Carbohydrate deficient transferrin in the assessment of alcohol misuse: absolute or relative measurements? A comparison of two methods with regard to total transferrin concentration

Carbohydrate deficient transferrin (CDT) is now accepted as a potentially useful marker for the detection of alcohol misuse. It is not clear whether absolute values or values expressed relative to the total transferrin concentration provide the same diagnostic efficiency. CDT was measured in 35 patients with alcohol related liver disease, 35 subjects abusing alcohol without evidence of liver disease and 35 patients with chronic viral hepatitis using two commercial methods (CDTect and %CDT). To compare the methods, results were normalised by dividing the actual result by the upper limit of the reference range. Subtracting normalised %CDT results from the normalised CDTect results demonstrated a linear relationship between CDTect and total transferrin. This linear relationship could be abolished by calculating the CDTect/total transferrin ratio. The sensitivity of the methods was similar with CDTect (43 and 57%) being slightly superior to %CDT (40 and 46%). Specificity was similar (78%) for both methods. Calculation of the CDTect/total transferrin ratio improved the sensitivity and specificity slightly. The linear relationship between CDTect and total transferrin may produce misleading results in populations with a high prevalence of abnormal total transferrin concentrations and could cause difficulties in method comparisons unless taken into account.

Childhood leg length and adult mortality: follow up of the Carnegie (Boyd Orr) Survey of Diet and Health in Pre-war Britain

OBJECTIVE

To investigate the relation between childhood height, its components--leg length and trunk length--and mortality in adulthood.

DESIGN

Cohort study based on the Carnegie (Boyd Orr) Survey of diet and health in pre-war Britain, 1937-9.

SETTING

The 14 centres in England and Scotland that participated in the Carnegie Survey and where children were examined. Scottish centres: Aberdeen, Dundee, West Wemyss, Coaltown of Wemyss, Hopeman, Methlick, Tarves, Barthol Chapel. English Centres: Liverpool, York-shire, Barrow in Furness, Wisbech, Fulham, and Bethnal Green.

SUBJECTS

2990 boys and girls aged between 2 years and 14 years 9 months when they were examined in 1937-9. These children were drawn from 1134 families who underwent a one week assessment of family diet and home circumstances. Of these, 2547 (85%) have been traced and flagged using the NHS Central Register.

MAIN OUTCOME MEASURES

Age adjusted overall, coronary heart disease, and cancer mortality in men and women in relation to age and sex specific z scores for height, leg length, and trunk length. All analyses were adjusted for the possible confounding effects of childhood and adult socioeconomic circumstances and childhood diet.

RESULTS

Leg length was the component of childhood height most strongly associated with socioeconomic and dietary exposures. There was no significant relation between childhood height and overall mortality. Height-mortality relations were observed in relation to both coronary heart disease (CHD) and cancer. Leg length was the component of height most strongly related to cause specific mortality. In men and women CHD mortality increased with decreasing childhood leg length. Men in the lowest leg length quintile had a relative risk (RR) of 2.5 (95% CI 1.0 to 6.2) compared to those with the longest legs (linear trend p = 0.14). Similarly, women in the lowest leg length quintile had a RR of 3.9 (95% CI 0.8 to 19.0; linear trend p < 0.01). Adjustment for childhood and adult socioeconomic circumstances had little effect on these trends. In men, but not women, those who as children had long legs experienced increased cancer mortality. The significant relations between anthropometry and both CHD and cancer mortality were restricted to those aged < 8 years when measured.

CONCLUSIONS

These findings suggest that adverse diet and living conditions in childhood, for which leg length seems to be a particularly sensitive indicator, are associated with increased risk of CHD in adulthood and possibly reduced cancer risk. It is likely that these influences operate after birth, during the first few years of life.

A randomized controlled trial and economic evaluation of counselling in primary care

BACKGROUND

Counselling in primary care settings remains largely unevaluated. Such evaluation has been strongly recommended.

AIM

To determine the relative effectiveness and cost-effectiveness of generic counselling and usual general practitioner (GP) care for patients with minor mental health problems.

METHOD

A randomized controlled trial and health economic evaluation were carried out in nine general practices. Access to generic counselling (brief counselling, generally involving up to six 50-minute sessions) was compared with usual GP care. A total of 162 patients aged 16 years and over with diverse mental health problems (excluding phobic conditions and psychoses) were randomized. The Hospital Anxiety and Depression (HAD) scale, COOP/WONCA (World Organization of Family Doctors) functional health assessment charts, and the delighted-terrible faces scale were used to assess outcome four months after randomization.

RESULTS

The two groups were similar at baseline. There were significant improvements in both groups between randomization and follow-up for most outcome measures, but no significant differences between the study arms. The 95% confidence limits were narrow and excluded clinically significant effects. Under various assumptions concerning the cost of secondary care referrals and of counselling time, no clear cost advantage was associated with either intervention.

CONCLUSIONS

This pragmatic trial demonstrates no difference in functional or mental health outcome at four months between subjects offered access to counselling and those given usual care by their GP. There is no clear difference in the cost-effectiveness of the two interventions. Purchasers should take account of these findings in allocating resources within primary care.

Childhood energy intake and adult mortality from cancer: the Boyd Orr Cohort Study

OBJECTIVE

To examine the relation between energy intake in childhood and adult mortality from cancer.

STUDY DESIGN

Cohort study.

SETTING

16 rural and urban centres in England and Scotland.

SUBJECTS

3834 people who took part in Lord Boyd Orr's Carnegie survey of family diet and health in prewar Britain between 1937 and 1939 who were followed up with the NHS, central register. Standardised methods were used to measure household dietary intake during a one week period.

MAIN OUTCOME MEASURES

Cancer mortality.

RESULTS

Significant associations between childhood energy intake and cancer mortality were seen when the confounding effects of social variables were taken into account in proportional hazards models (relative hazard for all cancer mortality 1.15 (95% confidence interval 1.06 to 1.24), P = 0.001, for every MJ increase in adult equivalent daily intake in fully adjusted models). This effect was essentially limited to cancers not related to smoking (relative hazard 1.20; 1.07 to 1.34; P = 0.001), with similar effects seen in men and women.

CONCLUSION

This positive association between childhood energy intake and later cancer is consistent with animal evidence linking energy restriction with reduced incidence of cancer and the association between height and human cancer, implying that higher levels of energy intake in childhood increase the risk of later development of cancer. This evidence for long term effects of early diet confirm the importance of optimal nutrition in childhood and suggest that the unfavourable trends seen in the incidence of some cancers may have their origins in early life.

Running a randomised controlled trial in a service setting: a progress report

This paper will give a progress report on a randomised controlled trial which is currently underway in the Bristol area. Some of the key influencing literature will be summarised, followed by an overview of the study design. The paper will also highlight some of the methodological and practical advantages and disadvantages afforded by the service setting of the study.

