The effect of diet in infancy on asthma in young adults: the Merthyr Allergy Prevention Study.

INTRODUCTION: Early infant diet might influence the risk of subsequent allergic disease. METHODS: The Merthyr Allergy Prevention Study (MAPS) was a randomised controlled trial in infants at high risk of allergic disease. The trial determined whether a cow's milk exclusion diet for the first 4 months of life decreased the risk of allergic disease including asthma compared with a normal diet. A soya milk preparation was offered to those in the intervention group. A standardised questionnaire for allergic disease was completed at ages 1, 7, 15 and 23 years, with clinical assessment at 1, 7 and 23 years. The effect of the intervention on the risk of atopy, asthma and wheeze at age 23 years was determined. FINDINGS: 487 subjects entered the study; at age 23 years 299 completed the questionnaire, of which 119 attended clinical assessment. Subjects randomised to the intervention group had a significantly increased risk of atopy (adjusted OR 2.97, 95% CI 1.30 to 6.80; p=0.01) and asthma (OR 2.07, 95%CI 1.09 to 3.91; p=0.03) at age 23 years, but not wheeze (OR 1.43, 95%CI 0.87 to 2.37; p=0.16). Earlier exposure to cow's milk was associated with a decreased risk of wheeze and asthma at age 23 years, while earlier exposure to soya milk was associated with an increased risk of atopy and asthma. INTERPRETATION: In infants at high risk of allergic disease, either cow's milk exclusion or early soya milk introduction for the first 4 months of life increases the risk of atopy, wheeze and asthma in adulthood.

Impact of the phased abolition of co-payments on the utilisation of selected prescription medicines in Wales.

We have taken advantage of a natural experiment to measure the impact of the phased abolition of prescription co-payments in Wales. We investigated 3 study periods covering the phased abolition: from £6 to £4, £4 to £3, and £3 to £0. A difference-in-difference modelling was adopted and applied to monthly UK general practice level dispensing data on 14 selected medicines which had the highest percentage of items dispensed subject to a co-payment prior to abolition. Dispensing from a comparator region (North East of England) with similar health and socio-economic characteristics to Wales, and where prescription co-payments continued during the study periods, was used to isolate any non-price effects on dispensing in Wales. Results show a small increase in dispensing of 14 selected medicines versus the comparator. Compared with NE England, monthly average Welsh dispensing was increased by 11.93 items (7.67%; 95% CI [7.2%, 8.1%]), 6.37 items (3.38%; 95% CI [2.9%, 3.7%]) and 9.18 items (4.54%; 95% CI [4.2%, 4.9%]) per practice per 1,000 population during the periods when co-payment was reduced. Price elasticities of the selected medicines utilisation were -0.23, -0.13, and -0.04 in 3 analyses, suggesting the abolition of co-payment had small effect on Welsh dispensing.

Improving Mental Health Through the Regeneration of Deprived Neighborhoods: A Natural Experiment.

Neighborhood-level interventions provide an opportunity to better understand the impact of neighborhoods on health. In 2001, the Welsh Government, United Kingdom, funded Communities First, a program of neighborhood regeneration delivered to the 100 most deprived of the 881 electoral wards in Wales. In this study, we examined the association between neighborhood regeneration and mental health. Information on regeneration activities in 35 intervention areas (n = 4,197 subjects) and 75 control areas (n = 6,695 subjects) was linked to data on mental health from a cohort study with assessments made in 2001 (before regeneration) and 2008 (after regeneration). Propensity score matching was used to estimate the change in mental health in intervention neighborhoods versus control neighborhoods. Baseline differences between intervention and control areas were of similar magnitude as produced by paired randomization of neighborhoods. Regeneration was associated with an improvement in the mental health of residents in intervention areas compared with control neighborhoods (ß = 1.54, 95% confidence interval: 0.50, 2.59), suggesting a reduction in socioeconomic inequalities in mental health. There was a dose-response relationship between length of residence in regeneration neighborhoods and improvements in mental health (P-trend = 0.05). These results show that targeted regeneration of deprived neighborhoods can improve mental health.

