Involvement of alcohol in injury cases in rural Sri Lanka: prevalence and associated factors among in-patients in three primary care hospitals

Background

Injuries account for a major proportion of global morbidity and mortality related to alcohol use. Information on the prevalence of alcohol-related injury in rural Sri Lanka is limited. The aims of this study were to determine the burden of alcohol-related injury in a hospital-based sample in rural Sri Lanka and explore factors associated with an increased risk of alcohol-related injury.

Methods

Involvement of alcohol in injury amongst in-patients was assessed in three hospitals in the North Central Province of Sri Lanka over 6 months. Adult (≥ 18 years) patients were eligible. Patients were assessed for: injury characteristics, current alcohol use (in the past year) using the Alcohol Use Disorder Identification Test (AUDIT), and acute intoxication. Patients with a blood alcohol concentration (BAC) reading equivalent of 10 mg/dL (2.17 mmol/L) were considered as having an alcohol-related injury. Binary logistic regression was used to explore association between alcohol-related injury and demographic and injury characteristics.

Results

A total of 883 injured patients were eligible and consented to the study. No alcohol use was reported by 487 (55.2%) of patients (35.6% of men, 95.2% of women). Prevalence of alcohol-related injuries was 14.8% overall and 32.8% among current alcohol users. Almost all patients with an alcohol-related injury were male (122/123; 99.2%); 24 (18.8%) of these patients scored positive for possible alcohol dependence. Patients with an alcohol-related injury had significantly higher AUDIT scores (median = 15 vs 6, p < 0.001), were significantly more likely to be aged 26–40 (OR 2.29, 95% CI:1.11, 4.72) or 41–55 years (OR 2.76, 95% CI: 1.29, 5.90) (compared to 18–25 years), to have a transport-related injury (OR 5.14, 95% CI: 2.30, 11.49) (compared to animal/plant sting/bite), and have intentional injuries (OR 3.47, 95% CI: 1.01, 11.87).

Conclusions

One in three injuries among people who drank alcohol in this sample were alcohol-related. In addition, problematic alcohol use was higher among those with alcohol-related injury. Further work is needed to explore whether this prevalence of alcohol-related injury is reflected in other rural settings in Sri Lanka.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12958-8.

The burden of COVID-19 infection in a rural Tamil Nadu community

Background

There have been over 30 million cases of COVID-19 in India and over 430,000 deaths. Transmission rates vary from region to region, and are influenced by many factors including population susceptibility, travel and uptake of preventive measures. To date there have been relatively few studies examining the impact of the pandemic in lower income, rural regions of India. We report on a study examining COVID-19 burden in a rural community in Tamil Nadu.

Methods

The study was undertaken in a population of approximately 130,000 people, served by the Rural Unit of Health and Social Affairs (RUHSA), a community health center of CMC, Vellore. We established and evaluated a COVID-19 PCR-testing programme for symptomatic patients—testing was offered to 350 individuals, and household members of test-positive cases were offered antibody testing. We also undertook two COVID-19 seroprevalence surveys in the same community, amongst 701 randomly-selected individuals.

Results

There were 182 positive tests in the symptomatic population (52.0%). Factors associated with test-positivity were older age, male gender, higher socioeconomic status (SES, as determined by occupation, education and housing), a history of diabetes, contact with a confirmed/suspected case and attending a gathering (such as a religious ceremony, festival or extended family gathering). Amongst test-positive cases, 3 (1.6%) died and 16 (8.8%) suffered a severe illness. Amongst 129 household contacts 40 (31.0%) tested positive. The two seroprevalence surveys showed positivity rates of 2.2% (July/Aug 2020) and 22.0% (Nov 2020). 40 tested positive (31.0%, 95% CI: 23.02 − 38.98). Our estimated infection-to-case ratio was 31.7.

Conclusions

A simple approach using community health workers and a community-based testing clinic can readily identify significant numbers of COVID-19 infections in Indian rural population. There appear, however, to be low rates of death and severe illness, although vulnerable groups may be under-represented in our sample. It’s vital these lower income, rural populations aren’t overlooked in ongoing pandemic monitoring and vaccine roll-out in India.

Female Urgency, Trial of Urodynamics as Routine Evaluation (FUTURE study): a superiority randomised clinical trial to evaluate the effectiveness and cost-effectiveness of invasive urodynamic investigations in management of women with refractory overactive bladder symptoms

BACKGROUND

Overactive bladder (OAB) syndrome is a symptom complex affecting 12-14% of the UK adult female population. Symptoms include urinary urgency, with or without urgency incontinence, increased daytime urinary frequency and nocturia. OAB has a negative impact on women's social, physical, and psychological wellbeing. Initial treatment includes lifestyle modifications, bladder retraining, pelvic floor exercises and pharmacological therapy. However, these measures are unsuccessful in 25-40% of women (refractory OAB). Before considering invasive treatments, such as Botulinum toxin injection or sacral neuromodulation, most guidelines recommend urodynamics to confirm diagnosis of detrusor overactivity (DO). However, urodynamics may fail to show evidence of DO in up to 45% of cases, hence the need to evaluate its effectiveness and cost-effectiveness. FUTURE (Female Urgency, Trial of Urodynamics as Routine Evaluation) aims to test the hypothesis that, in women with refractory OAB, urodynamics and comprehensive clinical assessment is associated with superior patient-reported outcomes following treatment and is more cost-effective, compared to comprehensive clinical assessment only.

METHODS

FUTURE is a pragmatic, multi-centre, superiority randomised controlled trial. Women aged ≥ 18 years with refractory OAB or urgency predominant mixed urinary incontinence, and who have failed/not tolerated conservative and medical treatment, are considered for trial entry. We aim to recruit 1096 women from approximately 60 secondary/tertiary care hospitals across the UK. All consenting women will complete questionnaires at baseline, 3 months, 6 months and 15 months post-randomisation. The primary outcome is participant-reported success at 15 months post-randomisation measured using the Patient Global Impression of Improvement. The primary economic outcome is incremental cost per quality-adjusted life year gained at 15 months. The secondary outcomes include adverse events, impact on other urinary symptoms and health-related quality of life. Qualitative interviews with participants and clinicians and a health economic evaluation will also be conducted. The statistical analysis of the primary outcome will be by intention-to-treat. Results will be presented as estimates and 95% CIs.

DISCUSSION

The FUTURE study will inform patients, clinicians and policy makers whether routine urodynamics improves treatment outcomes in women with refractory OAB and whether it is cost-effective.

TRIAL REGISTRATION

ISRCTN63268739 . Registered on 14 September 2017.

Mesh inlay, mesh kit or native tissue repair for women having repeat anterior or posterior prolapse surgery: randomised controlled trial (PROSPECT)

OBJECTIVE

To compare standard (native tissue) repair with synthetic mesh inlays or mesh kits.

DESIGN

Randomised controlled trial.

SETTING

Thirty-three UK hospitals.

POPULATION

Women having surgery for recurrent prolapse.

METHODS

Women recruited using remote randomisation.