Use of the EuroQoL among elderly acute care patients

The assessment of the validity and reliability of generic quality of life (QoL) instruments among elderly patient groups has tended to lag behind such assessments in general populations, yet it is an important methodological issue. This paper presents the findings from a study of the use of the EuroQoL among an elderly acute care patient group, focusing particularly on the ability to self-complete, construct validity and sensitivity to change. Two hundred and fourteen UK patients aged 65 years and over, participating in a randomized controlled trial comparing hospital at home and routine hospital care were asked to complete the EuroQoL and a number of other instruments at randomization and at 4 week and 3 month follow-ups. The inability to self-complete the EuroQol was found to be strongly related to both increased age and reduced cognitive function (p < 0.0001). From logistic regression, the expected probability of an acute care patient requiring interview administration at age 65 years is 11%, at age 75 years is 37% and at age 85 years is 73%. The relationships with age and limiting long-standing illness/disability were weaker than expected, but the results obtained from the EuroQoL were highly correlated with those from both the Barthel Index and the COOP-WONCA charts where this was anticipated. Preliminary evidence of sensitivity to change was found from descriptive statistics of the changes in scores for four specific subgroups of patients, but the small numbers and high variability in each sub-sample means that this should be interpreted with caution. The most important issue arising from the research concerns the impact of age on the ability to self-complete the EuroQoL questionnaire. It is argued that this research points to the need for rigorous studies (such as randomized controlled trials) to assess the impact of the format of administration of the EuroQoL on the scores obtained.

Effect of varying the time frame for COOP-WONCA functional health status charts: a nested randomised controlled trial in Bristol, UK

STUDY OBJECTIVES

To investigate whether changing the stated time frame for COOP-WONCA charts has any effect on responses. Specifically, to assess the effect of attempting to avoid the situation where the time frame crosses the onset of an acute episode.

DESIGN

A randomised controlled trial of two time frames, nested within a main trial comparing early discharge with a hospital at home scheme against routine discharge policy. The time frames compared were the standard two weeks (four for the pain chart) and a shorter period of 48 hours for all seven charts.

SETTING

Acute hospital wards in Frenchay Healthcare Trust and the Avon Orthopaedic Centre in Bristol.

PARTICIPANTS

Patients entered into the main trial, who were medically stable, in need of continued rehabilitative care but suitable for discharge to hospital at home.

MAIN RESULTS

A total of 200 patients were randomised, 106 to the shorter time frame, 94 to the standard charts. No clear differences were observed between the two groups for the proportion failing to self complete the charts. For the (seven) chart scores, only pain was statistically significantly different between the time frames (Mann-Whitney p = 0.0085; proportion reporting moderate or severe pain 19% higher in the standard group, 95% confidence intervals 5% to 33%). For both this chart and that for change in health, however, there was evidence of greater differences between the versions of the chart among those admitted more recently (p values for relevant interactions 0.004 and < or = 0.001 respectively).

CONCLUSIONS

While the present findings give some support for the wide applicability of the standard version, there is sufficient evidence here to indicate that the time frame may influence the results, particularly for patients with a recent acute episode. In the absence of further data, then, it would seem prudent to consider a shorter time frame for such patients, especially if the aim is to assess current health status or to measure changes over a comparatively short period of time, or both.

Oral and dental health in alcohol misusing patients

Dental and oral health and their relationship to nutritional status among a group of alcohol misusers (n = 107) from south London is reported. The Alcohol Use Disorders Identification Test (AUDIT) questionnaire was validated as an accurate and reliable screening questionnaire for use in alcohol misuse detection by a dentist. Half of the study population consumed >200 units of alcohol/week, and 80% were heavy smokers. A high incidence of tooth wear and trauma to the dentition was recorded. Eight subjects had oral mucosal lesions, including two previously treated carcinomas. The dental health in alcoholics overall was not compromised, but nutritional impairment (body mass index and reduced midarm muscle circumference) was associated with periodontal lesions. Oral mucosal health of alcoholics is of concern, particularly in heavy smokers. The interrelationships between dental-oral health and alcohol-tobacco usage have implications for preventative counseling in this patient group.

The Bristol Shared Care Glaucoma Study--validity of measurements and patient satisfaction

BACKGROUND

The aims of the study were to determine (1) whether community optometrists are able to make valid measurements of visual parameters in patients with established or suspect primary open angle glaucoma and (2) patient satisfaction with follow-up by community optometrists.

METHODS

A randomized study was carried out in the former county of Avon in South West England with patients allocated to follow-up by the hospital eye service or by community optometrists. The subjects were 403 patients with established or suspected primary open angle glaucoma attending Bristol Eye Hospital and meeting defined inclusion and exclusion criteria. The main outcome measures were 91) measurements of key visual parameters (intraocular pressure, visual fields and cup/disc ratio) made by hospital eye service and community optometrists, compared with a research clinic reference standard at baseline, and (2) patient satisfaction at baseline and at six months.

RESULTS

Community optometrists were able to make measurements of comparable accuracy to those made in the hospital eye service. Patients were significantly more satisfied with a number of aspects of care provided by community optometrists, particularly those relating to waiting times, compared with those from the hospital eye service.

CONCLUSIONS

Community optometrists are able to make measurements of key visual parameters in patients with established or suspect primary open angle glaucoma which are of comparable quality to the hospital eye service. Follow-up by community optometrists is acceptable to patients. The costs of each option are reported elsewhere.

Using the ICSOoL to measure the impact of lower urinary tract symptoms on quality of life: evidence from the ICS-'BPH' Study. International Continence Society--Benign Prostatic Hyperplasia

OBJECTIVE

To present and describe the validity and reliability of the International Continence Society-Benign Prostatic Hyperplasia study quality-of-life (ICSQoL) instrument, a new set of questions to assess the impact of lower urinary tract symptoms (LUTS) on quality of life (QoL) in middle-aged and elderly men.

PATIENTS AND METHODS

The study comprised 1271 consecutive men over the age of 45 years, attending urology departments in 12 countries, with LUTS and possible benign prostatic obstruction who were recruited to the ICS-'BPH' study (the clinic group); 423 ambulant men were recruited from a general practice in the UK to provide a community group. Each individual completed the ICS-'BPH' study questionnaire which includes six items addressing general and specific aspects of QoL (the ICSQoL). Content and construct validity were assessed by interviews with patients and by testing hypotheses within the study groups, e.g. the relationships with age, individual LUTS (as measured on the ICSmale questionnaire) and generic health status, as measured by the Short Form (SF-36) and EuroQol instruments. Reliability was assessed by measures of internal consistency and a test-retest analysis.

RESULTS

The ICSQoL items were easily understood by patients, were completed with low levels of missing data, and address some (but not all) concerns about the impact of LUTS on QoL. The ICSQoL items have good construct validity, showing expected differences between community and clinic samples, and expected relationships with each other and individual LUTS. Items had good test-retest reliability, but their internal consistency was poor, confirming that ICSQoL questions should not be combined into a score. General ICSQoL items were closely related with most domains of the SF-36 and the EuroQol.

CONCLUSION

ICSQoL items may be used individually or as a group in research studies or in clinical practice.

