Understanding frames: A qualitative study of young people's experiences of using standing frames as part of postural management for cerebral palsy

BACKGROUND

Consensus opinion supports standing frame use as part of postural management for nonambulant young people with cerebral palsy. Although the rationale for standing frame use and the associated challenges have been described, little attention has been given to the users' experiences. The aim of the current study was to explore young people's positive and negative experiences, and attitudes regarding standing frame use.

METHODS

Framework analysis informed an open exploration of young people's opinions of standing frames. Using semistructured interviews, 12 young people with cerebral palsy (6 female) were interviewed, providing the data set for transcription and thematic analysis.

FINDINGS

The first theme "attitudes to standing frames" describes the young people's understanding of why they use standing frames. Although standing frames can be painful, some young people believe they should be endured to improve their body structure and function. There were mixed views about the impact standing frames have socially, with some young people feeling excluded from their peers, and others feeling as though standing frames helped them "fit in." Some young people are not offered a choice about how and when they use their standing frame. The second theme "challenges of standing frame use" highlights the issues with standing frame use such as manual handling, interference from siblings, and the lack of aesthetically pleasing standing frame designs.

CONCLUSIONS

Young people report benefits related to choice, pain relief, and participation but can also cause pain, discomfort, and reduced independence and participation. Healthcare professionals should have open, informative conversations about potential benefits and challenges of standing frames on all aspects of the young people's lives, including participation and activity.

Understanding frames: A UK survey of parents and professionals regarding the use of standing frames for children with cerebral palsy

BACKGROUND

Standing frames are used for children with cerebral palsy (CP). They may improve body structure and function (e.g., reducing risk of hip subluxation, and improving bladder and bowel function), improving activity (e.g., motor abilities) and participation (e.g., interaction with peers), but there is little evidence that they do. We aimed to identify current UK standing frame practice for children with CP and to understand stakeholder views regarding their clinical benefits and challenges to use.

METHOD

Three populations were sampled: clinicians prescribing standing frames for children with CP (n = 305), professionals (health and education) working with children with CP who use standing frames (n = 155), and parents of children with CP who have used standing frames (n = 91). Questionnaires were developed by the co-applicant group and piloted with other professionals and parents of children with CP. They were distributed online via clinical and parent networks across the UK.

RESULTS

Prescribing practice was consistent, but achieving the prescribed use was not always possible. Respondents in all groups reported the perceived benefits of frames, which include many domains of the International Classification of Functioning Disability and Health for Children and Youth. Challenges of use are related to physical space and child-reported pain.

CONCLUSIONS

These survey findings provide information from key stakeholders regarding current UK standing frame practice.

Randomised preference trial of medical versus surgical termination of pregnancy less than 14 weeks' gestation (TOPS)

OBJECTIVES

To determine the acceptability, efficacy and costs of medical termination of pregnancy (MTOP) compared with surgical termination of pregnancy (STOP) at less than 14 weeks' gestation, and to understand women's decision-making processes and experiences when accessing the termination service.

DESIGN

A partially randomised preference trial and economic evaluation with follow-up at 2 weeks and 3 months.

SETTING

The Royal Victoria Infirmary, Newcastle upon Tyne, UK.

PARTICIPANTS

Women accepted for termination of pregnancy (TOP) under the relevant Acts of Parliament with pregnancies < 14 weeks' gestation on the day of abortion. A further group of women attending contraception and sexual health clinics participated in a discrete choice experiment (DCE).

INTERVENTIONS

STOP: all women > or = 6 weeks' and < 14 weeks' gestation were primed with misoprostol 400 micrograms 2 hours before the procedure. STOP was performed under general anaesthesia using vacuum aspiration. MTOP: all women < 14 weeks' gestation were given mifepristone 200 milligrams orally, returning 36-48 hours later for misoprostol.

OUTCOME MEASURES

Main outcome measure was acceptability of TOP method. Secondary outcome measures included strength of preference by willingness to pay (WTP); distress, using the Impact of Event Scale (IES); anxiety and depression; satisfaction with care; experience of care; frequency and extent of symptoms including self-assessment of pain; clinical effectiveness; and complications. A DCE was used to identify attributes that shape women's preferences for abortion services.

RESULTS

The trial recruited 1877 women, 349 in the randomised arms and 1528 in the preference arms. Of those in the preference arms, 54% chose MTOP. At 2 weeks after the procedure more women having STOP would choose the same method again in the future. Acceptability of MTOP declined with increasing gestational age. The difference in acceptability between STOP and MTOP persisted at 3 months. At 2 weeks after TOP, women in the preference arms were prepared to pay more to have their preferred option. There was no difference in anxiety or depression scores in women having MTOP or STOP. However, women randomised to MTOP had higher scores on subscales of the IES at both 2 weeks and 3 months. There was no difference in IES scores between MTOP and STOP in the preference arm. Women were more likely to be satisfied overall and with technical and interpersonal aspects of care if they had STOP rather than MTOP. Experience of care scores were lower after MTOP in both randomised and preference arms. During admission women undergoing MTOP had more symptoms and reported higher mean pain scores, and after discharge reported more nausea and diarrhoea. There were no differences in time taken to return to work between groups; around 90% had returned to work and normal activity by 2 weeks. Rates of unplanned or emergency admissions were higher after MTOP than after STOP. Overall complication rates were also higher after MTOP, although this only achieved statistical significance in the preference arm. Overall, STOP cost more than MTOP due to higher inpatient standard costs. Even though complication rates were higher with MTOP, it was still more cost-effective. DCE identified three attributes with an almost equal impact on women's preferences: provision of counselling, number of days delay to the procedure, and possibility of an overnight stay.