MAIN OUTCOME MEASURES

Prolapse symptoms, condition-specific quality-of-life and serious adverse effects.

RESULTS

A Mean Pelvic Organ Prolapse Symptom Score at 1 year was similar for each comparison (standard 6.6 versus mesh inlay 6.1, mean difference [MD] -0.41, 95% CI -2.92 to 2.11: standard 6.6 versus mesh kit 5.9, MD -1.21 , 95% CI -4.13 to 1.72) but the confidence intervals did not exclude a minimally important clinical difference. There was no evidence of difference in any other outcome measure at 1 or 2 years. Serious adverse events, excluding mesh exposure, were similar at 1 year (standard 7/55 [13%] versus mesh inlay 5/52 [10%], risk ratio [RR] 1.05 [0.66-1.68]: standard 3/25 [12%] versus mesh kit 3/46 [7%], RR 0.49 [0.11-2.16]). Cumulative mesh exposure rates over 2 years were 7/52 (13%) in the mesh inlay arm, of whom four women required surgical revision; and 4/46 in the mesh kit arm (9%), of whom two required surgical revision.

CONCLUSIONS

We did not find evidence of a difference in terms of prolapse symptoms from the use of mesh inlays or mesh kits in women undergoing repeat prolapse surgery. Although the sample size was too small to be conclusive, the results provide a substantive contribution to future meta-analysis.

TWEETABLE ABSTRACT

There is not enough evidence to support use of synthetic mesh inlay or mesh kits for repeat prolapse surgery.

ELECtric Tibial nerve stimulation to Reduce Incontinence in Care homes: protocol for the ELECTRIC randomised trial

BACKGROUND

Urinary incontinence (UI) is highly prevalent in nursing and residential care homes (CHs) and profoundly impacts on residents' dignity and quality of life. CHs predominantly use absorbent pads to contain UI rather than actively treat the condition. Transcutaneous posterior tibial nerve stimulation (TPTNS) is a non-invasive, safe and low-cost intervention with demonstrated effectiveness for reducing UI in adults. However, the effectiveness of TPTNS to treat UI in older adults living in CHs is not known. The ELECTRIC trial aims to establish if a programme of TPTNS is a clinically effective treatment for UI in CH residents and investigate the associated costs and consequences.

METHODS

This is a pragmatic, multicentre, placebo-controlled, randomised parallel-group trial comparing the effectiveness of TPTNS (target n = 250) with sham stimulation (target n = 250) in reducing volume of UI in CH residents. CH residents (men and women) with self- or staff-reported UI of more than once per week are eligible to take part, including those with cognitive impairment. Outcomes will be measured at 6, 12 and 18 weeks post randomisation using the following measures: 24-h Pad Weight Tests, post void residual urine (bladder scans), Patient Perception of Bladder Condition, Minnesota Toileting Skills Questionnaire and Dementia Quality of Life. Economic evaluation based on a bespoke Resource Use Questionnaire will assess the costs of providing a programme of TPTNS. A concurrent process evaluation will investigate fidelity to the intervention and influencing factors, and qualitative interviews will explore the experiences of TPTNS from the perspective of CH residents, family members, CH staff and managers.

DISCUSSION

TPTNS is a non-invasive intervention that has demonstrated effectiveness in reducing UI in adults. The ELECTRIC trial will involve CH staff delivering TPTNS to residents and establish whether TPTNS is more effective than sham stimulation for reducing the volume of UI in CH residents. Should TPTNS be shown to be an effective and acceptable treatment for UI in older adults in CHs, it will provide a safe, low-cost and dignified alternative to the current standard approach of containment and medication.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03248362. Registered on 14 August 2017. ISRCTN, ISRCTN98415244. Registered on 25 April 2018. https://www.isrctn.com/.

Reducing Asthma Attacks in Children using Exhaled Nitric Oxide as a biomarker to inform treatment strategy: a randomised trial (RAACENO)

Background

Childhood asthma is a common condition. Currently there is no validated objective test which can be used to guide asthma treatment in children. This study tests the hypothesis that the addition of fractional exhaled nitric oxide (F_ENO) monitoring in addition to standard care reduces the number of exacerbations (or attacks) in children with asthma.

Methods

This is a multi-centre, randomised controlled study. Children will be included of age 6–16 years who have a diagnosis of asthma, currently use inhaled corticosteroids (ICSs) and have had an exacerbation in the previous 12 months. Exclusion criteria include being unable to provide F_ENO measurement at baseline assessment, having another chronic respiratory condition and being currently treated with maintenance oral steroids. Participants will be recruited in both primary and secondary care settings and will be randomised to either receive asthma treatment guided by F_ENO plus symptoms (F_ENO group) or asthma treatment guided by symptoms only (standard care group). Within the F_ENO group, different treatment decisions will be made dependent on changes in F_ENO. Participants will attend assessments 3, 6, 9 and 12 months post randomisation. The primary outcome is asthma exacerbation requiring prescription and/or use of an oral corticosteroid over 12 months as recorded by the participant/parent or in general practitioner records. Secondary outcomes include time to first attack, number of attacks, asthma control score and quality of life. Adherence to ICS treatment is objectively measured by an electronic logging device. Participants are invited to participate in a “phenotyping” assessment where skin prick reactivity and bronchodilator response are determined and a saliva sample is collected for DNA extraction. Qualitative interviews will be held with participants and research nurses. A health economic evaluation will take place.

Discussion

This study will evaluate whether F_ENO can provide an objective index to guide and stratify asthma treatment in children.

Trial registration

ISRCTN, ISRCTN67875351. Registered on 12 April 2017. Prospectively registered.

Ciclosporin compared with prednisolone therapy for patients with pyoderma gangrenosum: cost-effectiveness analysis of the STOP GAP trial

Background

Pyoderma gangrenosum (PG) is a painful, ulcerating skin disease with poor evidence for management. Prednisolone and ciclosporin are the most commonly used treatments, although not previously compared within a randomized controlled trial (RCT).

Objectives

To compare the cost‐effectiveness of ciclosporin and prednisolone‐initiated treatment for patients with PG.

Methods

Quality of life (QoL, EuroQoL five dimensions three level questionnaire, EQ‐5D‐3L) and resource data were collected as part of the STOP GAP trial: a multicentre, parallel‐group, observer‐blind RCT. Within‐trial analysis used bivariate regression of costs and quality‐adjusted life years (QALYs), with multiple imputation of missing data, informing a probabilistic assessment of incremental treatment cost‐effectiveness from a health service perspective.

Results

In the base case analysis, when compared with prednisolone, ciclosporin was cost‐effective due to a reduction in costs [net cost: −£1160; 95% confidence interval (CI) −2991 to 672] and improvement in QoL (net QALYs: 0·055; 95% CI 0·018–0·093). However, this finding appears driven by a minority of patients with large lesions (≥ 20 cm²) (net cost: −£5310; 95% CI −9729 to −891; net QALYs: 0·077; 95% CI 0·004–0·151). The incremental cost‐effectiveness of ciclosporin for the majority of patients with smaller lesions was £23 374/QALY, although the estimate is imprecise: the probability of being cost‐effective at a willingness‐to‐pay of £20 000/QALY was 43%.