Prevalence of defined ultrasound findings of unknown significance at the second trimester fetal anomaly scan and their association with adverse pregnancy outcomes: the Welsh study of mothers and babies population-based cohort.

OBJECTIVE: The aim of this article was to estimate the population prevalence of seven defined ultrasound findings of uncertain significance ('markers') in the second trimester and the associated risk of adverse pregnancy outcomes. METHOD: A prospective record-linked cohort study of 30 078 pregnant women who had second trimester anomaly scans between July 2008 and March 2011 in Wales was conducted. RESULTS: The prevalence of markers ranged from 43.7 per 1000 singleton pregnancies for cardiac echogenic foci [95% confidence interval (CI): 38.8, 51.1] to 0.6 for mild-to-moderate ventriculomegaly (95% CI: 0.3, 1.0). Isolated echogenic bowel was associated with an increased risk of congenital anomalies [risk ratio (RR) 4.54, 95% CI: 2.12, 9.73] and preterm birth (RR 2.30, 95% CI: 1.08, 4.90). Isolated pelvicalyceal dilatation was associated with an increased risk of congenital anomalies (RR 3.82, 95% CI: 2.16, 6.77). Multiple markers were associated with an increased risk of congenital anomalies (RR 5.00, 95% CI: 1.35, 18.40) and preterm birth (RR 3.38, 95% CI 1.20, 9.53). CONCLUSIONS: These data are useful for counselling families and developing clinical guidance and care pathways following the detection of markers in clinical practice, particularly the need for follow-up scans to monitor placental function and growth in pregnancies with isolated echogenic bowel, and further investigation for multiple markers. © 2015 The Authors. Prenatal Diagnosis published by John Wiley & Sons Ltd.

Case-finding for common mental disorders of anxiety and depression in primary care: an external validation of routinely collected data.

BACKGROUND: The robustness of epidemiological research using routinely collected primary care electronic data to support policy and practice for common mental disorders (CMD) anxiety and depression would be greatly enhanced by appropriate validation of diagnostic codes and algorithms for data extraction. We aimed to create a robust research platform for CMD using population-based, routinely collected primary care electronic data. METHODS: We developed a set of Read code lists (diagnosis, symptoms, treatments) for the identification of anxiety and depression in the General Practice Database (GPD) within the Secure Anonymised Information Linkage Databank at Swansea University, and assessed 12 algorithms for Read codes to define cases according to various criteria. Annual incidence rates were calculated per 1000 person years at risk (PYAR) to assess recording practice for these CMD between January 1(st) 2000 and December 31(st) 2009. We anonymously linked the 2799 MHI-5 Caerphilly Health and Social Needs Survey (CHSNS) respondents aged 18 to 74 years to their routinely collected GP data in SAIL. We estimated the sensitivity, specificity and positive predictive value of the various algorithms using the MHI-5 as the gold standard. RESULTS: The incidence of combined depression/anxiety diagnoses remained stable over the ten-year period in a population of over 500,000 but symptoms increased from 6.5 to 20.7 per 1000 PYAR. A 'historical' GP diagnosis for depression/anxiety currently treated plus a current diagnosis (treated or untreated) resulted in a specificity of 0.96, sensitivity 0.29 and PPV 0.76. Adding current symptom codes improved sensitivity (0.32) with a marginal effect on specificity (0.95) and PPV (0.74). CONCLUSIONS: We have developed an algorithm with a high specificity and PPV of detecting cases of anxiety and depression from routine GP data that incorporates symptom codes to reflect GP coding behaviour. We have demonstrated that using diagnosis and current treatment alone to identify cases for depression and anxiety using routinely collected primary care data will miss a number of true cases given changes in GP recording behaviour. The Read code lists plus the developed algorithms will be applicable to other routinely collected primary care datasets, creating a platform for future e-cohort research into these conditions.

