Timing of standard chow exposure determines the variability of mouse phenotypic outcomes and gut microbiota profile

Standard chow diet contributes to reproducibility in animal model experiments since chows differ in nutrient composition, which can independently influence phenotypes. However, there is little evidence of the role of timing in the extent of variability caused by chow exposure. Here, we measured the impact of diet (5V5M, 5V0G, 2920X, and 5058) and timing of exposure (adult exposure (AE), lifetime exposure (LE), and developmental exposure (DE)) on growth & development, metabolic health indicators, and gut bacterial microbiota profiles across genetically identical C57BL6/J mice. Diet drove differences in macro- and micronutrient intake for all exposure models. AE had no effect on measured outcomes. However, LE mice exhibited significant sex-dependent diet effects on growth, body weight, and body composition. LE effects were mostly absent in the DE model, where mice were exposed to chow differences from conception to weaning. Both AE and LE models exhibited similar diet-driven beta diversity profiles for the gut bacterial microbiota, with 5058 diet driving the most distinct profile. Diet-induced beta diversity profiles were sex-dependent for LE mice. Compared to AE, LE drove 9X more diet-driven differentially abundant genera, majority of which were the result of inverse effects of 2920X and 5058. Our findings demonstrate that lifetime exposure to different chow diets has the greatest impact on reproducibility of experimental measures that are common components of preclinical mouse model studies. Importantly, weaning DE mice onto a uniform diet is likely an effective way to reduce unwanted phenotypic variability among experimental models.

Discovery of Anticancer Agents of Diverse Natural Origin

Research progress from mainly over the last five years is described for a multidisciplinary collaborative program project directed toward the discovery of potential anticancer agents from a broad range of taxonomically defined organisms. Selected lead compounds with potential as new antitumor agents that are representative of considerable structural diversity have continued to be obtained from each of tropical plants, terrestrial and aquatic cyanobacteria, and filamentous fungi. Recently, a new focus has been on the investigation of the constituents of U.S. lichens and their fungal mycobionts. A medicinal chemistry and pharmacokinetics component of the project has optimized structurally selected lead natural products, leading to enhanced cytotoxic potencies against selected cancer cell lines. Biological testing has shown several compounds to have in vivo activity, and relevant preliminary structure-activity relationship and mechanism of action studies have been performed. Several promising lead compounds worthy of further investigation have been identified from the most recent collaborative work performed.

Challenges in the design, interpretation, and reporting of randomized controlled clinical studies on the health effects of whole foods

Given the challenges with nutrition research, the Canadian Nutrition Society and Intertek Health Sciences Inc held an expert consultation in late 2019 to discuss the development and implementation of best practices for clinical trials on whole foods. Key challenges in the design, interpretation, and reporting of clinical efficacy studies on whole foods and opportunities for the future development of best practices are reported. Novelty: Outlines existing tools, resources, and checklists for clinical nutrition trials and provides clear and tangible steps to develop best practices for studies on whole foods.

Dietary Reference Intakes based on chronic disease endpoints: outcomes from a case study workshop for omega 3's EPA and DHA

Given the focus on developing Dietary Reference Intakes (DRIs) based on chronic disease risk reduction and recent research for omega-3 long chain PUFA since the last DRI review, the Canadian Nutrition Society convened a panel of stakeholders for a 1-day workshop in late 2019. Attendees discussed the new NASEM guidelines for establishing DRI values based on chronic disease risk endpoints and the strength of current evidence for EPA and DHA as it relates to the new guidelines. Novelty: Summarizes evidence and expert opinions regarding the potential for reviewing DRI values for EPA and DHA and cardiovascular disease risk and early development.

Participatory health research with migrants: opportunities, challenges, and way forwards

Background

Migration has become one of the most politically pressing issues of the 21st century. Still, migrant health remains an under-researched area in global health. Participatory Health Research (PHR) can potentially contribute to a paradigm shift, from a pathogenic deficit model that sees migrants as passively affected by policies to their re-conceptualization as creative, inspiring, and actively engaged citizens in search of solutions. However, PHR is not a panacea and there are specific challenges in enacting meaningful and impactful projects in this field.