Total contractile protein contents and gene expression in skeletal muscle in response to chronic ethanol consumption in the rat

An investigation was carried out to determine changes in the contents of skeletal muscle myofibrillary proteins (i.e., the contractile fraction composed principally of actin and myosin) and gene expression in skeletal muscle in response to ethanol feeding. Male Wistar rats were fed a nutritionally complete liquid diet, which contained 35% of total calories as ethanol. Controls were pair-fed isocaloric amounts of the same diet, in which ethanol was replaced by isocaloric glucose. Total mixed and contractile protein contents of the gastrocnemius in ethanol-fed rats were rapidly reduced by ethanol feeding: a response was discernible as early as 1 week after the commencement of the ethanol feeding regimen (approx. -10%, p < 0.025 and p = 0.05 for mixed and myofibrillary proteins, respectively). At 2, 4, and 6 weeks, mixed and myofibrillary protein contents were further reduced in alcohol-fed rats, by between 12% and 22%, compared to pair-fed controls. Similar changes occurred in the soluble (i.e., sarcoplasmic) protein fractions of skeletal muscle. At 2 weeks the composition of total messenger RNA and individual messenger RNA species was measured. Total messenger RNA content per muscle was reduced by 35% (p < 0.05). Messenger RNA levels for alpha-actin, beta-myosin heavy chain, and carbonic anhydrase III were not significantly altered. In conclusion, skeletal muscle protein contents are rapidly reduced by ethanol feeding, compared to pair-fed controls, though mRNA species encoding specific isoforms of myosin and actin are not affected. It is possible that chronic ethanol feeding may significantly alter the stability of mRNAs encoding other contractile proteins, or alternatively, defects in translation may predominate.

Time-course of iron overload and biochemical, histopathological and ultrastructural evidence of pancreatic damage in hypotransferrinaemic mice

1. The time course of iron overload of the pancreas in hypotransferrinaemic mice maintained on a standard rodent diet was compared with biochemical and histological markers of tissue damage. 2. Pancreatic iron levels increased linearly from weaning till 9 months of age [73.3 nmol/mg of tissue (SEM 9.9; n = 5) compared with 0.9 nmol/mg of tissue (SEM 0.1; n = 4) in age-matched controls] then decreased linearly till at least 18 months of age. 3. Investigation of tissue distribution of newly absorbed radioiron suggested that significant redistribution of iron from liver to pancreas (rather than direct dietary iron sources) must be invoked to explain the rate of pancreatic iron loading in hypotransferrinaemic mice. 4. Pancreatic epithelial cells first showed altered morphology at 9 months of age. At 12 months of age, the pancreatic epithelium had developed a micronodular appearance, with large numbers of acini replaced by atrophic, degenerated acinar cells. Increased collagen fibre deposition was evident by trichrome staining and by electron microscopy. Biochemical markers of pancreatitis (serum lipase, tissue pancreatitis-associated protein mRNA) were elevated before 9 months of age, whereas the levels of pancreatic amylase mRNA declined from 9 months of age. 5. The data suggest that iron loading of hypotransferrinaemic mouse pancreas proceeds up to a threshold level at 9 months of age followed by a progressive atrophy of secretory epithelium. The hypotransferrinaemic mouse pancreas is a useful model system for investigation of parenchymal cell damage by iron.

Metabolic consequences of alcohol dependency

Alcohol dependency leads to a variety of biochemical adaptations and morphological changes which may be considered as either adaptive or destructive. This ranges from the utilization of ethanol as a metabolic fuel, to overt tissue and cellular damage, and may lead to increases in morbidity and mortality. Virtually every organ system is affected by either acute and chronic ethanol exposure and numerous metabolic pathways are altered. As a consequence of these wide ranging effects, it is extremely difficult to cover every aspect of alcohol toxicity in a single review. Instead, attention is focussed on selected areas, such as nutrition and protein metabolism in the liver and bone (and to a lesser extent, skeletal muscle and the gastrointestinal tract). The aim is to illustrate the numerous ways in which alcohol affects the body.

Clinical guidelines and the management of hypertension: a between-practice and guideline comparison

It has previously been demonstrated that individual general practitioners (GPs) diagnose and treat at different levels of blood pressure and according to different risk factor profiles. This study sought to examine the variation in the achievement of control of hypertension in a sample of 20 treated hypertensive patients in 18 UK general practices. There was a marked between-practice variation in the percentage of patients with controlled hypertension. Practices appear to apply different hypertension guidelines to patients consistently, with significant correlations across practices in seven out of ten possible guideline combinations. There remains marked variation in the management of hypertension between different general practices in the UK. Factors other than recommendations in guidelines appear to be responsible for this variation.

Studies on the time-course of ethanol's acute effects on skeletal muscle protein synthesis: comparison with acute changes in proteolytic activity

A study of the effects of ethanol on skeletal muscle protein synthesis and protease activities was carried out in young male Wistar rats (150 g) for up to 24 hr after a single intraperitoneal dose of 75 mmol of ethanol/kg of body weight. At 20 min, the mean blood ethanol levels were 448 mg/dl. This level dropped steadily to zero through the following 24 hr. Compared with pair-fed controls, significant reductions in total protein, RNA, and DNA contents were seen only after 24 hr in all skeletal muscles studied: changes were more marked in the muscles containing large proportions of type II fibers. In plantaris muscle, the fractional rate of protein synthesis (ks, %/day) did not fall 20 min after dosage but was reduced after 1 hr by 23% (p < 0.001), and by 63% after 24 hr, compared with control saline-injected rats (p < 0.001). This effect was independent of dietary intake because, compared with the pair-fed group, the 24-hr ethanol-treated rats still showed a 52% decrease in fractional rates of protein synthesis (p < 0.001). Smaller reductions in ks were seen in soleus muscles in response to ethanol at 24 hr (-39%, p < 0.001). The activities of a variety of lysosomal and nonlysosomal proteases in plantaris muscle of 24-hr treated rats were not significantly affected by ethanol. Only alanyl- and tripeptidyl-aminopeptidase activities were reduced significantly (26%, p < 0.05 and 39%, p < 0.01, respectively). These results suggest that the muscle compositional changes seen over acute periods of ethanol toxicity are predominantly associated with impaired synthesis of protein and that the contribution of cellular proteolytic systems may be minimal. The effects of ethanol on skeletal muscle protein metabolism are greater in muscles containing a predominance of type II fibers than in those containing mainly type I fibers. Ethanol's effects on muscle may be influenced by hormonal changes after 24 hr, because protein synthesis is still compromised and free plasma T3 and corticosterone are altered at this time-point.

Factors associated with term low birthweight in Cardiff, Wales

This project was undertaken to examine the associations of a number of risk factors with impaired fetal growth, exemplified by delivery of a low-birthweight infant at term (TLBW). Utilising a large database of largely homogeneous (white) births in Wales, the Cardiff Births Survey, multivariable analysis by logistic regression examined the relative importance of these risk variables. Significant independent associations with TLBW were found (in decreasing order of magnitude) for low maternal weight, pre-eclampsia, smoking, short maternal height, late pregnancy bleeding, early pregnancy bleeding, history of a previous stillbirth, primiparity and older maternal age. In this population, risk of TBLW was associated with a number of demographic, medical and social factors. Of these, only smoking is likely to be modified by intervention.

Profiling outpatient workload: practice variations between consultant firms and hospitals in south west England

OBJECTIVES

To describe the variation in outpatient new to old ratios between consultants and between providers for seven high volume specialties (four surgical, three medical).

DESIGN

This was a descriptive study at consultant and provider unit level based upon patient administration system data from the South and West Regional Health Authority for the financial year 1992-93. Additional components of variance analysis was used to distinguish individual consultant effects from host institution effects.

SETTING

The former South Western Regional Health Authority area from Gloucestershire to Cornwall.

SUBJECTS

Altogether 345 consultant firms in seven specialties grouped into 13 provider unit groups.

MAIN MEASURES

New to old ratio, omitting elective inpatients followed up as outpatients.

