, HIV-related symptoms, non-TB AIDS, anti-Pneumocystis jiroveci prophylaxis, antiretroviral therapy, and household income, the hazard ratio for AIDS-related death comparing time after incident TB with time before incident TB was 4.0 (95% confidence interval (CI): 1.2, 14). The effect of incident TB on mortality was similar among highly active antiretroviral therapy (HAART)-exposed women (hazard ratio = 4.3, 95% CI: 0.9, 22) and non-HAART-exposed women (hazard ratio = 3.9, 95% CI: 0.9, 17; interaction p = 0.91). Although results were imprecise because few women incurred TB, irrespective of HAART exposure, incident TB increases the hazard of AIDS-related death among HIV-infected women.

Screening for colorectal cancer by faecal occult blood test: why people choose to refuse.

To better understand the personal barriers that limit participation in faecal occult blood test (FOBT) screening for colorectal cancer, non-participants from a recent screening initiative were sent detailed questionnaires, defining their reasons for not participating, as well as how to make screening more attractive. The important barrier was procrastination. The type of FOBT kit offered influenced the reasons for not participating. Convenient FOBT and greater general practitioner involvement may be important for optimizing community acceptance of FOBT-based screening.

Glomerular filtration rate via plasma iohexol disappearance: pilot study for chronic kidney disease in children.

To guide the design of a nation-wide cohort study of chronic kidney disease in children, we determined how iohexol plasma disappearance curves could be used in children to measure glomerular filtration rate (GFR). Iohexol (5 ml) was administered intravenously and blood samples were obtained at 10, 20, 30, 60, 120, 240, 300, and 360 min after injection (N=29) and assayed by high performance liquid chromatography. Four urines were also collected following the injection. Intra-assay coefficient of variation (CV) in serum was 1.3% at 100 mg/l, 2.6% at 15 mg/l, and 3.4% for duplicate unknowns. GFR(9) was computed from iohexol dose and area under the nine-point blood disappearance curve, using double exponential modeling. Only 2.8% of 254 data points deviated by >3 CV from the curves. GFR(4) calculated from 10, 30, 120, and 300 min points correlated well with GFR(9) (r=0.999) and showed no bias (means+/-s.d. of GFR(9) and GFR(4)=59.3+/-36.3 and 59.4+/-36.0 ml/min per 1.73 m(2)). Relationship of GFR(9) and one-compartment GFR followed quadratic equation as previously reported by Brochner-Mortensen, allowing GFR to be calculated from 120 and 300 min points. This GFR(2) correlated well with GFR(9) (r=0.986). Estimated GFR from Schwartz height/creatinine formula correlated with GFR(9)(r=0.934) but overestimated GFR by 12.2 ml/min per 1.73 m(2). Urine iohexol clearance was poorly correlated (r=0.770) with GFR(9) owing to variability in urine collections (median CV=24%). GFR can be measured accurately using four-point iohexol plasma disappearance (in most cases, two points suffice); estimated GFR and urinary clearances are less useful.

Interval faecal occult blood testing in a colonoscopy based screening programme detects additional pathology.

BACKGROUND: Colonoscopic based surveillance is recommended for patients at increased risk of colorectal cancer. The appropriate interval between surveillance colonoscopies remains in debate, as is the "miss rate" for colorectal cancer within such screening programmes. AIMS: The main aim of this study was to determine whether a one-off interval faecal occult blood test (FOBT) facilitates the detection of significant neoplasia within a colonoscopic based surveillance programme. Secondary aims were to determine if invitees were interested in participating in interval screening, and to determine whether interval lesions were missed or whether they developed rapidly since the previous colonoscopy PATIENTS: Patients enrolled in a colonoscopic based screening programme due to a personal history of colorectal neoplasia or a significant family history. METHODS: Patients within the screening programme were invited to perform an immunochemical FOBT (Inform). A positive result was followed by colonoscopy; significant neoplasia was defined as colorectal cancer, adenomas either > or =10 mm or with a villous component, high grade dysplasia, or multiplicity (>/=3 adenomas). Participation rates were determined for age, sex, and socioeconomic subgroups. Colonoscopy recall databases were examined to determine the interval between previous colonoscopy and FOBT offer, and correlations between lesion characteristics and interval time were determined. RESULTS: A total of 785 of 1641 patients invited (47.8%) completed an Inform kit. A positive result was recorded for 57 (7.3%). Fifty two of the 57 test positive patients completed colonoscopy; 14 (1.8% of those completing the FOBT) had a significant neoplastic lesion. These consisted of six colorectal cancers and eight significant adenomas. CONCLUSIONS: A one off immunochemical faecal occult blood test within a colonoscopy based surveillance programme had a participation rate of nearly 50% and appeared to detect additional pathology, especially in patients with a past history of colonic neoplasia.

