Patient activation in advanced chronic kidney disease: a cross-sectional study

BACKGROUND

Patient activation refers to the knowledge, confidence and skills required for the management of chronic disease and is antecedent to self-management. Greater self-management in chronic kidney disease (CKD) results in improved patient experience and patient outcomes.

AIM

To examine patient activation levels in people with CKD stage 5 pre-dialysis and determine associations with sociodemographic characteristics, treatment adherence and healthcare utilisation.

METHODS/DESIGN

People with CKD stage 5 not receiving dialysis from one Australian kidney care service. Patient activation was measured using the 13-item Patient Activation Measure (PAM-13). Sociodemographic and clinical outcome data (emergency department visits, admissions) were collected from medical records. Morisky Medication Adherence Scale was used to determine self-report medication adherence.

RESULTS

Two hundred and four participants completed the study. The mean PAM-13 score was 53.4 (SD 13.8), with 73% reporting low activation levels (1 and 2). Patient activation scores significantly decreased with increased age (P < 0.001) and significantly increased with higher educational levels (P < 0.001). Higher patient activation level was associated with fewer hospital emergency department visits (P = 0.03) and increased medication adherence (P < 0.001).

CONCLUSION

Patient activation levels are low in people with CKD stage 5 not receiving dialysis suggesting limited ability for self-management and capacity for optimally informed decisions about their healthcare. Efforts to improve patient activation need to consider age and education level.

The impact on patients of the tertiary-primary healthcare interface in kidney failure: a qualitative study

BACKGROUND

Clinicians and patients have reported fragmentation in the primary and tertiary healthcare interface. However, perspectives of service navigation and the impacts of fragmentation are not well defined, particularly for patients transitioning to dialysis. This study aimed to define patient perspectives of the functioning of the health service interface and impacts on healthcare experiences and engagement, informing patient-centred and outcomes-focused service models.

METHODS

A qualitative study was conducted through semi-structured interviews with 25 dialysis patients (16 males) aged 34-78 receiving dialysis across a multi-site tertiary service. Transcripts were analysed thematically.

RESULTS

Three main themes were identified: (1) The Changing Nature of General Practitioner (GP) Patient Relationships; (2) Ownership and Leadership in Kidney Care; and (3) The Importance of Nephrologist-GP Communications. Patients perceived an unreliable primary-tertiary service interface which lacked coordinated care and created challenges for primary care continuity. These impacted perceptions of healthcare provider expertise and confidence in healthcare systems. Patients subsequently increased the healthcare sought from tertiary kidney clinicians. The fractured interface led some to coordinate communication between health sectors, to support care quality, but this caused additional stress.

CONCLUSIONS

A fragmented primary-tertiary healthcare interface creates challenges for patient service navigation and can negatively impact patient experiences, leading to primary care disengagement, reduced confidence in health care quality and increased stress. Future studies are imperative for assessing initiatives facilitating health system integration, including communication technologies, healthcare provider training, patient empowerment, and specific outcomes in health, economic and patient experience measures, for patients transitioning to dialysis.

Sex differences in functional limitation level and the role of socioeconomic factors

Background

Women are more likely to have functional limitations than men, partly due to socioeconomic disadvantage. As much of this research is based on dichotomised measures of limitation, how sex differences vary by level of limitations remains unclear. The aim of our study was to examine sex differences in functional limitations in people born between 1895 and 1960, with attention to the role of socioeconomic factors and level of limitations.

Methods

Longitudinal data on limitations in basic/instrumental activities of daily living (ADL/IADL) and mobility activities were drawn from studies in 14 countries. For ADL, IADL, and mobility activities, participants were grouped into limitation levels based on number of limited activities (0, 1, 2, or ≥ 3). Sex differences in limitations in four birth cohorts (1895-1929, 1930-1938, 1939-1945, 1946-1960) were analysed before and after adjustment for socioeconomic factors using mixed effects ordinal logistic models.

Findings

Among 62,375 participants, sex differences in IADL and ADL limitations (≥1) were minor after adjustment for socioeconomic factors (sex difference in probability of limitations (female - male) age 75, 1895-1929 cohort for IADL=3.7% (95% CI 2.6, 4.7) before and 1.7% (1.1, 2.2) after adjustment; ADL=3.2% (2.3, 4.1) before, 1.4% (0.9, 1.8) after). Sex differences remained for mobility (16.1% (14.4, 17.7) before, 14.3% (12.7, 15.9) after). At older ages, women were more likely to have ≥3 IADL or mobility limitations, while men were more likely to have 1 to 2.

Conclusions

Socioeconomic factors explain the majority of sex differences in IADL and ADL limitations but not mobility, with women reporting greater mobility limitations than men starting in middle age. Our findings suggest sex differences in mobility limitations from middle age might be important targets for future study and interventions.

Key messages

Sex differences in disability vary considerably between disability measures. Comprehensive assessment of sex differences in disability should consider disability severity across different measures. Findings suggest there may be fewer sex differences in disability in the future with progressively decreasing socioeconomic disparities between men and women.

Ten-year alcohol consumption typologies and trajectories of C-reactive protein, interleukin-6 and interleukin-1 receptor antagonist over the following 12 years: a prospective cohort study

BACKGROUND

Moderate alcohol consumption is thought to confer cardiometabolic protective effects. Inflammatory pathways are hypothesized to partly underlie this association.

OBJECTIVES

The aim of this study was to examine the association between typologies of alcohol consumption and markers of inflammation, and their rate of change over time.