RESULTS

Variation between consultants is greater in surgical than in medical specialties, while absolute levels of new to old ratios tend to be higher in surgical specialties than in medical. Variation between provider unit groups is also greater in surgical specialties. Analysis of variance shows that more total variance is attributable to provider unit group in gynaecology than in other specialties.

CONCLUSIONS

Within individual specialties there is evidence of substantial variation that is not attributable to underlying differences in morbidity patterns. There is evidence of marked variation in terms of both individual consultants and institutions, a finding that provides the springboard for further analytical work. Published routine outpatient activity statistics should distinguish between new referrals, inpatient follow up, and clinic rebookings.

A randomized controlled trial of antibiotics on symptom resolution in patients presenting to their general practitioner with a sore throat

BACKGROUND

Sore throat is a common symptom presented to general practitioners (GPs), and there remains controversy about the appropriate use of antibiotics.

AIM

To compare, in a randomized controlled trial, the effectiveness of penicillin, cefixime and placebo on symptom resolution in patients presenting with a sore throat in general practice.

METHOD

Twenty-two GPs in Avon recruited 154 patients, aged 16-60 years, presenting to their GP with a sore throat, and for whom the GP would normally prescribe an antibiotic. Patients were randomized to one of three groups: penicillin V 250 mg four times a day; cefixime 200 mg daily; and placebo. Each was prescribed for five days. The main outcome measures were a diary of symptom resolution over seven days and eradication of group A beta-haemolytic streptococcus (GABHS).

RESULTS

Of the 103 (67%) patients who completed symptom diaries, 40 were allocated to receive penicillin, 29 cefixime and 34 placebo. In the analysis including all patients, symptom resolution was greater by day 3 in the cefixime group than in the placebo group. Penicillin did not improve symptom resolution by day 3 compared with placebo, and cefixime was not statistically significantly different from penicillin. There were significant differences in the proportion of patients using analgesia at day 3, with the proportion being lowest in the cefixime group. The results for the subgroup of patients without GABHS were similar to those for all patients; in particular, the only statistically significant difference was between cefixime and placebo. Although numbers were too small for statistical significance, among patients with GABHS the effects of penicillin and cefixime were similarly raised in relation to placebo.

CONCLUSION

Compared with placebo, cefixime can improve the rate of resolution of symptoms in patients with a sore throat who are selected for antibiotic treatment by their GP. The unexpected finding that cefixime was of benefit compared with placebo for patients without GABHS suggests that bacteria other than GABHS may be important in the pathogenesis of sore throat.

The International Continence Society "Benign Prostatic Hyperplasia" Study: international differences in lower urinary tract symptoms and related bother

PURPOSE

We investigated the international differences in the reporting of lower urinary tract symptoms and related bother in patients with symptoms suggestive of bladder outlet obstruction.

MATERIALS AND METHODS

Multiple logistic regression analysis was used to evaluate international differences in the reporting of lower urinary tract symptoms and related bother in 1,271 patients from 12 countries who participated in the International Continence Society "benign prostatic hyperplasia" study.

RESULTS

Country of origin was significantly associated with the prevalence of a large number of lower urinary tract symptoms (10 of 20), even after adjusting for potentially confounding variables, including physical and socio-demographic factors. Country of origin was also significantly associated with the reporting of bother but for a much smaller number of symptoms (2).

CONCLUSIONS

In different countries lower urinary tract symptoms may be reported to different extents. Therefore, the results of studies in particular countries may not be generally applicable to other countries. It is likely that symptom scores will conceal this variation, necessitating consideration of individual symptoms (as in the International Continence Society "benign prostatic hyperplasia" study) or the development of country specific scoring systems. An alternative would be to focus on bother, which appeared to be much less sensitive to international differences.

The International Continence Society "Benign Prostatic Hyperplasia" Study: the botherosomeness of urinary symptoms

PURPOSE

We assessed the bothersomeness of lower urinary tract symptoms as reported by men, and investigated relationships among occurrence, degree of problem caused and age.

MATERIALS AND METHODS

Questionnaire data from 1,271 men presenting with lower urinary tract symptoms in 12 countries were analyzed. Statistical methods included distributions, cross tabulations, chi-square analysis and Spearman's rank correlation coefficients.

RESULTS

Although prevalence and bothersomeness were moderately positively related, voiding symptoms were the most prevalent whereas the most bothersome were predominantly storage symptoms, including incontinence. While prevalence showed a broadly decreasing trend with age, bothersomeness was relatively unrelated to age.

CONCLUSIONS

These findings suggest that symptom occurrence alone does not necessarily reflect the degree to which patients are bothered by lower urinary tract symptoms. Therefore, when deciding on treatment it is important not only to consider the presence and frequency of lower urinary tract symptoms but also the bother that they cause.

Iron metabolism in transgenic mice with hypoplastic anaemia due to incomplete deficiency of erythropoietin

Iron overload is a serious complication of many forms of anaemia, arising in part from mechanisms associated with compensatory increases in erythropoiesis. To investigate other mechanisms by which anaemia itself may perturb iron metabolism, without the confounding effects of compensatory erythropoiesis, we studied transgenic mice with a partially disabling insertion in the erythropoietin gene, which manifested as incomplete erythropoietin deficiency. Mice were studied aged 7-8 weeks. Haemoglobin concentrations were 6.6 +/- 0.8 g/dl in mice homozygous for the modified erythropoietin gene, 12.9 +/- 2.2 g/dl in heterozygous mice and 14.1 +/- 1.0 g/dl in controls. Homozygous mice showed significant hepatic iron loading (2-fold increase in liver non-haem iron, compared with heterozygous mice and normal controls, with iron staining principally in the periportal hepatocytes). Absorption studies using 59Fe showed increased uptake from the lumen of an in vivo isolated duodenal segment in homozygous mice, although at this point in time overall transfer of radioiron to the circulation and other tissues (mucosal transfer) was not different from controls. These observations demonstrate that anaemia can lead to hepatic iron loading even in the absence of increased erythropoiesis, and are consistent with the possibility that anaemic hypoxia can enhance mucosal iron uptake by the duodenal enterocyte.

Oral health in alcohol misusers

One hundred and seven chronic alcohol misusers (mean age 42.9 years; range 21-65 years; 80 males) attending four centres in South East London were interviewed on their current and past alcohol consumption. Their nutritional status (body mass index (BMI) and mid arm muscle circumference) was also recorded. Each subject completed a dental and oral mucosal examination. Ninety four per cent of the sample consumed greater than 50 units of alcohol per week and 80 per cent greater than 100 units of alcohol per week. Smoking and alcohol misuse were found to be related, 81 per cent reporting both habits. Neither plaque index scores or mean subject pocket depths were correlated with alcohol consumption but both were positively correlated with the frequency and duration of smoking. Overall mean DMFT was 15.4; age specific mean DMFT and tooth loss of the sample were closely similar to the 1988 United Kingdom adult dental health survey data. The prevalence and severity of tooth wear and attrition were greater in the sample than levels described in the literature and these dental features may prove useful markers to the practitioner. Trauma to teeth and oral mucosae was noted in 25 per cent of the sample. Seven oral mucosal lesions (including one treated carcinoma) were detected; mucosal trauma could have acted as a co-factor. Furthermore, 21 per cent of the alcoholics were malnourished (BMI < 20). It is concluded that, unlike several reports from the United States, dental health in this sample of alcoholics is not compromised; however mucosal health is a cause for concern.