Methods

This literature review examines the opportunities and challenges posed by the use of this approach in migrant health research. We highlight critical issues for consideration and provide some examples of successful PHR with migrants.

Results

A number of successful initiatives illustrate the value of engaging migrants in the definition of the research agenda, the design and implementation of health interventions, the identification of health protective factors, and the operationalization and validation of indicators to monitor progress in this field. Still, within fragmented community landscapes that are not necessarily constructed along ethnicity traits, and real-world contexts that are far from the ideals of justice and equality, inadequate structures of representation and power dynamics can hamper a meaningful implementation of PHR with migrants.

Conclusions

For each particular research context it is essential to reflect on what is the “optimal” level and type of participation that is more likely to leverage migrants' empowerment so we can better advocate for our voices to be heard, and our rights to be addressed.

Key messages

Participatory Health research can potentially contribute to address migrant health challenges. The level and type of participation must be tailored to each research context.

Development and Validation of a Nutrition-Specific Set of Tools to Assess the Quality of Nutrition Studies

Objectives

To develop and validate a set of 3 quality assessment instruments (QAls) for evaluating the quality of nutrition studies, for each of the commonly used study designs: (1) randomized controlled trials (RCTs), (2) prospective cohort, and (3) case-control studies.

Methods

The QAI development and validation process included 8 steps: 1) identify and evaluate existing general QAls for adaptation with nutrition-specific quality appraisal items; 2) scan the literature to identify nutrition-specific quality appraisal issues; 3) generate nutrition-specific items to be added to each of the general QAIs, adapt existing guidance for general items for nutrition applications and develop guidance for added nutrition items; 4) review, by two experts in clinical and population nutrition, of the modified general QAIs with added nutrition-specific items and guidance; 5) assess reliability and validity of the QAI for each study design; 6) improve the usability and feasibility, of the QAIs by considering feedback from the validation exercise to refine the wording of the guidance; 7) develop a worksheet to help evaluate, a priori, topic-specific methodology to address risk of bias; and  8) validate the final QAIs using five peer-reviewed studies identified from published systematic reviews with reported quality assessment. Agreement and reliability were determined for each QAI.

Results

Results of the validation show good to perfect agreement among evaluators for the overall study rating and across domains. When compared to the study quality assessment reported in the systematic review, nutrition- specific items had the greatest impact on study ratings, generally resulting in a downgrade of the overall rating.

Conclusions

A set of nutrition-specific QAls were developed to assess the quality and robustness of nutrition studies. These tools incorporate general quality issues of study design and conduct, as well as address recognised nutrition study-specific issues. They will improve consistency in how nutrition studies are assessed particularly in nutrition-related systematic reviews. This will contribute to the overall quality of assessment of diet and

Funding Sources

This work was supported by Health Canada.

Gestational Exposures to Phthalates and Folic Acid, and Autistic Traits in Canadian Children

BACKGROUND

The etiology of autism spectrum disorder is poorly understood. Few studies have investigated the link between endocrine-disrupting chemicals and autistic traits. We examined the relationship between gestational phthalates and autistic traits in 3- to 4-y-old Canadian children. We also investigated potential effect modification by sex and folic acid supplementation.

METHODS

We enrolled 2,001 women>18 years of age during the first trimester of pregnancy between 2008 and 2011 from 10 cities in Canada. At 3-4 years of age, 610 children underwent neuropsychological assessments including the Social Responsiveness Scale-II (SRS-2) as a measure of autistic traits and social impairment. We measured 11 phthalate metabolites in maternal first trimester urine samples and assessed folic acid supplementation from reported intakes. We estimated covariate-adjusted differences in SRS-2 T-scores with a doubling in phthalate concentrations in 510 children with complete data.