METHODS

Data were collected from 8209 participants [69% men; mean age, 50 years (SD 6.1)] of the British Whitehall II study. Alcohol consumption typologies were defined using up to three measures during an approximately 10-year period spanning from 1985 to 1994 as (i) stable nondrinkers, (ii) stable moderate drinkers (referent), (iii) stable heavy drinkers, (iv) nonstable drinkers and (v) former drinkers. C-reactive protein (CRP), interleukin (IL)-6 and IL-1 receptor antagonist (IL-1 RA) were measured up to three times in the following 12 years.

RESULTS

Stable moderate drinkers had lower levels of CRP than stable nondrinkers, stable heavy drinkers, former drinkers and nonstable drinkers, but there were no differences in the rate of change in CRP over time between groups. Stable nondrinkers had higher levels of IL-6 as did stable heavy drinkers; rates of change in IL-6 over time were also increased in the latter group. Stable nondrinkers also had higher levels of IL-1 RA. These associations were robust to adjustment for confounding factors.

CONCLUSION

Our novel investigation of 10-year drinking typologies shows that stable moderate alcohol consumption is associated with a long-term inflammatory marker profile that is consistent with conferring a reduced risk of developing coronary heart disease.

Does physical activity moderate the association between alcohol drinking and all-cause, cancer and cardiovascular diseases mortality? A pooled analysis of eight British population cohorts

OBJECTIVE

To examine whether physical activity (PA) moderates the association between alcohol intake and all-cause mortality, cancer mortality and cardiovascular diseases (CVDs) mortality.

DESIGN

Prospective study using 8 British population-based surveys, each linked to cause-specific mortality: Health Survey for England (1994, 1998, 1999, 2003, 2004 and 2006) and Scottish Health Survey (1998 and 2003).

PARTICIPANTS

36 370 men and women aged 40 years and over were included with a corresponding 5735 deaths and a mean of 353 049 person-years of follow-up.

EXPOSURES

6 sex-specific categories of alcohol intake (UK units/week) were defined: (1) never drunk; (2) ex-drinkers; (3) occasional drinkers; (4) within guidelines (<14 (women); <21 (men)); (5) hazardous (14-35 (women); 21-49 (men)) and (6) harmful (>35 (women) >49 (men)). PA was categorised as inactive (≤7 MET-hour/week), active at the lower (>7.5 MET-hour/week) and upper (>15 MET-hour/week) of recommended levels.

MAIN OUTCOMES AND MEASURES

Cox proportional-hazard models were used to examine associations between alcohol consumption and all-cause, cancer and CVD mortality risk after adjusting for several confounders. Stratified analyses were performed to evaluate mortality risks within each PA stratum.

RESULTS

We found a direct association between alcohol consumption and cancer mortality risk starting from drinking within guidelines (HR (95% CI) hazardous drinking: 1.40 (1.11 to 1.78)). Stratified analyses showed that the association between alcohol intake and mortality risk was attenuated (all-cause) or nearly nullified (cancer) among individuals who met the PA recommendations (HR (95% CI)).

CONCLUSIONS

Meeting the current PA public health recommendations offsets some of the cancer and all-cause mortality risk associated with alcohol drinking.

Heart rate variability and depressive symptoms: a cross-lagged analysis over a 10-year period in the Whitehall II study

BACKGROUND

People with depression tend to have lower heart rate variability (HRV), but the temporal sequence is poorly understood. In a sample of the general population, we prospectively examined whether HRV measures predict subsequent depressive symptoms or whether depressive symptoms predict subsequent levels of HRV.

METHOD

Data from the fifth (1997-1999) and ninth (2007-2009) phases of the UK Whitehall II longitudinal population-based cohort study were analysed with an average follow-up of 10.5 years. The sample size for the prospective analysis depended on the analysis and ranged from 2334 (644 women) to 2276 (602 women). HRV measures during 5 min of supine rest were obtained. Depressive symptoms were evaluated by four cognitive symptoms of depression from the General Health Questionnaire.

RESULTS

At follow-up assessment, depressive symptoms were inversely associated with HRV measures independently of antidepressant medication use in men but not in women. Prospectively, lower baseline heart rate and higher HRV measures were associated with a lower likelihood of incident depressive symptoms at follow-up in men without depressive symptoms at baseline. Similar but statistically insignificant associations were found in women. Adjustments for known confounders including sociodemographic and lifestyle factors, cardiometabolic conditions or medication did not change the predictive effect of HRV on incident depressive symptoms at follow-up. Depressive symptoms at baseline were not associated with heart rate or HRV at follow-up in either sex.

CONCLUSIONS

These findings are consistent with an aetiological role of the autonomic nervous system in depression onset.

Polioencephalomalacia and Heart Failure Secondary to Presumptive Thiamine Deficiency, Hepatic Lipidosis, and Starvation in 2 Abandoned Siamese Cats

Two 4-year-old spayed female Siamese cats were seized by the British Columbia Society for the Prevention of Cruelty to Animals after confinement to an abandoned housing unit without food for 9 weeks. One cat was found dead, and the second was euthanized within 24 hours due to neurologic deterioration despite therapy. Polioencephalomalacia of the caudal colliculus, hepatic lipidosis, cachexia, and congestive heart failure with cardiomyocyte atrophy were identified in both cats through postmortem examination and attributed to a prolonged period of starvation. Brain lesions were likely the result of thiamine deficiency (Chastek paralysis), which can be associated with both malnutrition and liver disease. This case highlights the importance of thiamine supplementation during realimentation of cats with hepatic lipidosis. Heart failure resulting from cachexia may have contributed to the death of the first cat and the morbidity of the second cat.