Conclusions

Consistent with the clinical findings of the STOP GAP trial, patients with small lesions should receive treatment guided by the side‐effect profiles of the drugs and patient preference – neither strategy is clearly a preferred use of National Health Service resources. However, ciclosporin‐initiated treatment may be more cost‐effective for patients with large lesions.

What's already known about this topic?

Pyoderma gangrenosum is characterized by severe, painful skin ulcers.

Although prednisolone has been the main systemic treatment, ciclosporin has been used increasingly because of its perceived greater effectiveness and fewer side‐effects.

STOP GAP was a pragmatic randomized controlled trial comparing ciclosporin and prednisolone: clinical effectiveness was similar, but only 50% of ulcers had healed by 6 months on either drug and adverse events were common with both drugs.

What does this study add?

For patients with small lesions (< 20 cm²), neither treatment is clearly more cost‐effective than the other.

However, ciclosporin‐initiated treatment may be the more cost‐effective option in patients with large (≥ 20 cm²) lesions.

Decisions about treatment will continue to be informed primarily by patient preference, underlying comorbidities, and drug side‐effect profiles (e.g. serious infections with prednisolone, hypertension and renal dysfunction with ciclosporin).

Linked Comment: Bray. Br J Dermatol 2017; 177:1475–1476.

Plain language summary available online

Reducing alcohol-related harm in disadvantaged men: development and feasibility assessment of a brief intervention delivered by mobile telephone

Background

Socially disadvantaged men suffer substantial harm from heavy drinking. Brief alcohol interventions are effective in reducing consumption when delivered via health care. There is a need for tailored brief interventions for disadvantaged men who seldom attend health care.

Objectives

(1) To investigate the best ways to recruit and retain disadvantaged men in a study aimed at reducing the frequency of heavy drinking. (2) To identify the type of content and timing of the delivery that is most likely to engage disadvantaged young to middle-aged men in an intervention delivered by text messages. (3) To determine whether or not the intervention is likely to be an acceptable way to influence the frequency of heavy drinking.

Design

A three-phase study involving the development of the recruitment strategy and the intervention, an assessment of the feasibility of a randomised controlled trial, and a post-study evaluation.

Setting

Community-based study, conducted in Dundee, UK.

Participants

Disadvantaged men aged 25–44 years who had two or more episodes of heavy drinking (≥ 8 units in a single session) in the preceding month. Two recruitment strategies were employed: recruitment through general practice (GP) registers and recruitment through a community outreach strategy.

Interventions

Focus groups explored drinking motives and behaviours of the target group. The intervention also drew on reviews of the literature on: alcohol brief interventions, text message studies, communication theory and behaviour change theories and techniques. The intervention group received 36 text messages with images sent over a 28-day period.

Main outcome measures

The outcome measures evaluated the likely success of a full trial: recruitment of the participants; construction and delivery of a theoretically and empirically based intervention that successfully engages disadvantaged men; potential for the intervention to influence binge drinking.

Results

The focus group analyses identified that personal experience and knowledge of the harmful effects of alcohol was widespread. Furthermore, there was a discrepancy between frequent binge drinking and perceived social expectations and duties. This could usefully be targeted in the intervention. Theoretically and empirically based behaviour change strategies were successfully rendered in attractive, colourful, brief text messages. Both recruitment strategies (GP registers and community outreach) proved successful and a total of 67 men were recruited, exceeding the target of 60. The participants were at high risk of harm because of frequent episodes of heavy binge drinking. Baseline interviews established that those recruited through community outreach drank substantially more and had more frequent binge drinking sessions than those recruited through GP registers. Retention at follow-up was 96%. Extensive process evaluation was conducted. The evaluation showed that 95% of text messages were successfully delivered to participants' telephones. Furthermore, there was a high level of engagement with text messages which sought responses. Most men replied to these texts, often giving carefully structured personal responses. Analyses of the responses indicated a high level of engagement with key components of the behaviour change strategy. Post-trial evaluation showed high levels of satisfaction with the intervention.

Conclusions

This study has shown that disadvantaged men can be recruited and retained in an alcohol intervention trial. A theoretically and empirically based intervention was successfully delivered by text message. Furthermore, the messages were well received and elicited the types of response intended. A full trial of the intervention, incorporating a cost-effectiveness study, should be carried out.

Study registration

This study is registered as ISRCTN10515845.

Funding

The National Institute for Health Research Public Health Research programme.

Conservative treatment for urinary incontinence in Men After Prostate Surgery (MAPS): two parallel randomised controlled trials

OBJECTIVE

To determine the clinical effectiveness and cost-effectiveness of active conservative treatment, compared with standard management, in regaining urinary continence at 12 months in men with urinary incontinence at 6 weeks after a radical prostatectomy or a transurethral resection of the prostate (TURP).

BACKGROUND

Urinary incontinence after radical prostate surgery is common immediately after surgery, although the chance of incontinence is less after TURP than following radical prostatectomy.

DESIGN

Two multicentre, UK, parallel randomised controlled trials (RCTs) comparing active conservative treatment [pelvic floor muscle training (PFMT) delivered by a specialist continence physiotherapist or a specialist continence nurse] with standard management in men after radial prostatectomy and TURP.

SETTING

Men having prostate surgery were identified in 34 centres across the UK. If they had urinary incontinence, they were invited to enroll in the RCT.

PARTICIPANTS

Men with urinary incontinence at 6 weeks after prostate surgery were eligible to be randomised if they consented and were able to comply with the intervention.

INTERVENTIONS

Eligible men were randomised to attend four sessions with a therapist over a 3-month period. The therapists provided standardised PFMT and bladder training for male urinary incontinence and erectile dysfunction. The control group continued with standard management.

MAIN OUTCOME MEASURES

The primary outcome of clinical effectiveness was urinary incontinence at 12 months after randomisation, and the primary measure of cost-effectiveness was incremental cost per quality-adjusted life-year (QALY). Outcome data were collected by postal questionnaires at 3, 6, 9 and 12 months.

RESULTS

Within the radical group (n = 411), 92% of the men in the intervention group attended at least one therapy visit and were more likely than those in the control group to be carrying out any PFMT at 12 months {adjusted risk ratio (RR) 1.30 [95% confidence interval (CI) 1.09 to 1.53]}. The absolute risk difference in urinary incontinence rates at 12 months between the intervention (75.5%) and control (77.4%) groups was -1.9% (95% CI -10% to 6%). NHS costs were higher in the intervention group [£ 181.02 (95% CI £ 107 to £ 255)] but there was no evidence of a difference in societal costs, and QALYs were virtually identical for both groups. Within the TURP group (n = 442), over 85% of men in the intervention group attended at least one therapy visit and were more likely to be carrying out any PFMT at 12 months after randomisation [adjusted RR 3.20 (95% CI 2.37 to 4.32)]. The absolute risk difference in urinary incontinence rates at 12 months between the intervention (64.9%) and control (61.5%) groups for the unadjusted intention-to-treat analysis was 3.4% (95% CI -6% to 13%). NHS costs [£ 209 (95% CI £ 147 to £ 271)] and societal costs [£ 420 (95% CI £ 54 to £ 785)] were statistically significantly higher in the intervention group but QALYs were virtually identical.