Expression of genes involved in iron metabolism in mouse intestine

Intestinal nonheme iron levels and mRNA levels of genes implicated in iron metabolism were measured in mice with altered iron metabolism [chronic (4 wk) and acute (4 days) dietary iron deficiency; iron overload and hypoxia] to investigate their role in the process and regulation of intestinal iron absorption. Mucosal nonheme iron levels were decreased by both chronic and acute iron deficiency and increased by iron overload but were not affected by hypoxia. There was evidence of a gradient of mucosal nonheme iron along the small intestine (duodenum, jejunum > ileum). There were also regional differences in H-ferritin (duodenum > ileum) and transferrin receptor (ileum > duodenum) mRNA levels. Iron overload produced a decrease in transferrin receptor (TfR) mRNA in the duodenum, with ferritin mRNA levels unaffected in both the duodenum and ileum. Chronic iron deficiency induced a twofold increase in TfR mRNA levels in both the duodenum and ileum, whereas H- and L-ferritin mRNA levels did not change significantly. The ratio of H- to L-ferritin mRNA decreased significantly during exposure to hypoxia; however, individual ferritin and TfR mRNA levels were not significantly altered. Calreticulin (mobilferrin), cysteine-rich intestinal protein, and H(+)-adenosinetriphosphatase mRNA levels were virtually unchanged in all models. A comparison with previously published data on changes in iron absorption leads us to conclude that 1) iron absorption can be altered independently of effects on transcripts of genes for iron-related proteins, and 2) it is not essential for iron absorption to be coordinated with regulation of mucosal iron metabolism.

Serum neuron-specific enolase, carnosinase, and their ratio in acute stroke. An enzymatic test for predicting outcome?

BACKGROUND AND PURPOSE

Few admission variables adequately predict neuronal damage and prognosis in individual patients after stroke. Therefore, there is a need for a reliable non-invasive surrogate measure of clinical outcome.

METHODS

We have developed a surrogate measure of stroke outcome using the ratio of serum neuron-specific enolase (NSE) to human serum carnosinase (HSC) in 124 patients with acute ischemic or hemorrhagic stroke and 61 matched control subjects. Serum NSE is known to rise and HSC to fall after neuronal injury such as cerebral ischemia.

RESULTS

Serum NSE levels were significantly higher and HSC levels lower in the patient group. The NSE/HSC ratio was elevated in patients with stroke: median (semiquartile) hemorrhages, 0.072 (0.033); infarcts, 0.039 (0.026); and control subjects, 0.019 (0.014), P = .0001. Patients with a primary intracerebral hemorrhage had nonsignificantly higher ratios than those with an infarct (P = .082). The NSE/HSC ratio was significantly associated with 90-day outcome measured in two out of three disability and handicap scales: modified Barthel Index (rs = -.34, P = .001), modified Rankin Scale (rs = .30, P = .002), and Lindley Score (rs = .19, P = .057). Patients who died or were institutionalized had higher ratios than those who were discharged home: 0.069 (0.043) versus 0.038 (0.024), P = .011. Correlations between the NSE/HSC ratio and outcome were comparable to those between patient age or consciousness level on admission and clinical outcome.

CONCLUSIONS

We believe that measurement of NSE, HSC, or their ratio may be useful in the assessment of patients with acute stroke with respect to diagnosis and prediction of clinical outcome.

A general practice-based study examining the absolute risk of cardiovascular disease in treated hypertensive patients

BACKGROUND

When managing hypertension, the assessment of the absolute risk of a cardiovascular' event is now advocated as the most accurate way in which the risks and benefits of anti-hypertensive therapy should be judged. Most studies that have examined control of hypertension have relied solely on the blood pressure level attained after treatment, with no measurement of the likely absolute risk in individual patients.

AIM

To assess control of hypertension by quantifying the 10-year absolute risk of cardiovascular disease in patients treated by their general practitioners, and to assess which risk factors are associated with uncontrolled hypertension in this group of patients.

METHOD

A cross-sectional study was made of patients on drug treatment for hypertension in 18 Oxfordshire general practices subscribing to the VAMP (value-added medical products) computer system. The absolute risk of suffering a cardiovascular event in the following 10 years was measured according to each individual's risk factor profile. Factors associated with uncontrolled hypertension were ascertained using multiple logistic regression analysis.

RESULTS

Overall, 40.9% (37.6% to 44.1%) of the hypertensive population had an absolute risk exceeding 20% of having a cardiovascular event in the following 10 years. The distribution of risk factors varies throughout the population. A higher blood pressure reading was strongly associated with an increased likelihood of high absolute risk, but high blood pressure readings in individual patients did not necessarily equate to a high absolute risk. The factors independently associated with uncontrolled hypertension were age, sex, past history of stroke, ischaemic heart disease and transient ischaemic attack, a body mass index greater than 30, diabetes, and current smoking.

CONCLUSIONS

Absolute risk assessment maximizes the risk-benefit ratio in treated hypertensive patients. Individual control and management requires multifactorial assessment and management. Treatment of hypertension according to blood pressure reading alone is not a reliable way of reducing the absolute risk of cardiovascular disease.

Application of proton NMR spectroscopy to measurement of whole-body RNA degradation rates: effects of surgical stress in human patients

The urinary catabolites, N2,N2-dimethylguanosine (DMG), pseudouridine (PSU) and 7-methylguanine (m7-Gua) are formed from post-transcriptional methylation of RNA bases and are not reincorporated into RNA upon its degradation. Their quantitative urinary excretion may be used to determine rates of whole body degradation of individual RNA species since DMG occurs exclusively in tRNA, PSU occurs in rRNA and tRNA and m7-Gua occurs in all RNA species. Conventional HPLC analysis has several drawbacks since pre-analytical steps may involve selective losses and, under certain conditions, other urinary analytes may co-elute. In the present paper, we report analysis of these compounds by high-field 1H-nuclear magnetic resonance (1H-NMR) spectroscopy. Urinary concentrations of these metabolites were found to be in agreement with previously published HPLC and ELISA determinations. However, NMR analysis required minimal sample preparation (other than lyophilisation and reconstitution) and was capable of the simultaneous determination of other relevant analytes such as creatinine. This technique was therefore applied to urine samples from patients who had undergone surgical stress and insulin-like growth factor-1 (IGF-I) therapy. Surgical stress increased the excretion of DMG and m7-Gua. Degradation rates for tRNA and mRNA were also higher in surgically stressed subjects when compared with controls but degradation rates of rRNA decreased by approx. 30%. However, injection of IGF-I (40 micrograms/kg s.c.) had no significant effect on the excretion of these nucleosides. These data indicated that IGF-I therapy has no marked effects on RNA turnover following trauma. We suggest that this technique can be applied to study of RNA metabolism in any surgical or medical condition. Furthermore, since only 0.6 ml of urine is required, studies in neonates seem to be feasible.

