The effect of anaesthetic agents on induction, recovery and patient preferences in adult day case surgery: a 7-day follow-up randomized controlled trial.

BACKGROUND AND OBJECTIVE: To compare induction, pre- and post-discharge recovery characteristics and patient preferences between four anaesthetic regimens in adult day-surgery. METHODS: Randomized controlled trial. In all, 1158 adults assigned to: propofol induction and maintenance, propofol induction with isoflurane/N2O, or sevoflurane/N2O maintenance, or sevoflurane/N2O alone. We prospectively recorded induction and pre-discharge recovery characteristics, collected 7-day post-discharge recovery characteristics using patient diaries and patient preferences by telephone follow-up. RESULTS: Recruitment rate was 73%--of the 425 refusals, 226 were not willing to risk a volatile induction. During induction, excitatory movements and breath holding were more common with sevoflurane only (P < 0.01). Injection pain and hiccup were more common with propofol induction (P < 0.01). In the recovery room and the postoperative ward, both nausea and vomiting were more common with sevoflurane only (P < 0.01). This difference disappeared within 48 h. There was no difference between groups in the mental state on awakening, recovery time, time to discharge or overnight admissions; then was also no difference in pain between the four groups for each of the seven postoperative days (P < 0.01), nor any differences in concentration or forgetfulness. Patients took 6.5 days (95% CI: 6.0-7.0, n = 693) to resume normal activities. Patients who received sevoflurane only were more likely to recall an unpleasant induction and least likely to want the same induction method again (P < 0.01). CONCLUSION: Differences in outcome between the four regimens are transient; sevoflurane is not an ideal sole agent for adult day case anaesthesia and, in this setting, patients base their preferences for future anaesthetics on the method of induction.

Would a healthier population consume fewer health service resources? A life-table analysis using hospital in-patient enquiry (HIPE) bed-usage statistics as a proxy for hospital treatment costs.

The long-term effects upon acute-care hospital costs of reductions of morbidity and mortality from various causes are explored. The daily number of beds used per million population for all diagnostic categories is suggested as a proxy measure of hospital costs. An index of lifetime bed usage for a hypothetical cohort of persons living out their lives under specified age-specific mortality and morbidity patterns is derived. Examples of the application of this index are given for differing assumptions about mortality and morbidity in males. It is shown that reducing ischaemic heart disease or cancer morbidity will lead to increased overall hospital costs whereas reductions in the rate of occurrence of accidents, injuries and poisonings would reduce overall costs. The assumptions underlying the use of the index are discussed and extensions to the population model are proposed.

Statistical problems in studying the relative specificities of association between environmental agents and different diseases: a solution suggested.

If an environmental agent is strongly associated with only one disease then that is greater evidence in favour of a casual relationship than if that agent were also strongly associated with other unrelated diseases. Standard regression and correlation analysis are shown to be incapable of answering questions about disease specificity. A simple index, based upon regression, is proposed. The standardised regression coefficients in a regression equation based on the logistic transformation of a death rate are shown to have a particularly simple interpretation in terms of our index. The work is illustrated on an example drawn from the controversy concerning the association between area differences in ischaemic heart disease mortality and water hardness.

Are GP practice prescribing rates for coronary heart disease drugs equitable? A cross sectional analysis in four primary care trusts in England.

STUDY OBJECTIVE: To analyse the associations between proxies of healthcare need and GP practice prescribing rates for five major coronary heart disease (CHD) drug groups. DESIGN: Cross sectional secondary analysis. SETTING: Four primary care trusts (PCTs 1-4) in the north west of England, encompassing 132 GP practices. RESULTS: Prescribing rates were generally positively associated with the percentage of patients aged 55-74 years and PASS-PUs (regionally specific prevalence, age, and sex standardised prescribing units). However, the percentage of patients aged over 75 years showed a lack of association with prescribing rates in all PCTs other than PCT2. Correlations with the proportion of South Asian patients were generally negative, particularly in PCT2, PCT4, and the combined dataset. There was a general lack of association with deprivation proxies and SMRs for CHD, although there were negative associations with both variables in PCT4 and the combined dataset. Scatter plots showed that GP practices with similar prescribing rates had widely differing levels of comparative healthcare need, and GP practices with similar levels of healthcare need had widely differing prescribing rates. CONCLUSION: GP prescribing rates in some PCTs were negatively associated with proxies of healthcare need based on patient age (patients aged over 75 years), ethnicity, levels of deprivation, and SMRs for CHD. As such, this study suggests that prescribing rates in these PCTs may be inequitable as they are not positively associated with healthcare need. This study may form the baseline for further studies to assess the effectiveness of the NSF for CHD in reducing the inequities in prescribing rates.