The use of Alu-PCR to distinguish between typical pulmonary carcinoids versus classic midgut carcinoids.

Although histologically 'typical' pulmonary and 'classic' midgut carcinoids are similar, the small intestine tumors are more aggressive than their pulmonary counterpart. We believe that in contrast to pulmonary carcinoids arising from Kulchitsky cells, 'classical' midgut carcinoids develop from crypt stem cells that differentiate into endocrine ('classical') or exocrine-endocrine ('non-classical' adenocarcinoid) tumors. The different progenitor cells may determine different malignant potentials between these types of carcinoids. To identify genetic differences between 'classical' midgut and typical pulmonary carcinoids using an Alu-PCR genomic profiling method, we reviewed 54 cases of carcinoid tumors that were surgically removed at Hartford Hospital from 1996 through 2001. Histologically these cases were selected into three groups: i) foregut or pulmonary carcinoids, ii) 'classic' midgut carcinoids of small intestine and iii) multiple typical pulmonary carcinoids. Genomic-profiling of DNA from these cases was performed using an Alu-PCR method. Metastases were observed in 18/20 'classical' intestinal carcinoid tumors, 3/30 pulmonary carcinoids, and 0/4 multiple pulmonary carcinoids. These results confirm that pulmonary carcinoids behave in a more benign fashion than intestinal carcinoid tumors. Using Alu-PCR to profile tumor cell genomic DNA, we showed that 68% of small intestine carcinoids and 58% of pulmonary carcinoids had allelic banding patterns suggestive of either amplification or deletion of gene sequences. Alu-PCR demonstrated loss or gain of genetic sequences that were unique for each examined group. These findings strongly suggest that pulmonary carcinoids differ from their intestinal counterparts.

A randomised trial of the impact of new faecal haemoglobin test technologies on population participation in screening for colorectal cancer.

OBJECTIVES: To investigate the effect on participation in colorectal cancer screening of testing for blood products in faeces using technologies that remove dietary restrictions (i.e. immunochemical tests) and simplify faecal sampling (i.e. tests that use brush sampling). SETTING: Urban residents (n=1818) of Adelaide, Australia, aged between 50 and 69 years, randomly selected from the electoral roll. DESIGN: Three randomised cohorts of 606 invitees were offered a screening test by mail in 2001. The Hemoccult SENSA and FlexSure OBT cohorts were instructed to sample three stools using a spatula while the InSureTM cohort sampled two stools using a brush. The Hemoccult SENSA cohort was asked to restrict certain (high-peroxidase) foods and drugs. MAIN OUTCOME MEASURES: Participation (i.e. return of completed sample kits within 12 weeks) and generalised linear modelling (GLM) of relationships between participation, test technologies and demographic variables. RESULTS: Participation was 23.4%, 30.5% and 39.6% for the Hemoccult, FlexSure and InSure cohorts, respectively (chi(2)=37.1, p<0.00001). GLM demonstrated that participation was increased by 28% by removal of restrictions (p=0.01) and by 30% by simplification of sampling (p=0.001); both together increased participation by 66% (p<0.001). The differences in participation between tests occurred in the first three weeks. Socio-economic status, gender or age did not significantly influence technology-based improvements in participation. CONCLUSIONS: The brush-sampling faecal immunochemical test for haemoglobin (InSure) achieves the best participation rates by simplifying sampling and removing the need for restrictions of diet and drugs. Because participation in screening is vital to detection, this new technology should contribute to better detection of neoplasia at the population level.