Regulation of pancreatitis-associated protein (HIP/PAP) mRNA levels in mouse pancreas and small intestine

1. In the present study we have examined the expression of pancreatitis-associated protein mRNA in mouse pancreas and small intestine and determined the effect of a number of factors on the steady-state level of the RNA. 2. The normally low level of pancreatitis-associated protein mRNA in pancreas increased severalfold after 6 h of hypoxia, reaching peak levels (approximately 10-fold greater than normal) after 24 h hypoxia. After 3 days' hypoxia pancreatitis-associated protein mRNA levels were again undetectable. 3. In the pancreas the level of pancreatitis-associated protein mRNA was also increased by alcohol and iron overload, but not by paracetamol. 4. In the small intestine expression of pancreatitis-associated protein mRNA was higher in normal ileum than in duodenum. In the ileum pancreatitis-associated protein mRNA levels were increased 7 to 15-fold after 6 h hypoxia, reaching peak levels by 24 h. Levels declined after 3 days' hypoxia, but remained higher than normal. 5. In the ileum long-term (4 weeks) dietary iron deficiency reduced pancreatitis-associated protein mRNA levels compared with control fed mice, whereas parenteral iron overload increased pancreatitis-associated protein mRNA levels. 6. The data presented suggest regulation of pancreatitis-associated protein gene expression by both oxygen tension and iron status.

What constitutes controlled hypertension? Patient based comparison of hypertension guidelines

OBJECTIVES

To investigate and quantify the extent to which variations in guidelines influence assessment of control of hypertension.

DESIGN

Cross sectional study. Selected patients had hypertension assessed as controlled or uncontrolled with guidelines from New Zealand, Canada, the United States, Britain, and the World Health Organisation.

SETTING

18 general practices in Oxfordshire.

SUBJECTS

876 patients with diagnosed hypertension and taking antihypertensive drugs.

MAIN OUTCOME MEASURES

Proportion of patients with controlled hypertension according to each set of guidelines.

RESULTS

The proportion of patients with controlled hypertension varied from 17.5% to 84.6% with the different guidelines after adjustment for the sampling method. All five sets of guidelines agreed on the classification for 31% (277) of the patients. The New Zealand guidelines calculate an absolute risk of a cardiovascular event. When this was taken as the standard half of the patients with uncontrolled hypertension by the United States criteria would be treated unnecessarily and 31% of those classified as having controlled hypertension by the Canadian guidelines would be denied beneficial treatment.

CONCLUSIONS

Hypertension guidelines are inconsistent in their recommendations and need to make clear the absolute benefits and risks of treatment.

The effect of eccentric exercise on serum creatine kinase activity in different ethnic groups

Eccentric exercise causes release of muscle creatine kinase (CK) 3-4 days after exercise. Racial variation in basal serum CK has been reported but the reasons for this are unknown. We studied 30 subjects of different ethnic origin (Caucasian, Afro-Caribbean, Asian) before and after eccentric exercise. Basal serum CK was significantly higher in the Afro-Caribbean group (201 +/- 134 IU/L, median +/- SD) compared to Caucasians (81 +/- 57 IU/L). The Asian group had intermediate CK values (144 +/- 93 IU/L). The intra-individual range of peak post-exercise CK values obtained was very wide (95-30 200 IU/L) with little difference in median CK between the Afro-Caribbean (8450 +/- 9020 IU/L) and Caucasian groups (7600 +/- 8800 IU/L). The median value for the Asian group was lower (594 +/- 5410 IU/L). A sub-group of 15 individuals undertook a second bout of exercise 2 weeks later and all subjects demonstrated a training effect resulting in a marked attenuation of enzyme efflux. The variation in CK between the ethnic groups was not related to measurements of muscle strength or body mass, although the torque: body mass ratio followed the same order as the basal CK, i.e. the Afro-Caribbeans had the highest values. These results highlight the importance of considering ethnic origin and previous exercise history when interpreting serum CK assay results.

The value of multiple free-flow studies in men with lower urinary tract symptoms

OBJECTIVE

To assess the variability of free-flow studies in men presenting with lower urinary tract symptoms (LUTS) suggestive of benign prostatic obstruction (BPO) and to determine the sensitivity, specificity and predictive values of consecutive measurements of maximum flow rate for the presence of bladder outlet obstruction (BOO) at several threshold values.

PATIENTS AND METHODS

The value of multiple free-flow studies was assessed in 165 men presenting with LUTS suggestive of BPO. Each patient was requested to void four times into a uroflowmeter and the voided volume and post-void residual urine volume (PVR) were also measured. The variability of the maximum flow rate (Qmax), voided volume and PVR between consecutive voids was assessed. In addition, the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of various thresholds of Qmax for the presence of BOO were calculated for each consecutive void.

RESULTS

The mean Qmax on void 1 was 10.2 mL/s and the mean maximum value for Qmax between voids 1 and 2 was 12.5 mL/s. For voids 1, 2 and 3, the mean maximum Qmax was 13.9 mL/s and for voids 1 to 4 it was 15.2 mL/s. There were no significant changes in PVR among any of these voids. There was a statistically significant, although small, decrease in voided volume between voids 1 to 3 and voids 1 to 4. The specificity and PPV of Qmax for BOO increased with each subsequent void, such that using a threshold value for Qmax of 10 mL/s on the fourth void, the specificity and PPV for BOO were 96% and 93%, respectively.

CONCLUSIONS

There was a significant increase in Qmax with each successive void when men with LUTS suggestive of BPO performed multiple free-flow measurements and consequently, single free-flow measurements substantially underestimated the maximum Qmax that these patients achieved. The specificity and PPV of Qmax for BOO can be improved considerably by performing multiple free-flow studies and by carefully selecting an appropriate threshold value (although whether pressure-flow studies are unnecessary will depend on what level of specificity and PPV is deemed acceptable in clinical practice). These findings should be considered if free-flow studies are to be used as the basis for deciding the clinical management of men with LUTS and may be particularly useful for urologists with limited facilities for pressure-flow studies.

A duodenal mucosal abnormality in the reduction of Fe(III) in patients with genetic haemochromatosis

BACKGROUND

Previous in vitro studies have shown that the uptake of Fe(III) by freshly isolated duodenal mucosal biopsy specimens is increased in patients with genetic haemochromatosis. Moreover, in the mouse it has recently been found that reduction of Fe(III) to Fe(II) is a prerequisite for iron uptake by the proximal intestine.

AIMS/METHODS

This study used the in vitro technique to investigate the rates of reduction and uptake of 59Fe(III) by duodenal mucosal biopsy specimens obtained at endoscopy from treated and untreated patients with genetic haemochromatosis.

RESULTS

The rate of reduction of iron in the medium was proportional to the incubation time and was not caused by the release of reducing factors from the tissue fragments. Ferrozine, a specific Fe(II) chelator and ferricyanide, a non-permeable oxidising agent, inhibited uptake of 59Fe showing that reduction of Fe(III) precedes uptake. The rates (all values given as pmol/mg/min) of reduction (152 (49) v 92 (23)) and uptake (8.3 (4.0) v 3.6 (1.3), mean (SD)), were significantly increased in biopsy specimens from the untreated group (n = 6) compared with those from 10 control subjects (p < 0.04). Furthermore, the reduction and uptake rates were still increased in five patients in whom iron stores were normal after venesection treatment.

CONCLUSIONS

These results show that there is a persistent abnormality in the reduction and uptake of iron by the intestine in genetic haemochromatosis.

The significance of terminal dribbling in men with lower urinary tract symptoms

OBJECTIVE

To determine the relationship between the symptom of terminal dribbling, objective evidence of terminal dribbling on recordings of uroflow, benign prostatic enlargement (BPE) and bladder outlet obstruction (BOO) in men with lower urinary tract symptoms (LUTS).