Defining background DNA levels found on the skin of children aged 0-5 years.

There are currently no data available regarding the normal levels of DNA found on the skin of children engaging in routine day to day activities to assist with the forensic interpretation of DNA profiles generated from skin surface swabs. To address this deficit, skin surface swab samples were collected from 12 face/neck sites and 20 body sites on 50 children less than 5 years old. After exclusion of spoilt samples, 60 sets of swabs from 47 children (30 face/neck, 30 body) comprising of 944 individual samples were analysed. The number of alleles observed which could have originated from the child and the number which must have come from another source (non-child) were analysed. The following variables were evaluated: age, kissing, feeding and washing practices, number of contacts and application of cream. Overall, extremely small amounts of non-child DNA were retrieved from skin swabs. Child only (46.3%) or no DNA at all (18.6%) was observed for 64.9% of all swabbed samples. Low levels of non-child DNA (1-5 alleles) were observed on 31.6% of all swabs tested with only 3.4% of swabs showing six or more alleles. A great deal of variation between children and between sites in the levels of both child DNA and non-child DNA was observed. A multilevel model, taking account of clustering within children, showed that there was a strong direct association between the amounts of child and non-child DNA observed. There was no relationship between the amount of DNA recovered and the demographic and biographic variables analysed. These background data have the potential to assist the analysis of DNA from the skin of children during criminal investigation.

The Welsh study of mothers and babies: protocol for a population-based cohort study to investigate the clinical significance of defined ultrasound findings of uncertain significance.

BACKGROUND: Improvement in ultrasound imaging has led to the identification of subtle non-structural markers during the 18 - 20 week fetal anomaly scan, such as echogenic bowel, mild cerebral ventriculomegaly, renal pelvicalyceal dilatation, and nuchal thickening. These markers are estimated to occur in between 0.6% and 4.3% of pregnancies. Their clinical significance, for pregnancy outcomes or childhood morbidity, is largely unknown. The aim of this study is to estimate the prevalence of seven markers in the general obstetric population and establish a cohort of children for longer terms follow-up to assess the clinical significance of these markers. METHODS/DESIGN: All women receiving antenatal care within six of seven Welsh Health Boards who had an 18 to 20 week ultrasound scan in Welsh NHS Trusts between July 2008 and March 2011 were eligible for inclusion. Data were collected on seven markers (echogenic bowel, cerebral ventriculomegaly, renal pelvicalyceal dilatation, nuchal thickening, cardiac echogenic foci, choroid plexus cysts, and short femur) at the time of 18 - 20 week fetal anomaly scan. Ultrasound records were linked to routinely collected data on pregnancy outcomes (work completed during 2012 and 2013). Images were stored and reviewed by an expert panel.The prevalence of each marker (reported and validated) will be estimated. A projected sample size of 23,000 will allow the prevalence of each marker to be estimated with the following precision: a marker with 0.50% prevalence to within 0.10%; a marker with 1.00% prevalence to within 0.13%; and a marker with 4.50% prevalence to within 0.27%. The relative risk of major congenital abnormalities, stillbirths, pre-term birth and small for gestational age, given the presence of a validated marker, will be reported. DISCUSSION: This is a large, prospective study designed to estimate the prevalence of markers in a population-based cohort of pregnant women and to investigate associations with adverse pregnancy outcomes. The study will also establish a cohort of children that can be followed-up to explore associations between specific markers and longer-term health and social outcomes.

Perinatal outcomes and travel time from home to hospital: Welsh data from 1995 to 2009.