Prescreening evaluation of a brush-based faecal immunochemical test for haemoglobin.

OBJECTIVES: To undertake a prescreening evaluation of a new brush-based faecal immunochemical test for haemoglobin, relative to a traditional spatula-sampling immunochemical test. SETTING: Patients aged between 24 and 90 years, scheduled to undergo diagnostic colonoscopy in two major urban hospitals, for a range of clinical indications. DESIGN: Patients sampled three stools using a spatula for the reference FlexSure OBT test and two stools using a brush for the InSure test; order of sampling was randomised. Faecal haemoglobin was quantified by a modified InSure in a subset of patients to determine whether brush-sampling allowed discrimination between groups. MAIN OUTCOME MEASURES: Sensitivity for cancer or adenoma; false-positive rate in normals. Faecal haemoglobin levels. Preference for sampling method. RESULTS: InSure and FlexSure OBT did not differ in their sensitivities for cancer (27/36, 75% vs 29/36, 80.5%, respectively), adenomas >or= 10 mm (12/29, 41.4% vs 13/29, 44.8%) or adenomas <10 mm (each 8/56, 14.3%). Likewise, false-positive rates in normals were similar: 4/179 (2.2%) and 5/179 (2.8%) respectively (specificities of 97.8% and 97.2%, respectively). Levels of faecal haemoglobin were highest in those with cancers; those with adenomas had intermediate levels which were also significantly higher than those in normals. The brush sampling method was preferred by 38/46 (82.6%), while 4/46 (8.7%) preferred the spatula (p<0.00001). CONCLUSIONS: InSure is as sensitive and specific as FlexSure OBT for faecal haemoglobin. The novel stool-sampling method of InSure allows discrimination between normals and classes of neoplasia, and is highly preferred. The brush-sampling faecal immunochemical test InSure should now be evaluated in a screening population.

Participation in screening for colorectal cancer based on a faecal occult blood test is improved by endorsement by the primary care practitioner.

OBJECTIVES: To investigate the influence of general practitioner (GP) endorsement on participation in screening for colorectal cancer based on a faecal occult blood test (FOBT). SETTING: South Australian residents (n=2400), in 1999, aged >50 years. METHODS: Random selection of three groups (GP1, GP2, GP3) from two general practices and of one group (ER) from the federal electoral roll; n=600 per group. Without previous communication or publicity, subjects were posted an offer of screening by immunochemical FOBT. The GP1 and ER groups were invited without indication that their GP was involved; GP2 received an invitation indicating support from the practice; and GP3 received an invitation on practice letterhead and signed by a practice partner. A reminder was posted at 6 weeks. Participation was defined as return of correctly completed FOBT sample cards within 12 weeks. RESULTS: Participation rates were: GP1 192/600 (32.0%), GP2 228/600 (38.0%), and GP3 244/600 (40.7%); chi(2)=10.2, p=0.006. Both GP2 and GP3 differed significantly from GP1 (odds ratio (OR) 0.77, 95% confidence interval (95% CI) 0.60 to 0.98 and relative risk (RR)=0.69, 95% CI 0.54 to 0.87 respectively). ER (193/600 (32.2%)) and GP1 were not significantly different. Age but not sex was significantly associated with participation. Overall test positivity rate was 4.6%; five malignancies were found in the 918 who performed FOBT. CONCLUSIONS: Association of a GP of recent contact with a screening offer in the form of a personalised letter of invitation achieves better participation than does the same letter from a centralised screening unit that does not mention the GP. Thus, GP enhanced participation is achievable without their actual involvement. Additional strategies are needed to further improve participation.

Effect of dietary restriction on participation in faecal occult blood test screening for colorectal cancer.