The influence of fledgling location on adult provisioning: a test of the blackmail hypothesis

One theory to explain the existence of conspicuous solicitation is that it is a way for young to 'blackmail' carers into provisioning them, by threatening their own destruction. Fledgling birds offer a unique opportunity to investigate the 'blackmail theory', as their mobility enables them to influence the predation risk they face. We investigated a novel solicitation behaviour in fledgling pied babblers (Turdoides bicolor), where fledglings use their location to influence provisioning rates. We show that fledglings face a trade-off: the ground is a much more profitable location in terms of provisioning rate from adult carers, but they are at greater risk from predators owing to their limited flying ability and slow response to alarm calls. Young babbler fledglings move to the ground when hungry, signalling their state, and this stimulates adults to increase their provisioning rates. Once satiated, fledglings return to the safety of cover. By experimentally increasing terrestrial predation risk, we found that adults increased their provisioning rate to terrestrial but not arboreal fledglings. Thus, by moving to a riskier location, fledglings revealed their need and were able to manipulate adults to achieve higher provisioning rates. These results provide support for the 'blackmail theory'.

Hereditary spastic paraplegia and amyotrophy associated with a novel locus on chromosome 19

We identified a family in Mali with two sisters affected by spastic paraplegia. In addition to spasticity and weakness of the lower limbs, the patients had marked atrophy of the distal upper extremities. Homozygosity mapping using single nucleotide polymorphism arrays showed that the sisters shared a region of extended homozygosity at chromosome 19p13.11-q12 that was not shared by controls. These findings indicate a clinically and genetically distinct form of hereditary spastic paraplegia with amyotrophy, designated SPG43.

ENACCT's pilot education program (PEP): A model to enhance understanding of cancer clinical trials for community providers and community leaders

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Background: While nearly 20% of adult cancer patients are eligible for cancer clinical trials, less than 3% of cancer patients participate. Rates of participation are lower among communities of color and the medically underserved. Enhanced community engagement and provider training about cancer clinical trials can potentially result in greater awareness, access, and ultimately, patient accrual. Methods: A three-year Pilot Education Program was developed to explore the impact and feasibility of a community-driven outreach and education intervention focusing on community members, community health care providers, and cancer researchers in three medically underserved communities. Using a train-the-trainer model, PEP sought to raise clinical trial awareness among peers and encourage public inquiries about clinical trials. Workshops for clinical trials staff addressed recruitment and retention practices. Additionally, community sites worked to reduce local policy barriers to clinical trials participation.PEP used web-based surveys, interviews, focus groups and field observation to evaluate impact. Results: Seventy-five trainers were recruited. PEP reached 882 community members (63% minority), 374 health care providers (16% minority) and 61 cancer clinical trial staff. Approximately 5,800 individuals were exposed to educational activities through extended community outreach activities and dissemination of educational materials. Among those completing evaluation surveys, 66% of community leader trainees said they spoke to others about cancer clinical trials. Seventy-two percent of health care providers agreed their role is to inform patients about the possibility of receiving treatment through a clinical trial. Among cancer clinical trial staff, 80% indicated intention to work with community groups on cancer clinical trials education. Seventy-seven unique patient profiles were created with a national cancer clinical trials matching service also associated with PEP. Conclusions: Results from ENACCT's Pilot Education Program suggest promise in improving knowledge among community leaders and health care providers, and fostering greater peer-to-peer education about cancer clinical trials.

[Table: see text]

Who benefits most from the cardioprotective properties of alcohol consumption--health freaks or couch potatoes?

BACKGROUND

The cardioprotective properties of moderate alcohol consumption, compared with abstinence or heavy drinking, are widely reported, but whether the benefits are experienced equally by all moderate drinkers is less well known.

AIMS

To examine the association between average alcohol intake per week and the incidence of fatal and non-fatal myocardial infarction during 17 years of follow-up for 9655 men and women without prevalent disease in the general population; and to test whether the level of cardioprotection differs according to subjects' other health behaviours (healthy, moderately healthy, unhealthy) at entry to the study.

METHOD

A longitudinal, British civil service-based cohort study, baseline in 1985-8.

RESULTS

A significant benefit of moderate drinking compared with abstinence or heavy drinking was found among those with poor health behaviours (little exercise, poor diet and smokers). No additional benefit from alcohol was found among those with the healthiest behaviour profile (> or =3 hours of vigorous exercise per week, daily fruit or vegetable consumption and non-smokers).

CONCLUSION

The cardioprotective benefit from moderate drinking does not apply equally to all drinkers, and this variability should be emphasised in public health messages.

WITHDRAWN: Multidisciplinary team interventions for delirium in patients with chronic cognitive impairment

BACKGROUND

Delirium is common in hospitalized elderly people. Delirium may affect 60% of frail elderly people in hospital. Among the cognitively impaired, 45% have been found to develop delirium and these patients have longer lengths of hospital stay and a higher rate of complications which, with other factors, increase costs of care. The management of delirium has commonly been multifaceted, the primary emphasis has to be on the diagnosis and therapy of precipitating factors, but as these may not be immediately resolved, symptomatic and supportive care are also of major importance.

OBJECTIVES

The objective of this review is to assess the available evidence for the effectiveness, if any, of multidisciplinary team interventions in the coordinated care of elderly patients with delirium superimposed on an underlying chronic cognitive impairment in comparison with usual care.

SEARCH STRATEGY

The trials were identified from a last updated search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 3 July 2003 using the terms delirium and confus* . The Register is regularly updated and contains records of all major health care databases and many ongoing trial databases.

SELECTION CRITERIA

Selection for possible inclusion in this review was made on the basis of the research methodology - controlled trials whose participants are reported as having chronic cognitive impairment, and who then developed incident delirium and were randomly assigned to either coordinated multidisciplinary care or usual care.