RESULTS

Mean total SRS T-score was 45.3 (SD=6.1). Children with higher gestational exposure to mono-n-butyl (MBP) and mono-3-carboxypropyl (MCPP) concentrations exhibited significantly higher total SRS T-scores, indicating greater overall social impairment, as well as higher scores on subdomains, indicating deficits in social cognition, social communication, social motivation, and restricted interests/repetitive behaviors. A doubling in MBP or MCPP concentrations was associated with 0.6 (95% CI: 0.1, 1.0) and 0.5 (95% CI: 0.1, 0.8) higher total SRS T-scores. Associations were consistently and significantly stronger in boys (βMBP=1.0; 95% CI: 0.4, 1.6; n=252) compared with girls (βMBP=0.1; 95% CI: -0.6, 0.7; n=258) and among children who had lower prenatal folic acid supplementation (<400μg/d) (βMBP=1.3; 95% CI: 0.4, 2.3; n=59) compared with those who had adequate folic acid supplementation (≥400μg/d) (βMBP=0.4; 95% CI: -0.1, 0.8; n=451).

CONCLUSIONS

Higher gestational concentrations of some phthalate metabolites were associated with higher scores of autistic traits as measured by the SRS-2 in boys, but not girls; these small size effects were mitigated by first trimester-of-pregnancy folic acid supplementation. https://doi.org/10.1289/EHP5621.

Mutant p53s generate pro-invasive niches by influencing exosome podocalyxin levels

Mutant p53s (mutp53) increase cancer invasiveness by upregulating Rab-coupling protein (RCP) and diacylglycerol kinase-α (DGKα)-dependent endosomal recycling. Here we report that mutp53-expressing tumour cells produce exosomes that mediate intercellular transfer of mutp53's invasive/migratory gain-of-function by increasing RCP-dependent integrin recycling in other tumour cells. This process depends on mutp53's ability to control production of the sialomucin, podocalyxin, and activity of the Rab35 GTPase which interacts with podocalyxin to influence its sorting to exosomes. Exosomes from mutp53-expressing tumour cells also influence integrin trafficking in normal fibroblasts to promote deposition of a highly pro-invasive extracellular matrix (ECM), and quantitative second harmonic generation microscopy indicates that this ECM displays a characteristic orthogonal morphology. The lung ECM of mice possessing mutp53-driven pancreatic adenocarcinomas also displays increased orthogonal characteristics which precedes metastasis, indicating that mutp53 can influence the microenvironment in distant organs in a way that can support invasive growth.

Using Participatory Learning & Action (PLA) research techniques for inter-stakeholder dialogue in primary healthcare: an analysis of stakeholders' experiences

PLAIN ENGLISH SUMMARY

It is important for health care workers to know the needs and expectations of their patients. Therefore, service users have to be involved in research. To achieve a meaningful dialogue between service users, healthcare workers and researchers, participatory methods are needed. This paper describes how the application of a specific participatory methodology, Participatory Learning and Action (PLA) can lead to such a meaningful dialogue. In PLA all stakeholders are regarded as equal partners and collaborators in research.During 2011-2015, a European project called RESTORE used PLA in Austria, Greece, Ireland, The Netherlands and the UK to investigate how communication between primary health care workers and their migrant patients could be improved.Seventy eight migrants, interpreters, doctors, nurses and other key stakeholders (see Table 2) participated in 62 PLA sessions. These dialogues (involving discussions, activities, PLA techniques and evaluations) were generally 2-3 h long and were recorded and analysed by the researchers.Participants reported many positive experiences about their dialogues with other stakeholders. There was a positive, trusting atmosphere in which all stakeholders could express their views despite differences in social power. This made for better understanding within and across stakeholder groups. For instance a doctor changed her view on the use of interpreters after a migrant explained why this was important. Negative experiences were rare: some doctors and healthcare workers thought the PLA sessions took a lot of time; and despite the good dialogue, there was disappointment that very few migrants used the new interpreting service.