PATIENTS AND METHODS

The prevalence of the symptom of terminal dribbling was determined from a symptom questionnaire completed by 165 men presenting with LUTS. Objective evidence of terminal dribbling during voiding was assessed from uroflow recordings and prostate volume was measured by transrectal ultrasonography. Combined pressure-flow studies were performed to determine the presence or absence of BOO.

RESULTS

There was relatively poor agreement between the symptom of terminal dribbling and objective evidence of its presence; 48% of the patients who reported terminal dribbling most or all of the time showed no objective evidence of terminal dribbling on uroflowmetry. The symptom of terminal dribbling was not significantly related to the presence of BOO (P = 0.74) and the group-specific urethral resistance factor (URA) did not differ significantly (P = 0.79) between those men who complained of terminal dribbling and those who did not (median URA 33 and 31 cmH2O, respectively). However, objective evidence of terminal dribbling on uroflow traces was significantly related to BOO (P < 0.001) and those patients with objective evidence of terminal dribbling had higher values of URA (median 39 compared with 28 cmH2O). Objective terminal dribbling had a specificity of 92% and positive predictive value of 88% for the presence of BOO. Neither the symptom of terminal dribbling nor objective evidence of its presence were significantly related to prostatic enlargement.

CONCLUSION

While the symptom of terminal dribbling is probably not related to BOO or prostatic enlargement, objective evidence of terminal dribbling on flow curve recording is specific for BOO and as such, its presence could potentially be of value in the assessment of men with LUTS.

The ICS-'BPH' Study: the psychometric validity and reliability of the ICSmale questionnaire

OBJECTIVE

To assess the validity and reliability of the ICSmale questionnaire developed for the International Continence Society-'Benign Prostatic Hyperplasia' (ICS-'BPH') study.

PATIENTS AND METHODS

Urology departments in 12 countries recruited 1271 consecutive men > 45 years old, with lower urinary tract symptoms and possible benign prostatic obstruction, to the ICS-'BPH' study (the clinical group); 423 ambulent men were recruited from a general practice in the UK to provide a community group. Each individual was asked to complete the wide-ranging ICSmale questionnaire, comprising questions concerned with urinary symptoms, the bother they cause, and issues of quality of life and sexual function. Content, construct and criterion validity of the symptom and problem questions were assessed by interviews with patients and urologists, testing hypotheses within sub-studies, and in relation to frequency-volume diaries and uroflowmetry. Reliability was assessed by measures of internal consistency and a test-retest analysis.

RESULTS

The ICSmale questionnaire was easy to complete. It was clearly able to differentiate between men in clinical and community populations, and detected the expected positive age gradient for most symptoms in the community group. There was reasonable agreement between relevant parts of the questionnaire and frequency-volume charts when a relatively flexible approach was taken, but there was a very poor relationship between questions assessing strength of stream and the results of uroflowmetry. Internal consistency was high, and overall the questionnaire demonstrated good test-retest reliability.

CONCLUSION

The self-completed ICSmale questionnaire had high levels of psychometric validity and reliability.

Determination of prostatic volume with transrectal ultrasound: A study of intra-observer and interobserver variation

PURPOSE

We assessed the intra-observer and interobserver variation in measurements of prostatic volume using transrectal ultrasound.

MATERIALS AND METHODS

Two volume estimations were performed by 1 observer in 40 patients and by 2 observers in 75.

RESULTS

Mean prostatic volumes measured ranged from 18.9 to 87.0 ml. (median 39.8) for 1 observer and from 15.5 to 95.4 ml. (median 42.4) for 2 observers. The mean difference plus or minus standard deviation and limits of agreement between the paired volume estimations were 0.1 +/- 3.3 ml. and -6.5 +/- 6.7 ml., respectively, for 1 observer, and -0.3 +/- 5.3 ml and -10.9 to 10.3 ml., respectively, for 2 observers. The mean difference was 9.8% for 2 observers. The mean difference was 9.8% for 2 observers compared to 4.6% for 1.

CONCLUSIONS

The results show that there is considerable variation in repeated measurements of prostatic volume and the variation is greatest for 2 observers compared to 1 observer.

Breast screening: a randomised controlled trial in UK general practice of three interventions designed to increase uptake

STUDY OBJECTIVES

To determine the relative effectiveness of three interventions designed to increase the uptake of breast screening.

DESIGN

Randomised controlled trial of a nurse visit with health education (group A), nurse visit without health education (group B), and GP letter (group C).

SETTING

The area of south east London served by the Butterfly Walk Breast Screening Unit in Camberwell.

PARTICIPANTS

Women aged between 50 and 64 years who were registered with 27 GPs in the Lambeth, Southwark and Lewisham family health services authority and who had not attended for first round screening.

MAIN RESULTS

Altogether 799 women were randomly allocated to the three groups. In general, delivering the nurse based interventions proved difficult. In group A, 11.4% (95% CI 7.9, 14.9%) of women subsequently attended for screening compared with 7.8% (95% CI 5.1, 11.4%) in group B and 13.1% (95% CI 7.9, 18.4%) in group C. The differences between the groups (95% CIs) were not statistically significant: A versus C, -1.7% (-8.0, +4.6%); B versus C, -5.3% (-11.3, +0.7%); A versus B, +3.6% (-1.0, +8.2%).

CONCLUSIONS

A personal letter from the GP seems to be at least as effective at increasing the uptake of breast screening in non-attenders as a nurse making a home visit to discuss the issue of breast screening, and is not noticeably less effective than a visit at which a health education intervention is delivered. It is possible that the GP letter is considerably more effective than either of the two interview-based interventions. With regard to implementing strategies which will increase breast screening uptake and are cost effective, further trials of similar minimal interventions in primary care are required.

Epidemiology and patterns of hospital use after parasuicide in the south west of England

OBJECTIVE

To describe the epidemiology, management, and outcome of parasuicide in the south west of England.

DESIGN

Descriptive analysis using routine information systems.

SETTING

The former South Western Regional Health Authority, population aged 10 and over: 2.9 million.

SUBJECTS

These comprised 5080 residents of the South Western Health Region, admitted on 5770 occasions for parasuicide between April 1992 and March 1993 to hospitals in the south west.

MAIN OUTCOME MEASURES

Person based age and sex standardised admission ratios for parasuicide; readmission for parasuicide in the subsequent 12 months; admission to psychiatric hospital after parasuicide; in-hospital mortality for those admitted after attempted suicide.

RESULTS

The overall rate of parasuicide admission was 174 per 100,000 per year. Rates were highest in males aged 20-24 (381 per 100,000) and in females aged 15-19 (625 per 100,000). Parasuicide is the third most frequent cause of acute medical admission in the south west. A total of 10.0% of admissions received psychiatric inpatient care as a direct result of their parasuicide admission and 10.1% were readmitted in the following 12 months with a repeat episode of parasuicide. Significant variations in standardised admission ratios for parasuicide were observed between the districts. Some of this variation is related to socioeconomic differences between districts, the rest is probably due to differences in practice between districts. There is no clear evidence that these variations result in differences in readmission rates. Districts where psychiatric inpatient facilities were located on the same site as the general hospital tended to admit a greater percentage of parasuicide patients for psychiatric inpatient care. A quarter of all suicide deaths from overdose occurred in hospital. It is estimated that there are 87,000 parasuicide admissions in England and Wales annually.