AIM: To study the association between travel time from home to hospital and birth outcomes. METHODS: For all registrable births to women resident in Wales (1995-2009), we calculated the travel time between the mother's residence and the postcode-based location for both the birth hospital and all hospitals with maternity services that were open. Using logistic regression, we obtained odds ratios for the association between travel time and each birth outcome, adjusted for confounders. RESULTS: In our analysis of 412 827 singleton births, for every 15-min increase in travel time to the birth hospital, there was an increased risk of early (n = 609; OR: 1.13; 95%CI: 1.07, 1.20) and late neonatal death (n = 251; OR: 1.15; 95%CI: 1.05, 1.26). Results for intrapartum stillbirth were inconclusive (n = 135; OR: 1.13; 95%CI: 0.98, 1.30). For the above-combined (n = 995) results, we get OR: 1.15, 95%CI: 1.09, 1.20. No association was found with travel time to the nearest hospital (OR: 1.01; 95%CI: 0.90, 1.13 per 15-min increase in travel time) for the composite outcome of intrapartum stillbirth and neonatal deaths. CONCLUSION: Longer travel time to the birth hospital was associated with increased risk of neonatal deaths, but there was no strong evidence of association with the geographical location of maternity services.

Higher systolic blood pressure with normal vascular function measurements in preterm-born children.

UNLABELLED: Preterm birth, low birth weight and poor foetal nutrition have been linked to cardiovascular disease, but the underlying mechanisms remain unclear. We explored prematurity and vascular function by studying a UK cohort of 14 049 children and conducting a systematic review. CONCLUSION: Systolic blood pressure was higher in subjects born preterm than term, but there were no differences in endothelial dysfunction or arterial stiffness. The systematic review revealed no clear association between prematurity and vascular function.

Effect of preterm birth on later FEV1: a systematic review and meta-analysis.

BACKGROUND: Increasing evidence suggests that preterm birth affects later lung function. We systematically reviewed the literature to determine whether percentage predicted forced expiratory volume in 1 s (%FEV1) is lower in later life in preterm-born subjects, with or without bronchopulmonary dysplasia (BPD), compared with term-born controls. METHODS: Studies reporting %FEV1, with or without a term-born control group, in later life for preterm-born subjects (<37 weeks gestation) were extracted from eight databases. Data were analysed using Review Manager and STATA. The quality of the studies was assessed. RESULTS: From 8839 titles, 1124 full articles were screened and 59 were included: 28 studied preterm-born children without BPD, 24 with BPD28 (supplemental oxygen dependency at 28 days), 15 with BPD36 (supplemental oxygen dependency 36 weeks postmenstrual age) and 34 born preterm. For the preterm-born group without BPD and for the BPD28 and BPD36 groups the mean differences (and 95% CIs) for %FEV1 compared with term-born controls were -7.2% (-8.7% to -5.6%), -16.2% (-19.9% to -12.4%) and -18.9% (-21.1% to -16.7%), respectively. Pooling all data on preterm-born subjects whether or not there was a control group gave a pooled %FEV1 estimate of 91.0% (88.8% to 93.1%) for the preterm-born cohort without BPD, 83.7% (80.2% to 87.2%) for BPD28 and 79.1% (76.9% to 81.3%) for BPD36. Interestingly, %FEV1 for BPD28 has improved over the years. CONCLUSIONS: %FEV1 is decreased in preterm-born survivors, even those who do not develop BPD. %FEV1 of survivors of BPD28 has improved over recent years. Long-term respiratory follow-up of preterm-born survivors is required as they may be at risk of developing chronic obstructive pulmonary disease.

Incidence of Campylobacter and Salmonella infections following first prescription for PPI: a cohort study using routine data.