CONCLUSIONS

The provision of one-to-one conservative physical therapy for men with urinary incontinence after prostate surgery is unlikely to be effective or cost-effective compared with standard care that includes the provision of information about conducting PFMT. Future work should include research into the value of different surgical options in controlling urinary incontinence.

Long-term follow-up of patients with a painless inguinal hernia from a randomized clinical trial

BACKGROUND

Up to one-third of patients with an inguinal hernia have no symptoms from the hernia. The aim of this study was to determine the long-term outcome of patients with a painless inguinal hernia randomized to observation or operation.

METHODS

Some 160 men aged 55 years or more with a painless inguinal hernia were randomized to observation or operation between 2001 and 2003. All were invited to attend a research clinic at 6 and 12 months, and 5 years after randomization. Those unable to attend for clinical review were sent a questionnaire based on the clinical review pro forma.

RESULTS

After a median follow-up of 7.5 (range 6.2-8.2) years, 42 men had died (19 in the observation and 23 in the operation group); 46 of the 80 men randomized to observation had conversion to operation. The estimated conversion rate (using the Kaplan-Meier method) for the observation group was 16 (95 per cent confidence interval 9 to 26) per cent at 1 year, 54 (42 to 66) per cent 5 years and 72 (59 to 84) per cent at 7.5 years. The main reason for conversion was pain in 33 men, and two presented with an acute hernia. Sixteen men developed a new primary contralateral inguinal hernia and three had recurrent hernias. There have been 90 inguinal hernia repairs in the 80 patients randomized to surgery compared with 56 in those randomized to observation.

CONCLUSION

Most patients with a painless inguinal hernia develop symptoms over time. Surgical repair is recommended for medically fit patients with a painless inguinal hernia.

The PRaCTICaL study of nurse led, intensive care follow-up programmes for improving long term outcomes from critical illness: a pragmatic randomised controlled trial

OBJECTIVES

To test the hypothesis that nurse led follow-up programmes are effective and cost effective in improving quality of life after discharge from intensive care.

DESIGN

A pragmatic, non-blinded, multicentre, randomised controlled trial.

SETTING

Three UK hospitals (two teaching hospitals and one district general hospital).

PARTICIPANTS

286 patients aged >or=18 years were recruited after discharge from intensive care between September 2006 and October 2007.

INTERVENTION

Nurse led intensive care follow-up programmes versus standard care. Main outcome measure(s) Health related quality of life (measured with the SF-36 questionnaire) at 12 months after randomisation. A cost effectiveness analysis was also performed.

RESULTS

286 patients were recruited and 192 completed one year follow-up. At 12 months, there was no evidence of a difference in the SF-36 physical component score (mean 42.0 (SD 10.6) v 40.8 (SD 11.9), effect size 1.1 (95% CI -1.9 to 4.2), P=0.46) or the SF-36 mental component score (effect size 0.4 (-3.0 to 3.7), P=0.83). There were no statistically significant differences in secondary outcomes or subgroup analyses. Follow-up programmes were significantly more costly than standard care and are unlikely to be considered cost effective.

CONCLUSIONS

A nurse led intensive care follow-up programme showed no evidence of being effective or cost effective in improving patients' quality of life in the year after discharge from intensive care. Further work should focus on the roles of early physical rehabilitation, delirium, cognitive dysfunction, and relatives in recovery from critical illness. Intensive care units should review their follow-up programmes in light of these results.

TRIAL REGISTRATION

ISRCTN 24294750.

The cost-effectiveness of outpatient (at home) cervical ripening with isosorbide mononitrate prior to induction of labour

OBJECTIVES

To assess the cost-effectiveness of outpatient (at home) cervical ripening with isosorbide mononitrate (IMN) prior to induction of labour.

DESIGN

Economic evaluation was conducted alongside a randomised placebo controlled trial (the IMOP trial).

SETTING

Large UK maternity hospital.

POPULATION

A total of 350 nulliparous women with a singleton pregnancy, cephalic presentation > or = 37 weeks gestation, requiring cervical ripening prior to induction of labour.

INTERVENTIONS

Isosorbide mononitrate (n = 177) or placebo (n = 173) self-administered vaginally at home at 48, 32 and 16 hours prior to the scheduled time of admission for induction.

RESULTS

Mean health service costs between the period of randomisation and discharge for mother and infant were 1254.86 pound sterling in the IMN group and 1242.88 pound sterling in the placebo group, generating a mean cost difference of 11.98 pound sterling (bootstrap mean cost difference 12.86 pound sterling; 95%CI: -106.79 pound sterling, 129.39 pound sterling) that was not statistically significant (P = 0.842). The incremental cost per hour prevented from hospital admission to delivery was 7.53 pound sterling. At the notional willingness to pay threshold of 100 pound sterling per hour prevented from hospital admission to delivery, the probability that IMN is cost-effective was estimated at 0.67. This translated into a mean net monetary benefit of 98.13 pound sterling for each woman given IMN.

CONCLUSIONS

Although the probability that IMN is cost-effective approaches 0.7 at seemingly low willingness to pay thresholds for an hour prevented from hospital admission to delivery, our results should be viewed in the light of the clinical findings from the IMOP trial.

Evaluation of a mobile phone-based, advanced symptom management system (ASyMS) in the management of chemotherapy-related toxicity

OBJECTIVES

To evaluate the impact of a mobile phone-based, remote monitoring, advanced symptom management system (ASyMS) on the incidence, severity and distress of six chemotherapy-related symptoms (nausea, vomiting, fatigue, mucositis, hand-foot syndrome and diarrhoea) in patients with lung, breast or colorectal cancer.

DESIGN

A two group (intervention and control) by five time points (baseline, pre-cycle 2, pre-cycle 3, pre-cycle 4 and pre-cycle 5) randomised controlled trial.

SETTING

Seven clinical sites in the UK; five specialist cancer centres and two local district hospitals.

PARTICIPANTS

One hundred and twelve people with breast, lung or colorectal cancer receiving outpatient chemotherapy.

INTERVENTIONS

A mobile phone-based, remote monitoring, advanced symptom management system (ASyMS).

MAIN OUTCOME MEASURES

Chemotherapy-related morbidity of six common chemotherapy-related symptoms (nausea, vomiting, fatigue, mucositis, hand-foot syndrome and diarrhoea).

RESULTS

There were significantly higher reports of fatigue in the control group compared to the intervention group (odds ratio = 2.29, 95%CI = 1.04 to 5.05, P = 0.040) and reports of hand-foot syndrome were on average lower in the control group (odds ratio control/intervention = 0.39, 95%CI = 0.17 to 0.92, P = 0.031).