ABSTRACT

Background In order to be effective, primary healthcare must understand the health needs, values and expectations of the population it serves. Recent research has shown that the involvement of service users and other stakeholders and gathering information on their perspectives can contribute positively to many aspects of primary healthcare. Participatory methodologies have the potential to support engagement and dialogue between stakeholders from academic, migrant community and health service settings. This paper focuses on a specific participatory research methodology, Participatory Learning and Action (PLA) in which all stakeholders are regarded as equal partners and collaborators in research.Our research question for this paper was: "Does the application of PLA lead to meaningful engagement of all stakeholders, and if so, what elements contribute to a positive and productive inter-stakeholder dialogue?". Methods We explored the use of PLA in RESTORE, a European FP7-funded project, during 2011-2015 in 5 countries: Austria, Greece, Ireland, the Netherlands and the UK. The objective of RESTORE was to investigate and support the implementation of guidelines and training initiatives (G/TIs) to enhance communication in cross-cultural primary care consultations with migrants.Seventy eight stakeholders (migrants, interpreters, doctors, nurses and others - see Table 2) participated in a total of 62 PLA sessions (discussions, activities, evaluations) of approximately 2-3 h' duration across the five sites. During the fieldwork, qualitative data were generated about stakeholders' experiences of engagement in this dialogue, by means of various methods including participatory evaluations, researchers' fieldwork reports and researcher interviews. These were analysed following the principles of thematic analysis. Results Stakeholders involved in PLA inter-stakeholder dialogues reported a wide range of positive experiences of engagement, and very few negative experiences. A positive atmosphere during early research sessions helped to create a sense of safety and trust. This enabled stakeholders from very different backgrounds, with different social status and power, to offer their perspectives in a way that led to enhanced learning in the group - they learned with and from each other. This fostered shifts in understanding - for example, a doctor changed her view on interpreted consultations because of the input of the migrant service-users. Conclusion PLA successfully promoted stakeholder involvement in meaningful and productive inter-stakeholder dialogues. This makes it an attractive approach to enhance the further development of health research partnerships to advance primary healthcare.

Implementing guidelines and training initiatives to improve cross-cultural communication in primary care consultations: a qualitative participatory European study

Background

Cross-cultural communication in primary care is often difficult, leading to unsatisfactory, substandard care. Supportive evidence-based guidelines and training initiatives (G/TIs) exist to enhance cross cultural communication but their use in practice is sporadic. The objective of this paper is to elucidate how migrants and other stakeholders can adapt, introduce and evaluate such G/TIs in daily clinical practice.

Methods

We undertook linked qualitative case studies to implement G/TIs focused on enhancing cross cultural communication in primary care, in five European countries. We combined Normalisation Process Theory (NPT) as an analytical framework, with Participatory Learning and Action (PLA) as the research method to engage migrants, primary healthcare providers and other stakeholders. Across all five sites, 66 stakeholders participated in 62 PLA-style focus groups over a 19 month period, and took part in activities to adapt, introduce, and evaluate the G/TIs. Data, including transcripts of group meetings and researchers’ fieldwork reports, were coded and thematically analysed by each team using NPT.

Results

In all settings, engaging migrants and other stakeholders was challenging but feasible. Stakeholders made significant adaptations to the G/TIs to fit their local context, for example, changing the focus of a G/TI from palliative care to mental health; or altering the target audience from General Practitioners (GPs) to the wider multidisciplinary team. They also progressed plans to deliver them in routine practice, for example liaising with GP practices regarding timing and location of training sessions and to evaluate their impact. All stakeholders reported benefits of the implemented G/TIs in daily practice. Training primary care teams (clinicians and administrators) resulted in a more tolerant attitude and more effective communication, with better focus on migrants’ needs. Implementation of interpreter services was difficult mainly because of financial and other resource constraints. However, when used, migrants were more likely to trust the GP’s diagnoses and GPs reported a clearer understanding of migrants’ symptoms.

Conclusions

Migrants, primary care providers and other key stakeholders can work effectively together to adapt and implement G/TIs to improve communication in cross-cultural consultations, and enhance understanding and trust between GPs and migrant patients.

Role flexibility among telemedicine service providers in the north-west and west of Ireland

A recent review of telemedicine services in the north-west and west of Ireland identified 11 telemedicine services, most of which were in the early stages of implementation. A qualitative approach was used to review them. Semistructured interviews were conducted with a multidisciplinary group of primary- and secondary-care providers (n = 21) who were involved with either synchronous or asynchronous telemedicine services. Data were analysed according to the principles of framework analysis. Participants described the ways in which they were flexible about their workload, professional identities and roles to facilitate the organization and delivery of telemedicine services, and to ensure that services ran smoothly. While the positive effect of product champions and members of a wider supportive network or alliance on the conception and development of telemedicine services must be acknowledged, questions remain about associated long-term implementation and sustainability.