OBJECTIVES: To examine the incidence of Campylobacter and Salmonella infection in patients prescribed proton pump inhibitors (PPIs) compared with controls. METHODS: Retrospective cohort study using anonymous general practitioner (GP) data. Anonymised individual-level records from the Secure Anonymised Information Linkage (SAIL) system between 1990 and 2010 in Wales were selected. Data were available from 1,913,925 individuals including 358,938 prescribed a PPI. The main outcome measures examined included incidence of Campylobacter or Salmonella infection following a prescription for PPI. RESULTS: The rate of Campylobacter and Salmonella infections was already at 3.1-6.9 times that of non-PPI patients even before PPI prescription. The PPI group had an increased hazard rate of infection (after prescription for PPI) of 1.46 for Campylobacter and 1.2 for Salmonella, compared with baseline. However, the non-PPI patients also had an increased hazard ratio with time. In fact, the ratio of events in the PPI group compared with the non-PPI group using the prior event rate ratio was 1.17 (95% CI 0.74-1.61) for Campylobacter and 1.00 (0.5-1.5) for Salmonella. CONCLUSIONS: People who go on to be prescribed PPIs have a greater underlying risk of gastrointestinal (GI) infection beforehand and they have a higher prevalence of risk factors before PPI prescription. The rate of diagnosis of infection is increasing with time regardless of PPI use, and there is no evidence that PPI is associated with an increase in diagnosed GI infection. It is likely that factors associated with the demographic profile of the patient are the main contributors to increased rate of GI infection for patients prescribed PPIs.

Common mental disorders, neighbourhood income inequality and income deprivation: small-area multilevel analysis.

BACKGROUND: Common mental disorders are more prevalent in areas of high neighbourhood socioeconomic deprivation but whether the prevalence varies with neighbourhood income inequality is not known. AIMS: To investigate the hypothesis that the interaction between small-area income deprivation and income inequality was associated with individual mental health. METHOD: Multilevel analysis of population data from the Welsh Health Survey, 2003/04-2010. A total of 88,623 respondents aged 18-74 years were nested within 50,587 households within 1887 lower super output areas (neighbourhoods) and 22 unitary authorities (regions), linked to the Gini coefficient (income inequality) and the per cent of households living in poverty (income deprivation). Mental health was measured using the Mental Health Inventory MHI-5 as a discrete variable and as a 'case' of common mental disorder. RESULTS: High neighbourhood income inequality was associated with better mental health in low-deprivation neighbourhoods after adjusting for individual and household risk factors (parameter estimate +0.70 (s.e. = 0.33), P = 0.036; odds ratio (OR) for common mental disorder case 0.92, 95% CI 0.88-0.97). Income inequality at regional level was significantly associated with poorer mental health (parameter estimate -1.35 (s.e. = 0.54), P = 0.012; OR = 1.13, 95% CI 1.04-1.22). CONCLUSIONS: The associations between common mental disorders, income inequality and income deprivation are complex. Income inequality at neighbourhood level is less important than income deprivation as a risk factor for common mental disorders. The adverse effect of income inequality starts to operate at the larger regional level.

Effect of late preterm birth on longitudinal lung spirometry in school age children and adolescents.

BACKGROUND: Rates of preterm birth have increased in most industrialised countries but data on later lung function of late preterm births are limited. A study was undertaken to compare lung function at 8-9 and 14-17 years in children born late preterm (33-34 and 35-36 weeks gestation) with children of similar age born at term (≥37 weeks gestation). Children born at 25-32 weeks gestation were also compared with children born at term. METHODS: All births from the Avon Longitudinal Study of Parents and Children (n=14 049) who had lung spirometry at 8-9 years of age (n=6705) and/or 14-17 years of age (n=4508) were divided into four gestation groups. RESULTS: At 8-9 years of age, all spirometry measures were lower in the 33-34-week gestation group than in controls born at term but were similar to the spirometry decrements observed in the 25-32-week gestation group. The 35-36-week gestation group and term group had similar values. In the late preterm group, at 14-17 years of age forced expiratory volume in 1 s (FEV(1)) and forced vital capacity (FVC) were not significantly different from the term group but FEV(1)/FVC and forced expiratory flow at 25-75% FVC (FEF(25-75%)) remained significantly lower than term controls. Children requiring mechanical ventilation in infancy at 25-32 and 33-34 weeks gestation had in general lower airway function (FEV(1) and FEF(25-75)) at both ages than those not ventilated in infancy. CONCLUSIONS: Children born at 33-34 weeks gestation have significantly lower lung function values at 8-9 years of age, similar to decrements observed in the 25-32-week group, although some improvements were noted by 14-17 years of age.