CONCLUSION

The study demonstrates that ASyMS can support the management of symptoms in patients with lung, breast and colorectal cancer receiving chemotherapy.

Comparison of combined urea and creatinine clearance and prediction equations as measures of residual renal function when GFR is low

BACKGROUND

UK, US and European guidelines recommend the decision to initiate dialysis should be based on a combination of measurements of kidney function, nutritional status and clinical symptoms. Such recommendations assume an accurate and reproducible measure of glomerular filtration rate (GFR).

METHODS

Prospective study of 97 patients with chronic kidney disease (CKD) and serum creatinine >200 micromol/l (2.26 mg/dl) who between them contributed 388 24 h urine collections. Our main outcome measure was the number of patients with low residual renal function identified by different tests, using widely accepted thresholds. We calculated sensitivity, specificity, positive and negative predictive values and receiver operating characteristic curves for each comparison using a combined urea and creatinine clearance of <15 ml/min to indicate the likely presence of end stage renal disease (CKD stage 5).

RESULTS

Seventy five patients had a combined urea and creatinine clearance <15 ml/min during the study. Using the highest measurement of serum creatinine for each patient, the best of the prediction equations was the 4-variable modification of diet in renal disease (MDRD) equation (area under ROC curve 0.93). This was followed by Kt/V (AUC 0.91) and Cockroft Gault with and without correction for ideal body weight (AUC 0.89). Further analyses showed that the 4-variable MDRD equation had higher NPV (64%) but lower PPV (89%) than the other tests (NPV 40-49%, PPV 92-100%), for identifying patients whose combined clearance was <15 ml/min.

CONCLUSION

The 4-variable MDRD formula is currently the best available prediction equation for GFR, but will nevertheless over estimate residual renal function when this is significantly impaired in up to 36% cases. Collection of 24 h urine samples may still have a role in the assessment of patients with stages 4 and 5 CKD.

Nature and prognostic importance of abnormal glucose tolerance and diabetes in acute heart failure

OBJECTIVE

To investigate the nature and importance of blood glucose abnormalities in an unselected heart failure (HF) population.

DESIGN

Cohort study.

SETTING

Urban University hospital.

PATIENTS

All index emergency HF admissions to one University hospital during the year 2000 were studied.

RESULTS

454 consecutive index admissions had blood chemistry, diabetic status and follow-up information recorded. 390 (86%) patients had an echocardiogram, of whom 117 (30%) had preserved left ventricular systolic function and 110 (24%) had diabetes. Sixty (13%) patients had abnormal glucose tolerance (8.0-10.99 mmol/l), and 284 (63%) patients had a normal admission blood glucose (<8 mmol/l). 51 (11.2%) patients died in hospital. After adjustment for other prognostic attributes, abnormal glucose tolerance (Cox hazard ratio HR, 95% CI: 5.920, 1.03 to 34.00; p = 0.046) but not diabetes (HR 3.46, 0.75 to 16.02; p = 0.112) predicted in-hospital mortality. During follow-up (median 812 (range 632-978) days), 104 (36.6%), 30 (50.0%) and 55 (50%) patients with a normal admission blood glucose concentration, abnormal glucose tolerance and diabetes, respectively, died (log rank test p = 0.0037, adjusted p = 0.075). Compared with patients with normal admission blood glucose, abnormal glucose tolerance (adjusted HR: 1.41 (0.92 to 2.16); p = 0.12) and diabetes (adjusted HR: 2.02 (1.41 to 2.88); p = 0.0001) predicted mortality. Considering glucose on admission as a continuous covariate, a 2 mmol/l increase was associated with a HR of 1.08 (1.03 to 1.13), p = 0.0010, which after adjustment for the above covariates became 1.08 (1.03 to 1.13), p = 0.0023.

CONCLUSIONS

Admission blood glucose concentration and diabetes are prognostically important in HF and could help target some patients for more intensive therapy.

Genetic Variation in the Interleukin-10 Gene Promoter and Risk of Coronary and Cerebrovascular Events: The PROSPER Study

Proinflammatory cytokines, like interleukin-6 (IL-6) and tumor necrosis factor-alpha (TNF-alpha), are implicated in the development of atherosclerosis. The role of anti-inflammatory cytokines, like IL-10, is largely unknown. We investigated the association of four single nucleotide polymorphisms (SNPs) in the promoter region of the IL-10 gene (4259AG, -1082GA, -592CA, and -2849GA), with coronary and cerebrovascular disease in participants of the PROspective Study of Pravastatin in the Elderly at Risk (PROSPER) trial. All associations were assessed with Cox proportional hazards models adjusted for sex, age, pravastatin use, and country. Haplotype analysis of the four SNPs showed a significant association between haplotype 4 (containing the -592A variant allele) and risk of coronary events (P = 0.019). Moreover, analysis of separate SNPs found a significant association between -2849AA carriers with incident stroke (HR (95%CI) 1.50 (1.04-2.17), P value = 0.02). Our study suggests that not only proinflammatory processes contribute to atherosclerosis, but that also anti-inflammatory cytokines may play an important role.

The value of the electrocardiogram in risk assessment in primary prevention: experience from the West of Scotland Coronary Prevention Study

Electrocardiograms (ECGs) were recorded at baseline, annually thereafter, and at run-out in the West of Scotland Coronary Prevention Study to which 6595 men aged from 45 to 65 years on entry were recruited. The baseline ECGs were analyzed with respect to (a) the primary end point of the study, namely, fatal or nonfatal myocardial infarction (MI) and (b) all-cause mortality. In addition, incident MIs were reviewed to determine those detected by ECG only. Heart rate, indexed left ventricular mass, frontal T axis, and T amplitude in lead I were all significantly predictive with respect to the primary end point in a multivariate analysis. With respect to all-cause mortality, minor ST-T changes, 10-second heart rate variability, and frontal T axis were similarly predictive. Of 355 incident MIs, 47.3% were silent or unrecognized and detected by ECG only. A simple ECG-based risk prediction equation for fatal and nonfatal MI is introduced.

Increased titres of anti-human heat shock protein 60 predict an adverse one year prognosis in patients with acute cardiac chest pain

OBJECTIVE

To assess whether antibodies to human heat shock protein 60 (anti-huhsp60) or to mycobacterial heat shock protein 65 (anti-mhsp65) predict an adverse one year prognosis in patients admitted with acute cardiac chest pain.

DESIGN

Prospective observational study.

SETTING

Teaching hospital.

PATIENTS

588 consecutive emergency admissions of patients with acute chest pain of suspected cardiac origin.

MAIN OUTCOME MEASURES

Anti-huhsp60 and anti-mhsp65 titres were assayed on samples drawn on the morning after admission. The end points after discharge were coronary heart disease death, non-fatal myocardial infarction, coronary artery bypass grafting, percutaneous transluminal coronary angioplasty, angiogram, or readmission with further cardiac ischaemic chest pain.