DATA COLLECTION AND ANALYSIS

Nine controlled trials were identified for possible inclusion in the review, only one of which met the inclusion criteria. At present the data from that study cannot be analysed. We have requested additional data from the authors and are awaiting their reply.

MAIN RESULTS

No studies focused on patients with prior cognitive impairment, so management of delirium in this group could not be assessed. There is very little information on the management of delirium in the literature despite an increasing body of information about the incidence, risks and prognosis of the disorder in the elderly population.

AUTHORS' CONCLUSIONS

The management of delirium needs to be studied in a more clearly defined way before evidence-based guidelines can be developed. Insufficient data are available for the development of evidence-based guidelines on diagnosis or management. There is scope for research in all areas - from basic pathophysiology and epidemiology to prevention and management. Though much recent research has focused on the problem of delirium, the evidence is still difficult to utilize in management programmes. Research needs to be undertaken targeting specific groups known to be at high risk of developing delirium, for example the cognitively impaired and the frail elderly. As has been highlighted by Inouye 1999, delirium has very important economic and health policy implications and is a clinical problem that can affect all aspects of care of an ill older person.Delirium, though a frequent problem in hospitalized elderly patients, is still managed empirically and there is no evidence in the literature to support change to current practice at this time.

Suppression of behavioural and physiological oestrus in the mare by vaccination against GnRH

OBJECTIVE

To examine the immunogenicity of an equine immunocontraceptive vaccine and its efficacy in controlling hormone-related behaviour.

DESIGN

A total of 24 mares at two sites in Australia were vaccinated with an immunocontraceptive vaccine comprising gonadotrophin releasing hormone (GnRH) conjugated to a carrier protein in immunostimulating complex as an adjuvant. Twelve animals at each site received a placebo of adjuvant alone and served as controls for seasonal oestrus, hormonal and behaviour patterns. Animals were observed for injection site reactions, ovarian and follicular activity, and serum levels of antibody, 17beta-oestradiol and progesterone in the weeks following vaccination. Mares were also examined for oestrous behaviour by teasing with a stallion.

RESULTS

All mares responded to vaccination. Two weeks following the second vaccination there was a peak in antibody response to GnRH that declined gradually over the following weeks. Commensurate with the elevated anti-GnRH antibody there was a marked effect on ovarian activity with a reduction in 17beta-oestradiol and progesterone levels in the 24 vaccinated mares. There was also a reduction of oestrus-related behaviour as determined by a teaser stallion. This effect lasted a minimum of 3 months and correlated with the initial level of antibody response.

CONCLUSION

Following a conventional two-dose immunisation regime this commercially available equine immunocontraceptive vaccine was effective at inhibiting oestrous behaviour for at least 3 months. This vaccine has a high level of safety since there were no significant local reactions nor were there any adverse systemic responses to vaccination.

Multidisciplinary team interventions for delirium in patients with chronic cognitive impairment

BACKGROUND

Delirium is common in hospitalized elderly people. Delirium may affect 60% of frail elderly people in hospital. Among the cognitively impaired, 45% have been found to develop delirium and these patients have longer lengths of hospital stay and a higher rate of complications which, with other factors, increase costs of care. The management of delirium has commonly been multifaceted, the primary emphasis has to be on the diagnosis and therapy of precipitating factors, but as these may not be immediately resolved, symptomatic and supportive care are also of major importance.

OBJECTIVES

The objective of this review is to assess the available evidence for the effectiveness, if any, of multidisciplinary team interventions in the coordinated care of elderly patients with delirium superimposed on an underlying chronic cognitive impairment in comparison with usual care.

SEARCH STRATEGY

The trials were identified from a last updated search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 3 July 2003 using the terms delirium and confus*. The Register is regularly updated and contains records of all major health care databases and many ongoing trial databases.

SELECTION CRITERIA

Selection for possible inclusion in this review was made on the basis of the research methodology - controlled trials whose participants are reported as having chronic cognitive impairment, and who then developed incident delirium and were randomly assigned to either coordinated multidisciplinary care or usual care.

DATA COLLECTION AND ANALYSIS

Nine controlled trials were identified for possible inclusion in the review, only one of which met the inclusion criteria. At present the data from that study cannot be analysed. We have requested additional data from the authors and are awaiting their reply.

MAIN RESULTS

No studies focused on patients with prior cognitive impairment, so management of delirium in this group could not be assessed. There is very little information on the management of delirium in the literature despite an increasing body of information about the incidence, risks and prognosis of the disorder in the elderly population.

REVIEWERS' CONCLUSIONS

The management of delirium needs to be studied in a more clearly defined way before evidence-based guidelines can be developed. Insufficient data are available for the development of evidence-based guidelines on diagnosis or management. There is scope for research in all areas - from basic pathophysiology and epidemiology to prevention and management. Though much recent research has focused on the problem of delirium, the evidence is still difficult to utilize in management programmes. Research needs to be undertaken targeting specific groups known to be at high risk of developing delirium, for example the cognitively impaired and the frail elderly. As has been highlighted by Inouye 1999, delirium has very important economic and health policy implications and is a clinical problem that can affect all aspects of care of an ill older person.Delirium, though a frequent problem in hospitalized elderly patients, is still managed empirically and there is no evidence in the literature to support change to current practice at this time.