Effects of atenolol, perindopril and verapamil on haemodynamic and vascular function in Marfan syndrome - a randomised, double-blind, crossover trial.

BACKGROUND: Aortic dilatation is the main therapeutic target in patients with Marfan syndrome. Standard treatment with a ß-blocker may not lower central pulse pressure - the major objective - because it does not do so in hypertension, unlike angiotensin-converting enzyme inhibitors and calcium-channel blockers. We therefore performed a prospective, randomised, double-blind, crossover trial to compare the effects of these three agents on large artery function and central aortic pressure in patients with Marfan syndrome. METHODS AND RESULTS: Eighteen patients had applanation tonometry, pulse wave analysis and echocardiography, before and after atenolol 75 mg, perindopril 4 mg and verapamil 240 mg, each given for 4 weeks, in a random order, with 2 weeks between medications. Fourteen patients completed the study. Within-drug comparisons demonstrated that perindopril (-10·3 mmHg, P = 0·002), verapamil (-9·2 mmHg, P = 0·003) and atenolol (-7·1 mmHg, P = 0·01) all reduced central systolic pressure and brachial pressure; central changes were least, and peripheral changes greatest with atenolol but between-drug comparisons (analysis of covariance) were not significant. There was a trend for augmentation to be reduced by perindopril (-6·3%, P = 0·05), verapamil (-5·5%, P = 0·07) and atenolol (-3·2%, P = 0·09). Only atenolol reduced heart rate (by 16%) and delayed expansion in the arch and abdominal aorta (by 8% and 11%) (P < 0·001, P < 0·01 and P < 0·05, respectively, for between-drug comparisons). CONCLUSIONS: Perindopril, verapamil and atenolol all reduced peripheral and central systolic pressure. As atenolol slowed heart rate and delayed aortic wave travel, ß-blockade may have a continuing role in the treatment of patients with Marfan syndrome.

Change in alcohol outlet density and alcohol-related harm to population health (CHALICE).

BACKGROUND: Excess alcohol consumption has serious adverse effects on health and violence-related harm. In the UK around 37% of men and 29% of women drink to excess and 20% and 13% report binge drinking. The potential impact on population health from a reduction in consumption is considerable. One proposed method to reduce consumption is to reduce availability through controls on alcohol outlet density. In this study we investigate the impact of a change in the density of alcohol outlets on alcohol consumption and alcohol-related harms to health in the community. METHODS/DESIGN: A natural experiment of the effect of change in outlet density between 2005-09, in Wales, UK; population 2.4 million aged 16 years and over. Data on outlets are held by the 22 local authorities in Wales under The Licensing Act 2003. The study outcomes are change in (1) alcohol consumption using data from annual Welsh Health Surveys, (2) alcohol-related hospital admissions using the Patient Episode Database for Wales, (3) Accident & Emergency department attendances between midnight-6am, and (4) alcohol-related violent crime against the person, using Police data. The data will be anonymously record-linked within the Secure Anonymised Information Linkage Databank at individual and 2001 Census Lower Super Output Area levels. New methods of network analysis will be used to estimate outlet density. Longitudinal statistical analysis will use (1) multilevel ordinal models of consumption and logistic models of admissions and Accident & Emergency attendance as a function of change in individual outlet exposure, adjusting for confounding variables, and (2) spatial models of the change in counts/rates of each outcome measure and outlet density. We will assess the impact on health inequalities and will correct for population migration. DISCUSSION: This inter-disciplinary study requires expertise in epidemiology and public health, health informatics, medical statistics, geographical information science, and research into alcohol-related violence. Information governance requirements for the use of record-linked data have been approved together with formal data access agreements for the use of the Welsh Health Survey and Police data. The dissemination strategy will include policy makers in national and local government. Public engagement will be through the Clinical Research Collaboration-Cymru "Involving People" network, which will provide input into the implementation of the research.