Interventions to increase breast screening uptake: do they make any difference?

BACKGROUND: Breast screening has an important role in improving survival from breast cancer through early detection and treatment. Increasing uptake of screening in areas of low uptake is important in improving the effectiveness of the national screening programme. This review looks at which initiatives to boost uptake have been successful. OBJECTIVE: To evaluate the effectiveness of the different interventions to increase breast screening uptake. METHOD: A systematic review of interventions to promote breast screening uptake was undertaken. Studies were included if uptake was used as an outcome measure of the intervention and if relevant to the UK screening programme. RESULTS: Twenty eight studies were found among 25 citations. Interventions were grouped into "person directed", "system directed", "social network directed", and "multistrategy" categories. Most were person directed. These interventions were more likely to be effective in boosting uptake, be simple in design, and to have been evaluated by a randomized trial design. Evidence of effectiveness in the other groups is limited both by the number of studies and the study designs. A summary of the interventions reviewed is presented. CONCLUSIONS: Simple, brief, and effective interventions exist to boost breast screening uptake. More complicated approaches are not necessarily any more effective. These findings also have implications for other population based screening programmes of the future. In inner city areas the best approach to raising uptake rates is likely to be multistrategy.

Response by women aged 65-79 to invitation for screening for breast cancer by mammography: a pilot study.

OBJECTIVE: To determine whether there is sufficient benefit to be gained by offering screening for breast cancer with mammography to women aged 65-79, who are not normally invited for screening. DESIGN: Pilot study of women eligible for screening but not for personal invitation. The results of this study were compared with the results of routinely screened younger women (aged 50-64) from the same general practice. SETTING: One group general practice in south Manchester. PATIENTS: The 631 women aged 65-79 on the practice list. A total of 42 (7%) were excluded by the general practitioner, and 22 (4%) invitation letters were returned by the post office. MAIN OUTCOME MEASURES: Response rates to invitation for screening assessed by three indices: crude population coverage ratio, crude invited population coverage ratio, and corrected invited population coverage ratio. RESULTS: 344 Patients aged 65-79 (61% of those invited, excluding those who could not be traced) were screened compared with 77% of women aged 50-64. The three response indices were higher for younger women than older: crude population coverage ratio = 66.5%, crude invited population coverage ratio = 69.3%, corrected invited population coverage ratio = 76.8% for women aged 50-64, compared with 54.5%, 58.4%, and 60.7% respectively for women aged 65-79. All four biopsies done in the older women gave positive results, giving a cancer detection rate of 11.6/1000 compared with 4.1/1000 among younger women. CONCLUSIONS: These results show that there is a potential for high attendance at routine screening by older women if they are invited in the same way as younger women. If these results are found elsewhere the costs and benefits of screening older women should be reassessed.

Mortality and the concentration of elements in tap water in county boroughs in England and Wales.

To explain the associations of water hardness and air temperature with area differences in ischaemic heart disease mortality, samples of tap water were obtained from homes in 61 county boroughs in England and Wales, and the concentration of calcium and 12 other elements was estimated. Multiple regressions were calculated with the death rates from various causes as dependent variables and with the concentration of the elements in the tap water, mean annual temperature, mean annual rainfall, and a socioeconomic index as independent variables. The well known negative association between water hardness and ischaemic heart disease was shown to be due to calcium, and none of 12 other elements examined appeared to contribute significantly to the association. Area differences in other causes of death also showed an association with calcium. There was little association between temperature and ischaemic heart disease.

Housing conditions, respiratory illness, and lung function in children in South Wales.

The hypothesis was tested that respiratory illness in children occurs more commonly in old housing than in housing built to modern standards. Three areas of housing were chosen in a South Wales valley: a recently constructed council estate with district central heating; a modern council estate heated with open coal fires; and an area of much older, traditional valley housing. Mothers reported the greatest proportion of children free of colds and sore throats during the previous 12 months in the area of traditional valley housing; mothers of children in the centrally heated estate reported the least proportion of children free of colds. Children's lung function was best in the area of traditional valley housing and worst in the centrally heated council estate. Data on demographic indices and respiratory morbidity suggest that the inhabitants of the two council estates have comparable characteristics. Another hypothesis which may explain the findings is proposed.