Surface analysis and depth profiling of corrosion products formed in lead pipes used to supply low alkalinity drinking water

Modern analytical techniques have been applied to investigate the nature of lead pipe corrosion products formed in pH adjusted, orthophosphate-treated, low alkalinity water, under supply conditions. Depth profiling and surface analysis have been carried out on pipe samples obtained from the water distribution system in Glasgow, Scotland, UK. X-ray diffraction spectrometry identified basic lead carbonate, lead oxide and lead phosphate as the principal components. Scanning electron microscopy/energy-dispersive x-ray spectrometry revealed the crystalline structure within the corrosion product and also showed spatial correlations existed between calcium, iron, lead, oxygen and phosphorus. Elemental profiling, conducted by means of secondary ion mass spectrometry (SIMS) and secondary neutrals mass spectrometry (SNMS) indicated that the corrosion product was not uniform with depth. However, no clear stratification was apparent. Indeed, counts obtained for carbonate, phosphate and oxide were well correlated within the depth range probed by SIMS. SNMS showed relationships existed between carbon, calcium, iron, and phosphorus within the bulk of the scale, as well as at the surface. SIMS imaging confirmed the relationship between calcium and lead and suggested there might also be an association between chloride and phosphorus.

A comparison of the alcohol-attributable mortality in four European countries

BACKGROUND

Deaths due to alcohol consumption are an important component of all-cause mortality, particularly premature mortality. However, there are considerable regional variations, the reasons for which are unclear.

METHODS

Estimates were made as reliably as possibly using vital statistics and best estimates of risk of the alcohol-attributable mortality, by age, sex and cause for four European countries (England and Wales, Germany, Denmark and Italy). Twenty-seven alcohol-related conditions were considered including the possible cardio-protective effects of alcohol.

RESULTS

It was estimated that there are approximately 2% fewer deaths annually in England and Wales than would be expected in a non-drinking population and 0.3% fewer deaths among East German females. In West Germany, Denmark, Italy and among East German males there are more deaths caused by alcohol than are prevented (between 0.7 and 2.6% of all deaths). The highest age-specific proportion of alcohol-attributable deaths is found in East Germany where around 30% of deaths among males aged 25-44 years are due to drinking. Among young men in all four countries the largest contributor to alcohol-related deaths is road traffic accidents involving alcohol.

CONCLUSIONS

Possible explanations for the variation in alcohol-attributable deaths between countries include different underlying heart disease rates, different patterns of alcohol consumption and beverage preferences, and different use of mortality classification. Differences in the reported alcohol consumption levels explain little of the variation in alcohol-attributable deaths. Estimating alcohol-attributable mortality by age and sex across countries may be a useful indicator for developing alcohol strategies and exploring ways of preventing premature mortality.

Preferences and understanding their effects on health

Preference for a particular intervention may, possibly via complicated pathways, itself confer an outcome advantage which will be subsumed in unblind randomised trials as part of the measured effectiveness of the intervention. Where more attractive interventions are compared with less attractive ones, any difference could therefore be a consequence of attractiveness and not its intrinsic worth. For health promotion interventions this is clearly important, but we cannot tell how important it is for therapeutic interventions without special studies to measure or refute such effects. These are difficult to do and are complex. Until the therapeutic effects of preference itself are more clearly understood, understanding the true therapeutic effects will be compromised, at least in principle.

Curative resection for rectal carcinoma: definition influences outcome in terms of local recurrence

OBJECTIVE

There are wide variations in local recurrence rate following curative surgery for rectal cancer and there are substantial inconsistencies among surgeons regarding the method of defining curative resection. This paper seeks to explore whether defining criteria is one of the important factors driving the variations in outcome.

METHOD

A literature review was undertaken to find all UK-based studies that had data on curative resection and local recurrence rates. The studies were divided into groups with distinct definitions of curative resection for rectal cancer. Meta-analyses were performed to pool the risks of local recurrence by group definition. Statistical tests were used to explore the variation in local recurrence by group. Confounding relationships of age, sex, Dukes stage, length of follow-up and year of study were explored as far as possible given the limitations of the available data.

RESULTS

For rectal cancers significant differences were found between the pooled local recurrence risks by group definition (P < 0.01). Meta-regression tests including all the studies indicate that the definition of curative resection is an important predictor of local recurrence.

CONCLUSION

It is suggested that a standardized approach towards defining curative resection and local recurrence may have a significant effect on outcomes in colorectal cancer surgery and would enable comparisons to be made between different series.

Preferences and understanding their effects on health

Preference for a particular intervention may, possibly via complicated pathways, itself confer an outcome advantage which will be subsumed in unblind randomised trials as part of the measured effectiveness of the intervention. Where more attractive interventions are compared with less attractive ones, any difference could therefore be a consequence of attractiveness and not its intrinsic worth. For health promotion interventions this is clearly important, but we cannot tell how important it is for therapeutic interventions without special studies to measure or refute such effects. These are difficult to do and are complex. Until the therapeutic effects of preference itself are more clearly understood, understanding the true therapeutic effects will be compromised, at least in principle.

Daily variations in deaths in Lithuania: the possible contribution of binge drinking

BACKGROUND

During the early 1990s the countries of the Former Soviet Union experienced a dramatic rise in mortality, especially from cardiovascular diseases. Although still poorly understood there is evidence, particularly from Russia, that this mortality crisis is partly linked to alcohol consumption. In this paper we use data from Lithuania to explore the daily variations of deaths and the probable relationship with binge drinking.

METHODS

Computerized death certificates for those aged 20-59 years were analysed according to the day of death, place of death, and cause of death for the years 1988-1997.

RESULTS

There is a marked increase in deaths from accidents, violence, and alcohol poisoning at the weekend, suggesting a pattern of binge drinking in Lithuania. There is also a significant increase in ischaemic heart disease (IHD) deaths on Saturdays, Sundays and Mondays. If the analysis is performed separately according to place of death, the day of the week effect is strengthened for cardiovascular deaths outside of hospital; consistent with the idea of a sudden cardiac death.