Is sticky blood bad for the brain?: Hemostatic and inflammatory systems and dementia in the Caerphilly Prospective Study.

OBJECTIVE: Hemostasis and inflammation have been implicated in dementia. This study investigates the role of specific hemostatic and inflammatory pathways with incident vascular and nonvascular dementia. METHODS AND RESULTS: This was a prospective study of a population sample of men aged 65 to 84 years, with baseline assessment of hemostatic and inflammatory factors and cognition measured 17 years later. The sample included 865 men (59 had dementia and 112 had cognitive impairment, not dementia), free of vascular disease at baseline and for whom hemostatic and inflammatory marker data were available and cognitive status was known. A total of 15 hemostatic and 6 inflammatory markers were assessed. Factor analysis was used to identify hemostatic subsystems. The National Institute of Neurological Disorders and Stroke-Association Internationale pour la Recherche et l'Enseignement en Neurologie criteria were used to identify vascular dementia. By using standardized (z) scores for hemostatic and inflammatory markers, and after adjustment for age and risk factors, vascular dementia was associated with fibrinogen (hazard ratio [HR], 1.68; 95% confidence interval [CI], 1.02-2.76), factor VIII (HR, 1.79; 95% CI, 1.09-3.00), and plasminogen activator inhibitor 1 (HR, 3.13; 95% CI, 1.73-5.70). For vascular dementia, the HR risk from high levels of all three hemostatic variables (fibrinogen, factor VIII, and plasminogen activator inhibitor 1) was 2.97 (P<0.001). Inflammatory factors were not associated with vascular dementia. CONCLUSIONS: The associations of these hemostatic markers with vascular dementia may implicate clot formation as the primary mechanism and are consistent with a microinfarct model of vascular dementia.

Which is the preferred image modality for paediatricians when assessing photographs of bruises in children?

Images of bruises serve as a clinical record and may facilitate forensic analysis in the assessment of suspected physical child abuse. Currently, only conventional imaging techniques are employed; however, alternative imaging modalities using visible and non-visible light may provide additional information. We sought to determine the image modality preferences of paediatricians and the between-observer agreement therein. Nine paediatricians who work in child protection independently compared five image modalities (conventional colour, conventional grey-scale, cross-Polarised, ultraviolet, and infrared) of four bruises, with a compliance rate of 95%. All images were taken using a standardised set of protocols with Nikon D90 cameras and 105-mm macro-lenses. The paediatricians almost unanimously chose cross-Polarised as their preferred modality for all four bruises when assessing boundary, shape, colour, size, and absence of light reflectance. Conventional colour and grey-scale imaging were typically ranked second and third. Ultraviolet and infrared were consistently ranked in the least two favourable positions. Between-observer agreement on ranking order was high, with coefficients of concordance ranging from 0.76 to 0.96. Combinations of imaging modalities chosen to give the most complete picture of the bruise predominantly consisted of cross-Polarised and conventional (colour and grey-scale). This pilot study demonstrated that clinicians collectively favoured cross-Polarised in addition to conventional imaging. Further studies are required to determine the value of ultraviolet and infrared imaging in the assessment of childhood bruises.

Spirometric lung function in school-age children: effect of intrauterine growth retardation and catch-up growth.