Pre-conception Folic Acid and Multivitamin Supplementation for the Primary and Secondary Prevention of Neural Tube Defects and Other Folic Acid-Sensitive Congenital Anomalies

OBJECTIVE

To provide updated information on the pre- and post-conception use of oral folic acid with or without a multivitamin/micronutrient supplement for the prevention of neural tube defects and other congenital anomalies. This will help physicians, midwives, nurses, and other health care workers to assist in the education of women about the proper use and dosage of folic acid/multivitamin supplementation before and during pregnancy.

EVIDENCE

Published literature was retrieved through searches of PubMed, Medline, CINAHL, and the Cochrane Library in January 2011 using appropriate controlled vocabulary and key words (e.g., folic acid, prenatal multivitamins, folate sensitive birth defects, congenital anomaly risk reduction, pre-conception counselling). Results were restricted to systematic reviews, randomized control trials/controlled clinical trials, and observational studies published in English from 1985 and June 2014. Searches were updated on a regular basis and incorporated in the guideline to June 2014 Grey (unpublished) literature was identified through searching the websites of health technology assessment and health technology-related agencies, clinical practice guideline collections, clinical trial registries, and national and international medical specialty societies. Costs, risks, and benefits: The financial costs are those of daily vitamin supplementation and eating a healthy folate-enriched diet. The risks are of a reported association of dietary folic acid supplementation with fetal epigenetic modifications and with an increased likelihood of a twin pregnancy. These associations may require consideration before initiating folic acid supplementation. The benefit of folic acid oral supplementation or dietary folate intake combined with a multivitamin/micronutrient supplement is an associated decrease in neural tube defects and perhaps in other specific birth defects and obstetrical complications.

VALUES

The quality of evidence in the document was rated using the criteria described in the Report of the Canadian Task Force on Preventative Health Care (Table 1). Summary Statement In Canada multivitamin tablets with folic acid are usually available in 3 formats: regular over-the-counter multivitamins with 0.4 to 0.6 mg folic acid, prenatal over-the-counter multivitamins with 1.0 mg folic acid, and prescription multivitamins with 5.0 mg folic acid. (III) Recommendations 1. Women should be advised to maintain a healthy folate-rich diet; however, folic acid/multivitamin supplementation is needed to achieve the red blood cell folate levels associated with maximal protection against neural tube defect. (III-A) 2. All women in the reproductive age group (12-45 years of age) who have preserved fertility (a pregnancy is possible) should be advised about the benefits of folic acid in a multivitamin supplementation during medical wellness visits (birth control renewal, Pap testing, yearly gynaecological examination) whether or not a pregnancy is contemplated. Because so many pregnancies are unplanned, this applies to all women who may become pregnant. (III-A) 3. Folic acid supplementation is unlikely to mask vitamin B12 deficiency (pernicious anemia). Investigations (examination or laboratory) are not required prior to initiating folic acid supplementation for women with a risk for primary or recurrent neural tube or other folic acid-sensitive congenital anomalies who are considering a pregnancy. It is recommended that folic acid be taken in a multivitamin including 2.6 ug/day of vitamin B12 to mitigate even theoretical concerns. (II-2A) 4. Women at HIGH RISK, for whom a folic acid dose greater than 1 mg is indicated, taking a multivitamin tablet containing folic acid, should be advised to follow the product label and not to take more than 1 daily dose of the multivitamin supplement. Additional tablets containing only folic acid should be taken to achieve the desired dose. (II-2A) 5. Women with a LOW RISK for a neural tube defect or other folic acid-sensitive congenital anomaly and a male partner with low risk require a diet of folate-rich foods and a daily oral multivitamin supplement containing 0.4 mg folic acid for at least 2 to 3 months before conception, throughout the pregnancy, and for 4 to 6 weeks postpartum or as long as breast-feeding continues. (II-2A) 6. Women with a MODERATE RISK for a neural tube defect or other folic acid-sensitive congenital anomaly or a male partner with moderate risk require a diet of folate-rich foods and daily oral supplementation with a multivitamin containing 1.0 mg folic acid, beginning at least 3 months before conception. Women should continue this regime until 12 weeks' gestational age. (1-A) From 12 weeks' gestational age, continuing through the pregnancy, and for 4 to 6 weeks postpartum or as long as breast-feeding continues, continued daily supplementation should consist of a multivitamin with 0.4 to 1.0 mg folic acid. (II-2A) 7. Women with an increased or HIGH RISK for a neural tube defect, a male partner with a personal history of neural tube defect, or history of a previous neural tube defect pregnancy in either partner require a diet of folate-rich foods and a daily oral supplement with 4.0 mg folic acid for at least 3 months before conception and until 12 weeks' gestational age. From 12 weeks' gestational age, continuing throughout the pregnancy, and for 4 to 6 weeks postpartum or as long as breast-feeding continues, continued daily supplementation should consist of a multivitamin with 0.4 to 1.0 mg folic acid. (I-A). The same dietary and supplementation regime should be followed if either partner has had a previous pregnancy with a neural tube defect. (II-2A).