CONCLUSIONS

Parasuicide is a common cause of acute hospital admission and there is evidence that hospital admission practices for parasuicide vary across the south west. Randomised controlled trials are needed to evaluate the most appropriate form of management for those patients who do not require admission on medical grounds.

Factors associated with inappropriate emergency hospital admission in the UK

This paper reports an attempt to assess the factors associated with inappropriate acute hospital admission using the technique of logistic regression. Data were obtained from two separate studies of acute hospital utilization in south-west England, conducted between 1992 and 1994. The appropriateness of admission was assessed using explicit standardized criteria in the form of the intensity-severity-discharge review system with adult criteria (ISD-A). Up to 19 explanatory variables were available for the analyses. These variables were modelled for each centre separately, using logistic regression to produce final sets of factors independently related to the appropriateness of admission. For one centre, the final model contained age/ specialty and use of community services. For the other, the final model contained two measures of health status on admission-coping failure and admission with stroke. It is concluded that the complex interplay between the characteristics of patients, referrers, alternative forms of care and the acute hospital may result in quite different types of inappropriate admissions in different locations.

Influence of anti-rheumatic drugs on gut permeability and on the gut associated lymphoid tissue

There is great interest in the association between intestinal inflammation and the various arthropathies. However, most studies assessing intestinal function in these diseases are confounded by the fact that non-steroidal anti-inflammatory drugs (NSAIDs) have profound effects on the small intestine. Hence NSAIDs cause quite distinct and severe biochemical damage during drug absorption (uncoupling of mitochondrial oxidative phosphorylation proving to be most important) which results in increased intestinal permeability. All commonly used NSAIDs, apart from aspirin and nabumetone, are associated with increased intestinal permeability in man. Whilst reversible in the short term, it may take months to improve following prolonged NSAID use. Increased intestinal permeability appears to be the central mechanism of converting the biochemical damage to an inflammatory tissue reaction (NSAID enteropathy). The inflammatory enteropathy is not, however, unique to NSAIDs but similar changes are found with other permeability breakers. In intestinal infections and in diseases associated with reduced mucosal defence, suggesting that the small intestinal inflammation represents a common final pathway for a number of intestinal injuries. Spondylarthropathies are associated with a high prevalence of terminal ileitis, but as most patients have been receiving NSAIDs it has been difficult to dissociate the effects of NSAIDs on intestinal function from that of the ileitis itself. Nevertheless, two studies suggest that increased intestinal permeability in spondylarthropathies occur independently of NSAID ingestion. Whilst these findings may have implications for the development of arthritis, the permeability changes in spondylarthropathy do not differ quantitatively or qualitatively from that of NSAIDs or other permeability breakers. NSAID enteropathy can be differentiated from spondylarthropathic enteropathy by differences in location of disease and lack of predilection of certain HLA types. However, as the two may coexist both enteroscopy and ileocolonoscopy may be necessary for this distinction.

Relationship between duodenal cytosolic aconitase activity and iron status in the mouse

Cytosolic aconitase activity was assayed in duodenal mucosa from mice subjected to a variety of manipulations known to modulate duodenal iron status and duodenal iron absorption. No changes in cytosolic aconitase activity were observed 1 h after oral FeSO4 dosing or intramuscular desferrioxamine treatment. Three days of hypoxic exposure and two weeks treatment with intramuscular iron dextran also had no effect on cytosolic aconitase. Three weeks growth on an iron deficient diet significantly reduced cytosolic aconitase activity. In no situation was there any evidence for significant amounts of inactive aconitase which could be activated in vitro with FeSO4/cysteine. These data suggest that duodenal cytosolic aconitase is not sensitive to acute changes in mucosal iron levels and is generally much less sensitive to body iron status than is duodenal iron absorption. There is evidence that chronic iron depletion reduces cytosolic aconitase to a relatively small degree but generally activity is maintained, consistent with an important metabolic role for the enzyme.

In vitro duodenal iron uptake and serum and mucosal iron protein levels, with special reference to rheumatoid arthritis

Duodenal biopsies from control subjects, patients with iron-deficiency anaemia and rheumatoid arthritic patients with anaemia of chronic disorders (ACD) were investigated for their ability to take up 59Fe from iron ascorbate. Additionally, duodenal tissues were analysed for iron and immunoreactive ferritin and transferrin. Biopsies from iron-deficient subjects showed a 2- to 3-fold increase in the apparent Vmax for 59Fe uptake, compared to control values. Uptake was inversely related to body iron stores. ACD patients showed similar rates of 59Fe uptake to controls; the rates were independent of the degree of anaemia or serum ferritin levels. Tissue analysis showed reductions in mucosal iron and ferritin levels in iron-deficient patients, whilst transferrin levels were within the normal range. ACD patients also exhibited lower mucosal iron levels, but had iron protein levels within the normal range. It is suggested that factors distant from the intestinal mucosa influence iron absorption in ACD.

Evidence based purchasing: understanding results of clinical trials and systematic reviews

OBJECTIVE

To assess whether the way in which the results of a randomised controlled trial and a systematic review are presented influences health policy decisions.

DESIGN

A postal questionnaire to all members of a health authority within one regional health authority.

SETTING

Anglia and Oxford regional health authorities.

SUBJECTS

182 executive and non-executive members of 13 health authorities, family health services authorities, or health commissions.

MAIN OUTCOME MEASURES

The average score from all health authority members in terms of their willingness to fund a mammography programme or cardiac rehabilitation programme according to four different ways of presenting the same results of research evidence--namely, as a relative risk reduction, absolute risk reduction, proportion of event free patients, or as the number of patients needed to be treated to prevent an adverse event.

RESULTS

The willingness to fund either programme was significantly influenced by the way in which data were presented. Results of both programmes when expressed as relative risk reductions produced significantly higher scores when compared with other methods (P < 0.05). The difference was more extreme for mammography, for which the outcome condition is rarer.

CONCLUSIONS

The method of reporting trial results has a considerable influence on the health policy decisions made by health authority members.

Relationship between early liver graft viability and enzyme activities in effluent preservation solution

Determination of cellular enzyme activities in washout preservation solution used in hypothermic liver graft storage may allow development of an index that could be clinically valuable in prediction of early post-transplant graft function. In the present study, we collected washed out preservation fluid at the time of graft rinsing from 53 liver recipients. Aspartate aminotransferase and, to a lesser extent, lactate dehydrogenase levels correlated with early postoperative graft viability as assessed by 1-month graft survival and standard biochemical indices of liver function. Those patients with the highest aspartate aminotransferase activity in the washout preservation solution experienced the highest levels of this enzyme postoperatively (area-under-the-curve day 1-3; 1340 vs. 788 IU/L), total bilirubin (area-under-the-curve day 1-5; 901 vs. 538 mumol/L), and rejection frequency (67% vs. 31%) (all P < 0.05), with a significantly lower 1-month graft survival rate compared with patients with low effluent levels (62% vs. 92%, P < 0.05). Two markers of endothelial cell damage, purine nucleoside phosphorylase and a creatine kinase isoenzyme, measured in the fluid did not correlate with early graft viability. It is suggested that assay of aspartate aminotransferase activities in preservation fluid washout samples is a clinically useful indicator of graft viability.