RATIONALE: Few studies have investigated childhood respiratory outcomes of intrauterine growth retardation (IUGR), and it is unclear if catch-up growth in these children influences lung function. OBJECTIVES: We determined if lung function differed in 8- to 9-year-old children born at term with or without growth retardation, and, in the growth-retarded group, if lung function differed between those who did and those who did not show weight catch up. METHODS: Caucasian singleton births of 37 weeks or longer gestation from the Avon Longitudinal Study of Parents and Children (n = 14,062) who had lung spirometry at 8-9 years of age were included (n = 5,770). MEASUREMENTS AND MAIN RESULTS: Infants with gestation-appropriate birthweight (n = 3,462) had significantly better lung function at 8-9 years of age than those with IUGR (i.e., birthweight <10th centile [n = 576] [SD differences and confidence intervals adjusted for sex, gestation, maternal smoking during pregnancy, and social class: FEV(1), -0.198 (-0.294 to -0.102), FVC, -0.131 (-0.227 to -0.036), forced midexpiratory flow between 25 and 75% of vital capacity -0.149 (-0.246 to -0.053)]). Both groups had similar respiratory symptoms. All spirometry measurements were higher in children with IUGR who had weight catch-up growth (n = 430) than in those without (n = 146), although the differences were not statistically significant. Both groups remained significantly lower than control subjects. Growth-retarded asymmetric and symmetric children had similar lung function. CONCLUSIONS: IUGR is associated with poorer lung function at 8-9 years of age compared with control children. Although the differences were not statistically significant, spirometry was higher in children who showed weight catch-up growth, but remained significantly lower than the control children.

Can TEN4 distinguish bruises from abuse, inherited bleeding disorders or accidents?

OBJECTIVE: Does TEN4 categorisation of bruises to the torso, ear or neck or any bruise in <4-month-old children differentiate between abuse, accidents or inherited bleeding disorders (IBDs)? DESIGN: Prospective comparative longitudinal study. SETTING: Community. PATIENTS: Children <6 years old. INTERVENTIONS: The number and location of bruises compared for 2568 data collections from 328 children in the community, 1301 from 106 children with IBD and 342 abuse cases. MAIN OUTCOME MEASURES: Likelihood ratios (LRs) for the number of bruises within the TEN and non-TEN locations for pre-mobile and mobile children: abuse vs accidental injury, IBD vs accident, abuse vs IBD. RESULTS: Any bruise in a pre-mobile child was more likely to be from abuse/IBD than accident. The more bruises a pre-mobile child had, the higher the LR for abuse/IBD vs accident. A single bruise in a TEN location in mobile children was not supportive of abuse/IBD. For mobile children with more than one bruise, including at least one in TEN locations, the LR favouring abuse/IBD increased. Applying TEN4 to collections from abused and accidental group <48 months of age with at least one bruise gave estimated sensitivity of 69% and specificity for abuse of 74%. CONCLUSIONS: These data support further child protection investigations of a positive TEN4 screen in any pre-mobile children with a bruise and in mobile children with more than one bruise. TEN4 did not discriminate between IBD and abuse, thus IBD needs to be excluded in these children. Estimated sensitivity and specificity of TEN4 was appreciably lower than previously reported.

Abolition of prescription copayments in Wales: an observational study on dispensing rates.

OBJECTIVE: To assess effects of abolition of prescription copayments in Wales on rates of dispensing. METHODS: General practice-level monthly dispensing data were compared before/after abolition between Wales and North East (NE) England where the charge was retained. Data for 14 medicines that had most items dispensed subject to charge before abolition were similarly compared with NE England. For those with over-the-counter substitutes, wholesale sales to pharmacies were examined. A survey examined local initiatives, which might differentially affect dispensing between the two areas. RESULTS: Total dispensing rates (items/1000 patients) increased significantly in both areas but significantly less so in Wales (difference = -19.7, P = 0.024, 95% confidence interval [CI] = -36.7 to -2.6). For the 14 selected medicines, combined dispensing rates increased significantly in both areas but significantly more in Wales (difference = 27.51, P < 0.0001, 95% CI = 23.66-31.35). There was much variation for individual drugs, but categories tended to show this same trend except for antibiotics, where rates increased in Wales but decreased in NE England. The survey revealed few local initiatives that could explain these differences. Sales of over-the-counter substitutes did not explain the changes in dispensing. CONCLUSIONS: The Welsh policy was associated with a modest increase in dispensing rates relative to NE England for the 14 medicines with the highest number of items dispensed subject to charge before abolition. Although factors besides the copayment may have influenced these observations, the smaller relative increase in total dispensing rates in Wales suggests that the overall impact of abolition was minimal.