Health service 'input' and mortality 'output' in developed countries.

The relationship between age-specific mortality rates and some indices of health facilities and some environmental and dietary factors has been studied in 18 developed couuntries. The indices of health care are not negatively associated with mortality, and there is a marked positive association between the prevalence of doctors and mortality in the younger age groups. No explanation of this doctor anomaly has so far been found. Gross national product per head is the principal variable which shows a consistently strong negative association with mortality.

Respiratory illness, maternal smoking habit and lung function in children.

Two hundred and fourteen children aged 7-11 years had tests of lung function performed. Mothers were asked about their past and current smoking habits and whether their children had ever had pneumonia or severe bronchitis. The findings suggest a relationship between early childhood bronchitis or pneumonia and impairment of lung function in later childhood and also suggest that maternal smoking habit may contribute directly to impairment of lung function in children.

The prevalence, severity and factors associated with urinary incontinence in a random sample of the elderly.

A study to determine the prevalence of urinary incontinence in a random sample of a total elderly community is described. The prevalence of incontinence in women aged 65 years or more was found to be 17% and in men 11%. The findings show that the prevalence of incontinence is particularly high among residents of old people's homes and geriatric hospitals, but that the majority of cases occur within the general community. The prevalence increases with age in both sexes; associations with a history of cerebrovascular disease, certain surgical procedures, multiple hospital admissions and drug usage are described. The findings of a follow-up study suggest that, although the disorder is long-standing and severe in a proportion of subjects, it is transient in approximately a third of all elderly subjects with the condition.

Hearing aids: value for money and health gain.

BACKGROUND: The aim of this study was to assess the ability of hearing aids to reduce the handicap associated with hearing impairment in adults. METHODS: Fifty adults aged over 60 who were supplied with an NHS hearing aid had their hearing handicap and communication function recorded at initial hearing aid assessment, and after three months of aid use. Hearing communication function was assessed by a key informant. RESULTS: Hearing aid use was associated with considerable score improvements for social and emotional function [20.5, 95 per cent confidence interval (Cl) 15.4-25.6] and communication function (22.9, 95 percent Cl 14.6-31.2). Younger people recorded the greatest reduction in handicap. Overall satisfaction with hearing aid performance was high. CONCLUSIONS: Hearing aids are effective in reducing hearing handicap in adults. They represent a good buy for purchasers seeking to achieve health gain for adults with hearing impairment.

Factors associated with cardiac mortality in developed countries with particular reference to the consumption of wine.

Deaths from ischaemic heart-disease in 18 developed countries are not strongly associated with health-service factors such as doctor and nurse density. There is a negative association with gross national product per capita and a positive but inconsistent association with saturated and monounsaturated fat intake. The principal finding is a strong and specific negative association between ischaemic heart-disease deaths and alcohol consumption. This is shown to be wholly attributable to wine consumption.

Respiratory morbidity and lung function in schoolchildren aged 7 to 11 years in South Wales and the West of England.

The present study tests the suggestion that the respiratory morbidity of children resident in South Wales is substantially higher than that among children resident in some other areas of the United Kingdom. A case control survey was carried out among 2228 children aged 7 to 11 years in schools matched for size and socioeconomic characteristics in urban and rural areas in South Wales and the West of England. The survey confirmed that respiratory morbidity was higher among children in South Wales and that this excess could not readily be dismissed as being caused by over-reporting. However, objective measurements of the children's respiratory health did not detect any consistent difference in the lung function of children in South Wales compared with that of children in the West of England.

Respiratory infections and their influence on lung function in children: a multiple regression analysis.

The relationship between a history of respiratory infections (and associated variables) in children and lung function in later life was examined in a study among 228 children aged 7 to 11 years. In a multiple regression analysis only a few variables showed marked and consistent effects on lung function. Respiratory tract infections showed increasing impairment of lung function with repeated infections, but the impairment was smaller than that caused by current asthma.

Anti-mite measurements in mite-sensitive adult asthma. A controlled trial.

A cross-over controlled trial has been conducted among 32 adult patients with mite-sensitive asthma. The bedclothes and pillows of each subject were laundered and vacuum-cleaned and a plastic cover applied to the mattress for six weeks in an attempt to reduce exposure to mites. No improvement in daily peak-flow reading or drug usage was found in comparison with a control period.