Primary care teams in Ireland: a qualitative mapping review of Irish grey and published literature

INTRODUCTION

The Irish government published its primary care strategy, Primary Care: A New Direction in 2001. Progress with the implementation of Primary care teams is modest. The aim of this paper is to map the Irish grey literature and peer-reviewed publications to determine what research has been carried out in relation to primary care teams, the reform process and interdisciplinary working in primary care in Ireland.

METHODS

This scoping review employed three methods: a review of Web of Science, Medline and Embase databases, an email survey of researchers across academic institutions, the HSE and independent researchers and a review of Lenus and the Health Well repository.

RESULTS

N = 123 outputs were identified. N = 14 were selected for inclusion. A thematic analysis was undertaken. Common themes identified were resources, GP participation, leadership, clarity regarding roles in primary care teams, skills and knowledge for primary care team working, communication and community.

CONCLUSION

There is evidence of significant problems that disrupt team formation and functioning that warrants more comprehensive research.

Can social cognitive theory constructs explain socio-economic variations in adolescent eating behaviours? A mediation analysis

Adolescents of low socio-economic position (SEP) are less likely than those of higher SEP to consume diets in line with current dietary recommendations. The reasons for these SEP variations remain poorly understood. We investigated the mechanisms underlying socio-economic variations in adolescents' eating behaviours using a theoretically derived explanatory model. Data were obtained from a community-based sample of 2529 adolescents aged 12-15 years, from 37 secondary schools in Victoria, Australia. Adolescents completed a web-based survey assessing their eating behaviours, self-efficacy for healthy eating, perceived importance of nutrition and health, social modelling and support and the availability of foods in the home. Parents provided details of maternal education level, which was used as an indicator of SEP. All social cognitive constructs assessed mediated socio-economic variations in at least one indicator of adolescents' diet. Cognitive factors were the strongest mediator of socio-economic variations in fruit intakes, while for energy-dense snack foods and fast foods, availability of energy-dense snacks at home tended to be strong mediators. Social cognitive theory provides a useful framework for understanding socio-economic variations in adolescent's diet and might guide public health programmes and policies focusing on improving adolescent nutrition among those experiencing socio-economic disadvantage.

Expanding the value of qualitative theories of illness experience in clinical practice: a grounded theory of secondary heart disease prevention

Qualitative theories of illness experience are about the individual interpretations of the psychosocial and cultural aspects of living with illness. Thus, they contribute to a better understanding of health and health care provision. In this paper, we examine how a grounded theory (GT) of heart disease experience can inform secondary prevention. In-depth interviews of individual experience of heart disease were conducted with 26 patients, using GT iterative data collection and analysis framework. A GT was compiled from data and examined within a sociocultural framework to ascertain how experience influenced health behaviour. Despite individual contextual variations, the theory of 'keeping it going' describes the study sample's common attitude to living with heart disease. The theory was adequate in explaining secondary cardiac behaviour, because it identified the aspects of patients' beliefs and attitudes which are key to effective secondary prevention. The assessment of the impact of illness experience on health behaviour within a sociocultural framework helped to articulate the strong influence of social and contextual factors. The study offers an appropriate explanatory framework for encouraging health behaviour change. It emphasizes the importance of interventions being relevant to individual perceptions and interpretations. It provides a framework for designing and evaluating cardiac interventions and the theoretical principles which underpin them.