CONCLUSION

The increase in mortality from cardiovascular diseases observed at the weekend in Lithuania is similar to that observed in Moscow and other populations. The relationship with alcohol consumption is supported by the available physiological evidence. We propose that bingeing can be solely responsible for, or acts as a 'catalyst' for, pathophysiological events by increasing blood pressure, cardiac rhythm and coagulability. The increased IHD mortality observed throughout the weekend and on Monday in Lithuania may reflect the influence of alcohol consumption patterns in a population already subject to high psychosocial stress.

Mortality in England and Wales attributable to current alcohol consumption

STUDY OBJECTIVE

To estimate the number of deaths attributable to current alcohol consumption levels in England and Wales by age and sex.

DESIGN

Epidemiological approach using published relative risks and population data.

SETTING

England and Wales.

MAIN OUTCOME MEASURES

Numbers of deaths by age and sex and years of life lost for alcohol related conditions.

RESULTS

Because of the cardioprotective properties of alcohol, it is estimated that there are approximately 2% fewer deaths annually in England and Wales than would be expected in a non-drinking population. This proportion varies greatly by age and sex and only among men aged over 55 years and women aged over 65 years is there likely to be found a net favourable mortality balance. It is also estimated that there were approximately 75 000 premature years of life lost in England and Wales in 1996 attributable to alcohol consumption. The main causes of alcohol attributable mortality among the young include road traffic fatalities, suicide and alcoholic liver disease.

CONCLUSIONS

At a population level, current alcohol consumption in England and Wales may marginally reduce mortality. However, the benefit is disproportionately found among the elderly. Estimating alcohol attributable mortality by age and sex may be a useful indicator for developing alcohol strategies. More research into the possible effect modifications of pattern of consumption, beverage type, age and gender will enable these estimates to be improved.

H2-receptor antagonists may increase the risk of cardio-oesophageal adenocarcinoma: a case-control study

Adenocarcinoma of the lower oesophagus and the gastric cardia has shown a dramatic worldwide increase in incidence over the last 25 years, but the cause is unknown. A large number of drugs have been introduced over this period of time, and it has been suggested that drugs that relax the lower oesophageal sphincter (DRLOS) might be causative, and on the other hand that non-steroidal anti-inflammatory drugs (NSAIDS) may be protective. H2-receptor antagonists (H2RAs) may allow achlorhydric reflux to continue without symptoms, and it is postulated that such asymptomatic reflux is uncontrolled by the usual conservative measures and may lead to increased oesophageal damage. H2RAs were first marketed in 1970 and might be the cause of the observed increase of cardio-oesophageal adenocarcinoma (COA). In a case-control study, the records of 56 subjects who died of COA in the period 1 January 1990 to 31 December 1992 were compared with those of 56 age-/sex-matched controls who died of myocardial infarction. They were 28 females and 84 males, mean age 69.8 years. The NHS records containing the lifetime prescription history of each subject were retrieved from the health authority. Each prescription was recorded, omitting drugs taken in the two years before diagnosis. Analysis was performed using conditional logistic regression. Other variables, including the use of antacids, steroids, smoking and alcohol, were also examined. Subjects dying of COA were more likely to have consumed H2RAs (relative risk (RR) 7.50, 95% CI 1.33-42.09, P < 0.02). On the other hand, they were less likely to have consumed NSAIDs (RR 0.16, 95% CI 0.03-0.93, P < 0.04) or DRLOS (RR 0.14, 95% CI 0.02-1.0, P = 0.05). This study supports a protective effect from NSAIDs against COA, but the similar effect of DRLOS is related to the increased use of cardiac drugs in the control group. H2RAs appear to have a harmful effect, which may be related to the worldwide increase in COA. However, the trend may have been apparent before cimetidine was widely available, and it is possible that the cause is multi-factorial.

Public health implications of new guidelines for lead in drinking water: a case study in an area with historically high water lead levels

Concern about the neurotoxicity of lead, particularly in infants and young children, has led to a revision of blood lead levels which are considered to involve an acceptable level of human exposure. Drinking water guidelines have also been reviewed in order to reduce this source of population exposure to lead. In the last 20 years, guidelines have been reduced from 100 to 50 to 10 microg/litre. Lead in tap water used to be a major public health problem in Glasgow because of the high prevalence of houses with lead service pipes, the low pH of the public water supply and the resulting high levels of lead in water used for public consumption. Following two separate programmes of water treatment, involving the addition of lime and, a decade later, lime supplemented with orthophosphate, it is considered that maximal measures have been taken to reduce lead exposure by chemical treatment of the water supply. Any residual problem of public exposure would require large scale replacement of lead service pipes. In anticipation of the more stringent limits for lead in drinking water, we set out to measure current lead exposure from tap water in the population of Glasgow served by the Loch Katrine water supply, to compare the current situation with 12 years previously and to assess the public health implications of different limits. The study was based on mothers of young children since maternal blood lead concentrations and the domestic water that mothers use to prepare bottle feeds are the principal sources of foetal and infant lead exposure. An estimated 17% of mothers lived in households with tap water lead concentrations of 10 microg/litre (the [WHO,] guideline) or above in 1993 compared with 49% in 1981. Mean maternal blood lead concentrations fell by 69% in 12 years. For a given water lead concentration, maternal blood lead concentrations were 67% lower. The mean maternal blood lead concentration was 3.7 microg/litre in the population at large, compared with 3.3 microg/litre in households with negligible or absent tap water lead. Nevertheless, between 63% and 76% of cases of mothers with blood lead concentrations of 10 microg/dl or above were attributable to tap water lead. The study found that maternal blood lead concentrations were well within limits currently considered safe for human health. About 15% of infants may be exposed via bottle feeds to tap water lead concentrations that exceed the WHO guideline of 10 microg/litre. In the context of the health and social problems which affect the well-being and development of infants and children in Glasgow, however, current levels of lead exposure are considered to present a relatively minor health problem.