RESULTS

During follow up after discharge (mean of 304 days, range 1-788 days), 277 patients had at least one of the study outcomes. Patients with increased titres of anti-huhsp60 had an adverse prognosis (hazard ratio 1.56 (95% confidence interval 1.09 to 2.23) comparing highest versus lowest quartiles, p = 0.015). Anti-mhsp65 titres were not predictive.

CONCLUSIONS

Patients admitted with acute cardiac chest pain and increased titres of anti-huhsp60 had an adverse one year prognosis.

Heart failure with preserved left ventricular systolic function: a hospital cohort study

OBJECTIVE

To investigate how patients with heart failure with preserved left ventricular systolic function (LVSF) compare with patients with reduced LVSF.

DESIGN

Cohort study.

SETTING

Urban university hospital.

PATIENTS

528 index emergency admissions with heart failure during the year 2000. Information on LVSF and follow up was available for 445 (84%) of these patients.

RESULTS

130 (29%) patients had preserved LVSF (defined as an ejection fraction > 40%). The median follow up was 814 days (range 632-978 days). The average (SD) age was 72 (13) years. Women accounted for 62% and 45% of patients with preserved and reduced LVSF, respectively (p = 0.001). Patients with preserved LVSF (compared with those with reduced LVSF) had a higher prevalence of left ventricular hypertrophy (56% v 29%) and aortic valve disease (mean gradient > 20 mm Hg; 31% v 9%). Fewer patients with preserved LVSF received an angiotensin converting enzyme inhibitor (65% v 78%, p = 0.008) or spironolactone (12% v 21%, p = 0.027). Anaemia tended to occur more often in patients with preserved LVSF than in those with reduced LVSF (43% v 33% for women, p = 0.12; 59% v 49% for men, p = 0.22). There was a similarly high prevalence of significant renal dysfunction in both groups (estimated glomerular filtration rate < 60 ml/min/1.73 m2 in 68% with preserved and 64% with reduced LVSF, p = 0.40). Mortality was similar in both groups (preserved versus reduced 51 (39%) v 132 (42%), p = 0.51). Compared with patients with reduced LVSF, patients with preserved LVSF tended to have a lower risk of death or hospital admission for heart failure (56 (42%) v 165 (53%), p = 0.072) but a similar rate of death or readmission for any reason.

CONCLUSION

Patients with preserved LVSF had more co-morbid problems than those with reduced LVSF; however, prognosis was similar for both groups.

Early and late mortality after myocardial infarction in men and women: prospective observational study

OBJECTIVE

To compare characteristics, management, and outcome of myocardial infarction (MI) in men and women.

DESIGN

Prospective observational study.

SETTING

District general hospital in southwest Scotland.

PARTICIPANTS

966 men and 597 women admitted with first MI between 1994 and 2000 with follow up to the end of 2001.

RESULTS

393 (40.7%) men and 305 (51.1%) women died during a median follow up of 3.4 years for the survivors. Univariate analysis indicated an excess mortality among women (hazard ratio (HR) 1.45, 95% confidence interval (CI) 1.25 to 1.68), which disappeared after adjustment for age, smoking, co-morbidity, previous vascular disease, diabetes, hypertension, and social deprivation (HR 1.02, 95% CI 0.87 to 1.20). There was also an excess early mortality within 30 days among women (HR 1.54, 95% CI 1.20 to 1.98), though this did not retain significance after adjustment for the same covariates (HR 1.04, 95% CI 0.79 to 1.37). Small and insignificant differences were found in the proportion of men and women receiving thrombolysis on admission and secondary prophylactic drugs at discharge, except for statins and beta blockers, which were respectively more (adjusted odds ratio 1.48, 95% CI 1.10 to 1.98) and less (adjusted odds ratio 0.78, 95% CI 0.60 to 1.00) commonly prescribed to women.

CONCLUSION

Results suggest that the poorer outcome for women after MI reported in other studies may reflect sex bias in management as well as differences in age and co-morbidity and support the view that if women have access to the same quality of care as men then survival will be the same.

The link between circulating markers of endothelial function and proteinuria in patients with primary glomerulonephritis

INTRODUCTION

It is well established that there is an increase in the incidence of cardiovascular mortality in patients with proteinuric renal disease. The magnitude of the increase in risk is unlikely to be explained by traditional risk factors for cardiovascular disease alone. Proteinuria itself may constitute an additional risk factor, and proteinuric patients are known to have a degree of endothelial dysfunction. The nature of this relationship between proteinuria and endothelial function is the subject of intense investigation.

AIM

The aim of this study was to examine the relationship between proteinuria and endothelial dysfunction, as reflected by serum von Willebrand factor (vWF), and the soluble cell adhesion molecules VCAM and ICAM, in patients with primary glomerulonephritis (GN). A secondary aim was to discern whether any relationship could be explained by renal function, lipid profile, inflammation or blood pressure.

METHODS

A cross-sectional study was undertaken in consecutive patients attending a general nephrology clinic with biopsy-proven primary GN. Patients with end-stage renal disease (ESRD), those on immunosuppressive drugs, or with intercurrent infective illnesses were excluded. Blood pressure and body mass index were recorded. Routine lab assays were undertaken for serum creatinine, lipid profile, and 24-hour urinary protein (U(Prot)). Additional serum samples were stored at -80 degrees C for subsequent measurement of vWF, VCAM, ICAM and sensitive C reactive protein (sCRP).

RESULTS

Data were collected from 129 (86 male) patients. Mean (standard deviation) estimated creatinine clearance was 64 (32) ml/min, and median (interquartile range) 24-hour proteinuria was 1.1 (0.22-2.9) g. Mean vWF was 173 (68) IU/dl, median VCAM, ICAM and sCRP were 594 (410-708) ng/ml, 235 (208-286) ng/ml, and 2.33 (0.83-5.68) mg/l, respectively. There was a significant positive correlation between vWF and U(Prot) (Spearman rank correlation, r = 0.41, p < 0.001). When split into tertiles, according to U(Prot) (0-500 mg, 500-2000 mg, and > 2000 mg), there was a significant, stepwise increase in mean vWF (p < 0.001), log VCAM (p < 0.001), and log ICAM (p = 0.002). On multivariate analysis with vWF as the continuous dependent variable, U(Prot), age, total cholesterol and sCRP were the only significantly independent correlates (model-adjusted R2 = 33%).

CONCLUSION

In patients with primary GN, there is a significant association between endothelial activation as reflected by vWF, VCAM, or ICAM and increasing proteinuria. Elevations in vWF, as well as being related to classical risk factors, are associated with increases in total proteinuria and low-grade inflammation. Thus, future prospective studies should examine the extent to which vWF and other circulating markers of endothelial activation predict coronary heart disease risk in patients with proteinuric renal disease.

Relation between coronary pressure derived collateral flow, myocardial perfusion grade, and outcome in left ventricular function after rescue percutaneous coronary intervention

OBJECTIVE

To evaluate the relation between pressure derived coronary collateral flow (PDCF) index and angiographic TIMI (thrombolysis in myocardial infarction) myocardial perfusion (TMP) grade, angiographic collateral grade, and subsequent recovery of left ventricular function after rescue percutaneous coronary intervention (PCI) for failed reperfusion in acute myocardial infarction.