Should patients with facial fractures be regarded as high risk for HIV?

OBJECTIVE

To determine the prevalence of HIV seropositivity in patients with facial fractures in Edinburgh, UK.

DESIGN

A prospective study of 100 consecutive patients in 1994.

SETTING

Department of Maxillofacial Surgery, City Hospital, Edinburgh, UK.

SUBJECTS

100 patients with facial fractures who were willing to participate in the study.

MAIN OUTCOME MEASURES

Details of facial fractures. Assessment of risk factors for HIV. The seroprevalence of HIV based on unlinked anonymous testing of saliva.

RESULTS

None of the participants were HIV positive on saliva testing. Nine patients were found to have one or more risk factors for HIV. Eight patients had been tested for HIV previously.

CONCLUSION

Direct history taking appears to be effective in eliciting risk factors for HIV. A detailed risk factor history should be taken for all patients with facial fractures. Continuation of this study may establish whether or not there is a link between facial bone fractures and HIV seropositivity.

Planning and commissioning of health services for children and young people

BACKGROUND

Local audits in England and Wales performed in 1994 showed that child health commissioning was not being given priority. We were concerned that child health commissioning was in addition not performed in a child-centred way, with the best interests of children to the fore.

METHOD

A survey of health authorities and boards was performed, to investigate child health commissioning in the United Kingdom. A questionnaire was sent to all directors of public health medicine in post in November 1994. The main outcome measures were child health experience within commissions and the context of children's services within the wider commissioning process.

RESULTS

A total of 120 (92%) of 129 authorities replied. Sixty-nine (58 per cent) had a named person with responsibility for child health services, of who 7 (5 per cent) worked exclusively within this area, 42 (32 per cent) had experience within clinical child health, and 19 (15 per cent) had postgraduate qualifications in child health. One hundred and five (81 per cent) authorities replied to a question on the comprehensiveness of the commissioning process; of these, 45 (34 per cent) planned and commissioned children's services in their entirety and 60 (46 per cent) planned and commissioned children's services in the context of other service areas. A majority did not plan and commission acute and community services together.

CONCLUSION

Many authorities had no named person with responsibility for a child health strategy. Of those that did, most named persons had inadequate experience and few had postgraduate qualifications in child health. Most authorities had no comprehensive planning mechanisms for children's services. In consequence, most commissions were failing to comply with the UN Convention on the Rights of the Child.

Labour and delivery of 'normal' primiparous women: analysis of routinely collected data

OBJECTIVE

To ascertain whether there is variation in obstetric practice within a defined subgroup of primiparous women.

DESIGN

Analysis of routinely collected data.

SUBJECTS

Ten thousand two hundred and ninety-five primiparous deliveries defined as 'normal' in Scotland during 1990 and 44,820 primiparous deliveries defined as 'normal' in England between April 1990 and April 1991.

RESULTS

Little variation was found in the distribution of mothers' ages and gestational ages at delivery, and babies' birthweights. In both England and Scotland there was considerable variation between regions in instrumental delivery rates and caesarean section rates. There were many deficiencies in the quality of the data provided by the English Maternity Hospital Episode System.

CONCLUSIONS

There is regional variation in instrumental delivery rates and caesarean section rates in England and Scotland. The poor quality of data for England makes interpretation of the cause of variation difficult because the extent to which variation may reflect deficiencies in the data, rather than differences in practice, is unknown. Improvements need to be made in Maternity Hospital Episode system data, increasing both coverage and data quality. Nevertheless, similar variations in instrumental delivery and caesarean section rates may be associated with differences in population characteristics not measured in these data sets of differences in obstetric practice.