The relation between alcohol and cardiovascular disease in Eastern Europe: explaining the paradox

BACKGROUND

Recent evidence from Eastern Europe of a positive association between alcohol and cardiovascular disease has challenged the prevailing view that drinking is cardioprotective. Consuming amounts of alcohol comparable to those consumed in France has been linked to detrimental cardiovascular effects. One possibility is that this could be related to the particular consequences of binge drinking, which is common in Russia.

METHODS

A systematic review of literature on the relation between cardiovascular disease and heavy drinking and irregular (binge) drinking.

RESULTS

Most existing reviews of the relation between alcohol and cardiovascular disease have examined the amount drunk per week or month and have not looked at the pattern of drinking. These have consistently shown that alcohol has a cardioprotective effect, even at high levels of consumption. In contrast, studies that have looked at pattern of drinking, either directly, or indirectly, using indicators such as frequency of hangovers or reports of the consequences of drunkenness, have consistently found an increased risk of cardiovascular death, particularly sudden death. A separate review of the physiological basis for a difference between regular heavy drinking and heavy binge drinking demonstrates that the two types of drinking have quite different effects.

CONCLUSION

An association between binge drinking and cardiovascular death meets the standard criteria for causality. It is important that future studies of alcohol related harm examine the pattern of drinking as well as the amount drunk.

Multidisciplinary team interventions for delirium in patients with chronic cognitive impairment

BACKGROUND

Delirium is common in hospitalized elderly people. In the frail elderly, delirium may occur in 60% of those hospitalized. In the cognitively impaired, 45% have been shown to develop delirium and these patients have longer lengths of stay and a higher rate of complications which, amongst other things, together contribute to an increase in cost of care. The combination of being elderly and chronically cognitively impaired leads to a high risk of delirium with the associated increased risk of prolonged hospital stay, complications, and poor outcomes. The management of delirium has commonly been multifaceted - the primary emphasis has always been on the diagnosis and therapy of the precipitating factors, but as this may not be immediately resolved, symptomatic and supportive care may become of major importance.

OBJECTIVES

The objective of this review is to assess the available evidence for the effectiveness, if any, of multidisciplinary team interventions in the coordinated care of patients with delirium superimposed on an underlying chronic cognitive impairment compared with the usual care of older cognitively impaired patients.

SEARCH STRATEGY

The Cochrane Controlled Trials Register (Cochrane Library, up to and including Issue 1, 1998) was searched using the terms 'delirium, controlled trial, cognitive'. MEDLINE, EMBASE and Psychlit (Ovid via Winspirs up to Feb 1998) were also searched with the same terms. Other sources including personal communications, ongoing trials, conference proceedings, handsearching and reference lists of published papers and books were all searched for relevant randomized controlled trials. The total yield from searching was 157 from which 8 (eight) were retained for consideration in the review.

SELECTION CRITERIA

From the initial search yields, all randomised controlled trials involving the management of elderly patients with delirium were identified. A single reviewer (AMB) discarded irrelevant publications based on the title of the publication and its abstract. In the event that the article could possibly be relevant, it was retrieved for further assessment. All references were compiled in a list with a commentary on type of article, eg review, prospective study etc and this was independently considered by the second reviewer (RR) who agreed to review all randomised controlled studies reported on patients with delirium. Selection for possible inclusion in this review was then made on the basis of the participants reported as having chronic cognitive impairment, who then developed incident delirium and were randomly assigned to either coordinated multidisciplinary care or usual care. The outcomes of interest were length of stay in hospital, morbidity (including complications), patient distress & impact on care environment, mortality, discharge arrangements and follow-up including assessment of cognitive function at 6 months. Studies in which patients with chronic cognitive impairment or dementia, managed for incident delirium, according to ICD 9 criteria (see note) were considered eligible for inclusion in the review. Studies of risk factors and non-randomized studies were excluded. Note: this classification has been widely utilised throughout the English speaking medical literature over the past 20 years: ICD 10 is still being incorporated into clinical coding systems and has not been utilised in studies published in 1996. (ABSTRACT TRUNCATED)

Mortality attributable to drinking, drinking too much, or drinking too little: a comparison of methods

BACKGROUND

The existence of a U-shaped relationship between alcohol consumption and all-cause mortality complicates the calculation and interpretation of mortality attributable to alcohol consumption.

METHODS

We used the relationships between all-cause mortality and alcohol consumption from four British cohort studies. For each study we defined a 'sensible drinking level' asthe level with lowest observed mortality. We estimated the fractions of deaths that were attributable to (1) any drinking (compared with not drinking), (2) drinking more than the 'sensible level', and (3) drinking less than the 'sensible level'.

RESULTS

Data from the Doctors' study suggest that on balance 22.3 per cent of deaths are prevented by alcohol consumption, yet the fractions of deaths attributable to drinking more than 8-14 units per week and less than 8-14 units per week are nearly equal (6.5 per cent and 6.4 per cent, respectively). In a sensitivity analysis we show that it is possible for alcohol consumption to prevent deaths overall yet for more deaths to be attributable to drinking above a sensible level than are attributable to drinking below the sensible level.

CONCLUSIONS

The balance of deaths attributable to or prevented by alcohol consumption provides no information about the deaths attributable to drinking above or below sensible levels. Using all-cause data in this way is likely to exaggerate the protective effect of alcohol consumption, so our results are only illustrative.