METHODS

The pressure wire was used as the guidewire in 38 consecutive patients who underwent rescue PCI between December 2000 and March 2002. Follow up angiography was performed at six months. Baseline and follow up single plane ventriculograms were analysed off line by an automated edge detection technique. A linear model was fitted to assess the relation between 0.1 unit increase in PDCF and change in left ventricular regional wall motion.

RESULTS

Patients with TMP 0 grade had significantly higher mean (SD) PDCF than patients with TMP 1-3 (0.30 (0.11) v 0.15 (0.07), p < 0.0001, r = -0.5). A similar relation was observed between TMP grade and coronary wedge pressure (mean (SD) 28 (16) mm Hg with TMP 0 v 9 (7) mm Hg with TMP 1-3, p = 0.001, r = -0.4). Higher PDCF was associated with increased left ventricular end diastolic pressures (0.28 (0.14) with end diastolic pressure > 20 mm Hg v 0.22 (0.09) with end diastolic pressure < 20 mm Hg, p = 0.08, r = 0.2). No correlation was observed between PDCF and Rentrops collateral grade (0.26 (0.13) with grade 0 v 0.25 (0.11) with grades 1-3, p = 0.4, r = -0.06). No linear relation existed between changes in PDCF and changes in left ventricular regional wall motion.

CONCLUSION

PDCF in the setting of rescue PCI for failed reperfusion after thrombolysis does not predict improvement in left ventricular function. Increased PDCF and coronary wedge pressure in acute myocardial infarction reflect a dysfunctional microcirculation rather than good collateral protection.

Awareness and analysis of a significant event by general practitioners: a cross sectional survey

OBJECTIVES

To determine the extent to which general practitioners (GPs) were aware of a recent significant event and whether a structured analysis of this event was undertaken to minimise the perceived risk of recurrence.

DESIGN

Cross sectional survey using a postal questionnaire.

SETTING

Greater Glasgow primary care trust.

PARTICIPANTS

466 principals in general practice from 188 surgeries.

MAIN OUTCOME MEASURES

GPs' self-reported personal and practice characteristics, awareness of a recent significant event, participation in the structured analysis of the identified significant event, perceived chance of recurrence, forums for discussing and analysing significant events, and levels of primary care team involvement.

RESULTS

Four hundred and sixty six GPs (76%) responded to the survey. GPs from single handed practices were less likely to respond than those in multi-partner training and non-training practices. 401 (86%) reported being aware of a recent significant event; lack of awareness was clearly associated with GPs from non-training practices. 219 (55%) had performed all the necessary stages of a structured analysis (as determined by the authors) of the significant event. GPs from training practices were more likely to report participation in the structured analysis of the recent event, to perceive the chance of this event recurring as "nil" or "very low", and to report significant event discussions taking place.

CONCLUSIONS

Most GPs were aware of a recent significant event and participated in the structured analysis of this event. The wider primary care team participated in the analysis process where GPs considered this involvement relevant. There is variation in the depth of and approach to significant event analysis within general practice, which may have implications for the application of the technique as part of the NHS quality agenda.

Implementation of videoconferencing to support a managed clinical network in Scotland: lessons learned during the first 18 months

Managed clinical networks (MCNs) are usually built on established groups of health professionals from both acute and primary care sectors. We have used videoconferencing to support the gynaecological oncology MCN in the west of Scotland. Videoconferencing was implemented simultaneously at five sites in 2001 and DICOM image-capture software was added in 2003. Videoconferencing and live PC links allowed the multidisciplinary teams to discuss individual cancer diagnoses without the extensive travelling previously required. Our experience of the implementation suggests that local ownership is crucial. In the present project, each of the stakeholders had an important role in the delivery of a successful system. High-quality project management is required during implementation and for some time thereafter to achieve sustainability.

Acute respiratory distress syndrome: an audit of incidence and outcome in Scottish intensive care units

This prospective audit of incidence and outcome of the acute respiratory distress syndrome was conducted as part of the national audit of intensive care practice in Scotland. All patients with acute respiratory distress syndrome in 23 adult intensive care units were identified using the diagnostic criteria defined by the American-European Consensus Conference. Daily data collection was continued until death or intensive care unit discharge. Three hundred and sixty-nine patients were diagnosed with acute respiratory distress syndrome over the 8-month study period. The frequency of acute respiratory distress syndrome in the intensive care unit population was 8.1%; the incidence in the Scottish population was estimated at 16.0 cases.100,000(-1).year(-1). Intensive care unit mortality for acute respiratory distress syndrome was 53.1%, with a hospital mortality of 60.9%. In our national unselected population of critically ill patients, the overall outcome is comparable with published series (Acute Physiology and Chronic Health Evaluation II standardised mortality ratio = 0.99). However, mortality from acute respiratory distress syndrome in Scotland is substantially higher than in recent other series suggesting an improvement in outcome in this condition.

Randomized clinical trial comparing consultant-led or open access investigation for large bowel symptoms

BACKGROUND

Referral of patients with large bowel symptoms is common and increasing. Currently most of these referrals are assessed at an outpatient clinic to determine the need and priority for investigation.

METHODS

Over 21 months, 1131 patients referred by the general practitioner with large bowel symptoms were randomized. Patients in the consultant-led group were assessed by surgeons with a colorectal interest while those in the open access group underwent colonoscopy if they were 55 years or older and flexible sigmoidoscopy if younger.

RESULTS

The most common symptom among referred patients was rectal bleeding (69.1 per cent) followed by change in bowel habit (48.8 per cent) and abdominal pain (32.3 per cent). There was a significant trend (P < 0.001) for patients in the consultant-led to have more investigations, and more patients in this group had no investigations (P < 0.001). Despite this, the percentage of patients with colonic or other pathology diagnosed was the same in both groups, 63.6 per cent in the consultant-led group compared with 61.8 per cent in the open access group (P = 0.558). Likewise the percentage of patients with cancer or other significant pathology was similar in both groups (13.9 versus 15.4 per cent; P = 0.532). The mean(s.d.) time to diagnose cancer or other significant pathology was 55.1(39.2) days in the consultant-led group compared with 57.4(33.6) days in the open access group (P = 0.514). The cost per patient was almost pound 105 more for patients in the consultant-led group.

CONCLUSION

Patients referred by the general practitioner with large bowel symptoms should go directly to a properly managed and staffed open access large bowel investigation unit. This would enable most patients to have their investigations completed at one hospital attendance.