The value of internal fixation and radiotherapy in the management of upper and lower limb bone metastases

Fifty-four consecutive patients underwent 61 orthopaedic operations for metastatic bone disease affecting the upper and lower limbs. These patients were subsequently managed using a consistent postoperative radiotherapy (RT) policy. There were 27 prophylactic internal fixations and 34 internal fixations of pathological fractures. There was a marked difference in survival between these groups. The median postoperative survival of the prophylactic (P) group was 15 months whereas that of the fracture (F) group was 2 months (P less than 0.0001). Ninety-three per cent of the P group and 59% of the F group were able to be discharged home following treatment. Subsequent local fracture requiring further surgical intervention occurred in 11% of the P group and in none of the F group. Seventy-eight per cent of the P group and 62% of the F group did not suffer any further sequelae at the operation site until the time of death or last follow-up. Patient mobility following surgery and RT for metastatic lesions occurring in the lower limb was significantly improved in both the P group (P less than 0.05) and in the F group (P less than 0.0001) such that 91% and 58%, respectively, of these patients were subsequently able to walk.

The Sheffield splint for controlled early mobilisation after rupture of the calcaneal tendon. A prospective, randomised comparison with plaster treatment

Forty patients with acute complete rupture of the calcaneal tendon were managed conservatively and randomly allocated to treatment groups using either cast immobilisation for eight weeks, or cast immobilisation for three weeks, followed by controlled early mobilisation in a Sheffield splint. The splint is an ankle-foot orthosis which holds the ankle in 15 degrees of plantar flexion, but allows some movement at the metatarsophalangeal joints. It is removed to allow controlled movement during physiotherapy. Patients treated with the splint regained mobility significantly more quickly (p less than 0.001) and preferred the splint to the plaster cast. The range of dorsiflexion at the ankle improved more rapidly after treatment in the splint (p less than 0.001), and patients were able to return to normal activities sooner. Recovery of the power of plantar flexion was similar in the two treatment groups, and no patient had excessive lengthening of the tendon. One re-rupture occurred in each group.

Possible transmission of Mycobacterium leprae in a group of UK leprosy contacts

A case of infectious leprosy in residential accommodation in the UK prompted a study of the cellular and humoral response to Mycobacterium leprae in two groups of individuals who were in contact with the index case for almost a year. In the younger staff group (mean age 44 years) 23 of 30 individuals had positive Mitsuda skin tests, 25 showed lymphocyte transformation to a soluble sonciate of M leprae and 2 had slightly raised IgM antibody concentrations to the terminal disaccharide of M leprae phenolic glycolipid-1. In the older group of residents (mean age 83 years) 7 of 36 individuals were skin-test positive, 25 of 33 were positive by lymphocyte transformation, but none had raised antibody levels. When retested on two further occasions, the same 2 individuals in the younger group still had raised antibody concentrations, 1 of whom had a persistent lepromin skin-test response for over 8 months and showed a pronounced increase in lymphocyte transformation to mycobacterial antigens. The findings suggest that transmission of M leprae may have occurred in these 2 contacts, who were therefore given 6 months' chemoprophylaxis with rifampicin.

General public education

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Do general practitioners and health visitors like 'parent held' child health records?

The study examines the reactions of general practitioners and health visitors to parents holding the main record of their own child's health and development. From 1986 the parents in part of the Oxfordshire district were given their child's records while in the other part of the health district the records remained with the clinic. The responses to questionnaires sent out to all general practitioners and health visitors in the two areas were analysed and compared. The results show that over 90% of the general practitioners and health visitors with experience of parent held records are in favour of them, wish to continue to use them, find them to be available in the clinic and are able to use them at other times. By comparison only 59% of those general practitioners who had no experience of parent held records are in favour of such a scheme. In general this latter group show greater concern in almost all areas investigated. Thus general practitioners' and health visitors' experience of the record suggests that it is not only workable but actually desirable.

Place of delivery: a review

Policies about place of delivery have tended to be formulated without either looking at existing evidence or doing new research into the relative safety for women and babies of delivery in different settings. This article reviews published research on the subject, and finds that many of the data required have not been collected. Furthermore, many analyses fail to take account of selection biases or differences in the birthweight distribution and the incidence of congenital malformations among babies born in different settings. Nevertheless, some tentative conclusions can be drawn. The available evidence does not support claims that, for the baby, the iatrogenic risks of obstetric intervention outweigh the possible benefits. At the same time, there is no evidence to support the claim that the shift to hospital delivery is responsible for the decline in perinatal mortality in England and Wales nor the claim that the safest policy is for all women to be delivered in hospital.