The impact of patient treatment preferences on the interpretation of randomised controlled trials

Reliable information about aggregate main treatment effects in cancer research comes from randomised controlled trials (RCTs). The possibility of important interactions, such as between treatment preferences and their effects, is necessarily subordinated in the quest for evidence about main treatment effects. If patient preferences can influence the effectiveness of treatments, for which there is some indirect evidence, then those estimates of the treatment's main organic effects from unblind RCTs might be wrong. RCTs clearly disallow patient choice and it is, therefore, important to know the extent of any preference effects in order to interpret the RCT evidence. It may be important to know whether they exist, and where and by how much they affect outcome. It is argued that measuring these effects reliably is methodologically difficult, and will require massive trials each directed at measuring one particular preference effect. Such effects have a slightly fanciful image, particularly in cancer treatment, and may be transient. Given the current uncertainties about their true nature and plausible biological mechanisms, the accumulated evidence is unlikely to provide sufficient justification for investing in such trials, given other current priorities.

Threats to applicability of randomised trials: exclusions and selective participation

BACKGROUND

Although the randomised controlled trial (RCT) is regarded as the 'gold standard' in terms of evaluating the effectiveness of interventions, it is susceptible to challenges to its external validity if those participating are unrepresentative of the reference population for whom the intervention in question is intended. In the past, reporting on numbers and types of potential subjects that have been excluded by design, and centres, clinicians or patients that have elected not to participate, has generally been poor, and the threat to inference posed by possible selection bias is unclear.

METHODS

A systematic review was undertaken, based largely on MEDLINE and EMBASE with follow-up of cited references, to assess the extent, nature and importance of excluding potential subjects or the unwillingness of particular centres, clinicians or patients to participate.

RESULTS

RCTs vary widely in the extent to which potential future recipients of treatment are included. The reasons cited for excluding certain categories of patient may be medical or scientific. Medical reasons include a high risk of adverse effects and the belief that benefit will be relatively small or absent (or has already been established) in the groups in question. Scientific reasons include more precise estimates of treatment effect because of a relatively homogeneous sample and the reduction of potential bias by excluding those individuals most likely to be lost to follow-up. Many RCTs have blanket exclusions, such as the elderly, women and ethnic minorities, but reasons for these exclusions are seldom given. Evaluative research is undertaken predominantly in university or teaching centres. Non-randomised studies are more likely than RCTs to include non-teaching centres. The effect of patient non-participation appears to depend on whether the RCT is concerned with treatment of an existing condition or with disease prevention. Participants in treatment trials tend to be more severely ill than those who do not participate. In contrast, those who participate in prevention trials are more likely to have adopted a healthy lifestyle than those who decline. Most evaluative studies fail to document adequately the characteristics of those who, while eligible, do not participate. However, subjects included in RCTs (i.e. eligible and participating) tend to have a different prognosis than patients identified from clinical databases.

CONCLUSIONS

Narrow inclusion criteria may offer benefits such as increased precision and reduced loss to follow-up, but there are important disadvantages, such as uncertainty about extrapolation of results, which may result in denial of effective treatment to groups who might benefit, and delay in obtaining definitive results because of reduced recruitment rate. Selective participation by teaching centres and sicker patients in treatment RCTs may exaggerate the measured treatment effect. Prevention trials, on the other hand, may underestimate effects as participants have less capacity to benefit.

The costs and benefits of primary total hip replacement. How likely are new prostheses to be cost-effective?

Many new hip prostheses are now available for use in total hip replacement. The majority remain untested relative to standard prostheses; however, many new prostheses are substantially more costly. We examine how much more effective new prostheses must be, in terms of reducing the need for revision operations, in order to justify this increased cost.

The positive relationship between alcohol and heart disease in eastern Europe: potential physiological mechanisms

Research into the effect of alcohol on cardiovascular disease has indicated protective effects from moderate consumption. These observations, made in industrialized countries, have influenced policies on alcohol in countries where the situation may be quite different--specifically, where consumption is substantially higher or patterns of drinking are different. In central and eastern Europe and the former Soviet Union, a growing body of epidemiological research indicates a positive rather than negative association between alcohol consumption and cardiovascular deaths, especially sudden cardiac deaths. By means of a systematic review of published work, we examine whether there is a physiological basis for the observed association between alcohol and heart disease seen in eastern Europe, focusing on the effects of high levels of consumption and of irregular or binge drinking. In binge drinkers, cardioprotective changes in high-density lipoproteins are not seen, and adverse changes in low-density lipoproteins are acquired. Irregular drinking is associated with an increased risk of thrombosis, occurring after cessation of drinking. It predisposes both to histological changes in the myocardium and conducting system and to a reduction in the threshold for ventricular fibrillation. Measures of frequency as well as quantity of consumption should be included in epidemiological studies. Taken with the epidemiological evidence emerging from eastern Europe, these observations have important implications for estimates of the burden of disease attributable to alcohol.

The Stanmore total hip arthroplasty. A 15- to 20-year follow-up study

An ongoing study was made of 804 primary Stanmore total hip prostheses implanted in 839 patients between 1973 and 1991. The earliest surviving implants were brought back for radiologic and clinical review in 1995 at an average of 17 years after surgery. The remainder of the patients still living were sent a questionnaire to assess their current status. Survivorship was 95% at 10 years, 85% at 15 years, and 73% at 20 years. The average Merle d'Aubigné-Postel score was excellent up until 14 years. Patient satisfaction remained high until 22 years. Overall, 10% of the prostheses had failed. The results of this study suggest that the Stanmore prosthesis is capable of producing satisfactory long-term results that compare favorably with those of other cemented prostheses.