Diarrhoea, vomiting and ACE inhibitors:--an important cause of acute renal failure

The occurrence of severe acute renal failure in 3 patients who developed diarrhoea while taking angiotensin converting enzyme (ACE) inhibitors led us to undertake a retrospective cohort survey to determine the frequency with which diarrhoea and vomiting are associated with acute renal failure in patients taking this class of drug. Serum creatinine was measured as part of the diagnostic workup of 2398 consecutive admissions to an acute medical receiving unit in a district general hospital. Outcome measures were the presence of diarrhoea and/or vomiting, and whether taking an ACE inhibitor, NSAID or diuretic at the time of admission, also previous, initial and follow up serum creatinine concentrations. Peak serum creatinine in the 3 cases was 1159, 989 and 765 micromol/l. None of the 3 required dialysis and all recovered renal function completely after receiving large volumes of intravenous fluid. In the cohort study, 89 of 2398(3.7%) admissions had serum creatinine >/=200 micromol/l. Nine were regular dialysis patients. Of the remaining patients, 30 (37.5%) were taking an ACE inhibitor. Six of 30 (20%) gave a history of diarrhoea and/or vomiting. Median creatinine concentration in this group was 135 (range 111-209) micromol/l before admission, 292 (216-724) micromol/l when first seen in hospital, and 134 (94-219) micromol/l following the withdrawal of drug therapy and fluid replacement. In conclusion, volume depletion causing acute renal failure in patients taking ACE inhibitors is not uncommon. Such patients and their general practitioners should be aware that reversible renal impairment may occur during intercurrent illnesses, particularly if characterised by diarrhoea and/or vomiting.

Early intervention for relapse in schizophrenia: results of a 12-month randomized controlled trial of cognitive behavioural therapy

BACKGROUND

The paper describes a randomized controlled trial of targeting cognitive behavioural therapy (CBT) during prodromal or early signs of relapse in schizophrenia. We hypothesized that CBT would result in reduced admission and relapse, reduced positive and negative symptoms, and improved social functioning.

METHOD

A total of 144 participants with schizophrenia or a related disorder were randomized to receive either treatment as usual (TAU) (N = 72) or CBT+TAU (N = 72). Participants were prospectively followed up between entry and 12 months.

RESULTS

At 12 months, 11 (15.3%) participants in the CBT group were admitted to hospital compared to 19 (26.4%) of the TAU group (hazard ratio = 0.53, P = 0.10, 95% CI 0.25, 1.10). A total of 13 (18.1%) participants in CBT relapsed compared to 25 (34.7%) in TAU (hazard ratio = 0.47, P < 0O05, 95% CI 0.24, 0.92). In addition, the CBT group showed significantly greater improvement in positive symptoms, negative symptoms, global psychopathology, performance of independent functions and prosocial activities.

CONCLUSIONS

The study provides evidence for the feasibility and effectiveness for targeting CBT on the appearance of early signs of relapse in schizophrenia. The results are discussed in context of the study's methodological limitations.

The value of routine non-invasive tests to predict clinical outcome in stable angina

BACKGROUND

Chronic stable angina is a common condition, but considerable differences exist in the likelihood of acute coronary events such as CHD death, non-fatal myocardial infarction (MI) and unstable angina between individual patients. Effective risk prediction is necessary for optimum management. The aim of this study was to identify clinical features and non-invasive test parameters associated with high risk of these coronary events in stable angina and compose a clinically useful model to predict adverse outcomes in this population.

METHODS

Six hundred and eighty-two patients with stable angina and a positive exercise test (1mm ST depression) from the Total Ischaemic Burden European Trial (TIBET) study, were studied. Resting ECG, exercise tolerance testing and echocardiography were performed at baseline, off anti-anginal therapy. The patients were then randomised to treatment with atenolol, nifedipine or a combination of both. Clinical follow up continued for an average of 2 years (range 1-3 years).

RESULTS AND CONCLUSIONS

Prior MI or prior CABG were the clinical parameters associated with adverse outcome in patients with stable angina and a positive exercise test. On the ECG, left ventricular hypertrophy was predictive, and on echocardiogram, increased left ventricular dimensions were predictive of adverse events. When combined with time to ischaemia on exercise testing in a simple clinically applicable table these factors could be used to predict of 2 year probability of events for an individual patient.

'Airway Alerts'. How UK anaesthetists organise, document and communicate difficult airway management

A questionnaire on organisation, documentation and communication of airway problems during anaesthesia was sent to 271 anaesthetic college tutors in the UK. Their responses were compared with three published recommendations. There was a 72% response rate (195/271). The recommendations of the American Society of Anaesthesiologists Task Force on the Management of the Difficult Airway were met by 71% of respondents; 2% met those suggested by the Canadian Airway Focus Group and 2% met those suggested in a standard UK textbook on difficulties in tracheal intubation. Guidelines for management of the difficult airway were available in 142 departments (73%), but only 41 (21%) had guidelines for communication and dissemination of information. We present an 'Airway Alert' scheme which has since been adopted by the Difficult Airway Society.

Testing cognitive function in elderly populations: the PROSPER study. PROspective Study of Pravastatin in the Elderly at Risk

OBJECTIVES

For large scale follow up studies with non-demented patients in which cognition is an endpoint, there is a need for short, inexpensive, sensitive, and reliable neuropsychological tests that are suitable for repeated measurements. The commonly used Mini-Mental-State-Examination fulfils only the first two requirements.

METHODS

In the PROspective Study of Pravastatin in the Elderly at Risk (PROSPER), 5804 elderly subjects aged 70 to 82 years were examined using a learning test (memory), a coding test (general speed), and a short version of the Stroop test (attention). Data presented here were collected at dual baseline, before randomisation for active treatment.

RESULTS

The tests proved to be reliable (with test/retest reliabilities ranging from acceptable (r=0.63) to high (r=0.88) and sensitive to detect small differences in subjects from different age categories. All tests showed significant practice effects: performance increased from the first measurement to the first follow up after two weeks.

CONCLUSION

Normative data are provided that can be used for one time neuropsychological testing as well as for assessing individual and group change. Methods for analysing cognitive change are proposed.

High incidence of renal failure requiring short-term dialysis: a prospective observational study

BACKGROUND

Previous estimates of incidence of acute renal failure (ARF) requiring renal replacement therapy have varied from 18 to 75 patients per million per year, but have been beset by problems of definition.

AIM

To investigate whether the '90-day rule' provides a more reliable, reproducible and robust estimate of the need for short-term dialysis.

SETTING

District general hospital serving a population of 147 000.

DESIGN

Prospective observational study.

METHODS

Patients who received renal replacement therapy in Dumfries and Galloway between 01/01/94 and 31/12/2000 were divided into two groups: long-term dialysis (> or =90 days) and short-term dialysis (<90 days).

RESULTS

Of 302 patients, 193 received short-term dialysis, giving an incidence for short-term dialysis of 187 patient episodes per million per year (95%CI 170-203). Use of a more conventional definition for ARF (including all ARF and acute-on-chronic renal failure, but excluding patients with chronic renal failure who present acutely) produced a similar estimate at 176 patients per million per year (95%CI 160-193).

DISCUSSION

The 90-day rule estimated the incidence of short-term dialysis/ARF at nearly twice the incidence of chronic renal failure requiring dialysis, and more than twice the most recent estimate of the incidence of ARF in the UK. The main attraction of the 90-day rule is its simplicity. If the high level of short-term dialysis/ARF found in our study is confirmed by other centres, there are significant resource implications for the provision of renal care.