OBJECTIVES: To determine if participation in colorectal cancer screening using faecal occult blood testing (FOBT) is affected by a restrictive diet and if it is associated with certain demographic variables. PARTICIPANTS AND SETTING: 1,203 residents of South Australia aged 50-69 years, with no "currently active bowel disease", randomly selected from a database of people willing to be contacted about unspecified health issues. DESIGN: Randomised controlled trial: participants were offered screening by immunochemical FOBT by mail in 1998. Half were randomly allocated to a group instructed to follow a low-peroxidase diet, as required for guaiac FOBT, while the other group was not so restricted. MAIN OUTCOME MEASURES: Effect of diet restriction on participation (return of correctly completed FOBT sample cards within 15 weeks); time taken to return cards; relationships between participation and demographic variables. RESULTS: Participation rates were 65.9% (no-diet group) and 53.3% (diet group) (difference, 12.6%; 95% CI, 7.1%-18.1%). In the first week, rates of return as a proportion of all tests returned were 13.1% (no-diet) and 1.6% (diet) (difference, 11.5%; 95% CI, 8.6%-14.4%), increasing to 54.3% and 44.5%, respectively, after five weeks (difference, 9.8%; 95% CI, 4.2%-15.4%). Participation was significantly associated with older age (odds ratio, 1.40; 95% CI, 1.10-1.78), but not sex, Index of Social Disadvantage or rural versus urban address. CONCLUSIONS: Dietary restrictions create a barrier to FOBT-based screening for colorectal cancer. The use of immunochemical rather than guaiac FOBT removes this barrier.

The Amblyopia Treatment Index.

OBJECTIVE: To develop a questionnaire to assess the acceptability of amblyopia treatment and its effect on the child and family. METHODS: A 20-item parental survey was developed and pilot tested on 64 subjects, aged 3 to 6 years, participating in the Amblyopia Treatment Study, a randomized trial comparing patching and atropine as treatments for moderate amblyopia. The survey was administered after 4 weeks of treatment. A descriptive item analysis and an internal consistency reliability analysis were performed. RESULTS: Nineteen of the 20 items demonstrated adequate variability as evidenced by the frequency distributions for item responses. Only 4 (<1%) of 1280 possible item responses were missing, one each by 4 different respondents. Factor analysis identified 3 treatment-related factors--"adverse effects," "compliance," and "social stigma"--among 11 of the 20 items. The internal-consistency reliability alpha for the 5-item adverse effects subscale was 0.82, the 4-item compliance subscale alpha was 0.81, and the 2-item social stigma subscale alpha was 0.84. CONCLUSIONS: The Amblyopia Treatment Index appears to be a useful instrument for assessing the impact of amblyopia treatment in 3- to 6-year-old children.

Time urgency and risk of non-fatal myocardial infarction.

BACKGROUND: Inconsistencies in the literature linking Type A behaviour pattern (TAB) to coronary heart disease (CHD) may be due to differences in the effects of various components of TAB, namely aggressiveness, hostility, ambitiousness, competitive drive, and a chronic sense of time urgency. METHODS: We investigated the association between sense of time urgency/impatience and non-fatal myocardial infarction (MI) in a study of 340 cases and an equal number of age-, sex-, and community-matched controls. RESULTS: A dose-response relation was apparent among subjects who rated themselves higher on the four-item time urgency/impatience scale (P-value for trend <0.001), with a matched odds ratio (OR) for non-fatal MI of 4.45 (95% CI : 2.20-8.99) comparing those with the highest rating to those with the lowest. After further adjustment for family history of premature MI, physical activity, body mass index, occupation, cigarette smoking, total caloric intake, per cent calories from saturated fat, alcohol intake, lipid levels, treated hypertension and diabetes, the dose-response relation remained (P-value for trend = 0.015) and the adjusted OR for MI was 3.99 (95% CI : 1.32-12.0) comparing those with the highest rating to those with the lowest. CONCLUSION: In these data, a sense of time urgency/impatience was associated with a dose-response increase in risk of non-fatal MI, independent of other risk factors. Prospective cohort studies of time urgency/impatience and incident CHD events are needed to confirm or refute these observations from a case-control study.