CONCLUSIONS

MTOP was associated with more negative experiences of care and lower acceptability. Acceptability of MTOP declined with increasing gestational age. MTOP was less costly but also less effective than STOP. The majority of women choosing MTOP were satisfied with their care and found the procedure acceptable. RECOMMENDATIONS FOR FURTHER RESEARCH: An audit of provision of MTOP and STOP in England and Wales is urgently required. Further studies exploring the barriers to offering women the choice of method of TOP are needed, together with research on the acceptability and effectiveness of (1) MTOP and manual VA in pregnancies below 9 weeks' gestation and (2) MTOP and dilatation and evacuation after 14 weeks' gestation.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN07823656.

Does living near heavy industry cause lung cancer in women? A case-control study using life grid interviews

BACKGROUND

The incidence of lung cancer among women is high in the highly industrialised area of Teesside in north-east England. Previous research has implicated industrial pollution as a possible cause. A study was undertaken to investigate whether prolonged residence close to heavy industry is associated with lung cancer among women in Teesside.

METHODS

Two hundred and four women aged <80 years with incident primary lung cancer and 339 age matched community controls were recruited to a population based case-control study. Life course residential, occupational, and active and passive smoking histories were obtained using an interviewer administered questionnaire.

RESULTS

The age adjusted odds ratio (OR) for lung cancer among people living >25 years v 0 years near (within 0-5 km) heavy industry in Teesside was 2.13 (95% CI 1.34 to 3.38). After adjustment for confounding factors the OR was 1.83 (95% CI 0.82 to 4.08) for >25 years or 1.10 (95% CI 0.96 to 1.26) for an additional 10 years living near industry. ORs were similar after residence near heavy industry outside Teesside was also included, and when latency was allowed for by disregarding residential exposures within the last 20 years. Adjustment for active smoking had the greatest effect on the OR.

CONCLUSIONS

This population based study using life grid interviews for life course exposure assessment has addressed many deficiencies in the design of previous studies. The findings support those in most of the international literature of a modestly raised risk of lung cancer with prolonged residence close to heavy industry, although the confidence intervals were wide. The effect of air pollution on the incidence of lung cancer merits continued study.

Factors associated with non-participation in a physical activity promotion trial

BACKGROUND

Non-participation can bias outcome in intervention studies of physical activity.

OBJECTIVES

To compare characteristics, knowledge and attitudes to physical activity in participants and non-participants of a physical activity intervention trial in primary care.

STUDY DESIGN

Cross-sectional survey.

METHODS

Patients aged 40-64 years were recruited opportunistically during surgery visits in an inner city general practice in Newcastle upon Tyne, UK. Attitudes to physical activity, views of its health benefits, and barriers to participation were elicited in interviews with participants, and by postal questionnaire from non-participants. Data held by general practitioners were used to compare anthropometry and lifestyle between groups.

RESULTS

Of 842 eligible patients, 276 (33%) refused outright (non-volunteers) and 566 volunteered for the intervention study, of which 353 (42%) attended a baseline assessment and 213 (25%) subsequently defaulted. The initial refusal rate was higher amongst men, smokers and those with addresses in more deprived areas. The response rate to the postal survey of non-volunteers was 45%. Compared with participants, the non-volunteers were more likely to be an adult carer and to report poorer health, and were less likely to have had higher education or to have children living at home. Far more non-volunteers considered that they already did enough exercise to maintain health. Non-volunteers had slightly less knowledge of the benefits of physical activity; attached far less importance to it in maintaining health; were more likely to cite 'fear of leaving their home unattended', 'do not enjoy exercise' and 'poor health' as barriers to exercise; and were less likely to cite 'no one to exercise with' as a barrier to exercise.

CONCLUSION

Recruitment of 'hard to engage' individuals requires careful phrasing of the message to focus on their personal goals and to address gaps in their knowledge about physical activity and the principal barriers they perceive. Differential uptake across population subgroups could lead to a widening of health inequalities.

Does long term residency near industry have an impact on the body burden of polychlorinated dibenzo-p-dioxins, furans, and polychlorinated biphenyls in older women?

BACKGROUND

For the retrospective study of environment and health linkages biomarkers of exposure are required. Polychlorinated dibenzo-dioxins and furans (PCDD/F) and polychlorinated biphenyls (PCBs) have been useful markers in some settings. This is the first study of PCDD/F body burden in a population based sample from the UK.

AIMS AND METHODS

The authors aimed to investigate whether long term residents close to a heavy chemical industrial complex (Teesside, UK) had a higher body burden and distinct pattern of PCDD/F and PCBs. We measured current levels of PCDD/F and PCBs in a population based sample of older women (mean 64 years, range 42-79 years). Forty women were recruited, 20 living near (zone A: 0.1-2.7 km) and 20 distant (zone C: 5-40 km) from industry during 2000-03. The authors ascertained occupational exposure to lung carcinogens, residential history, consumption of local produce, breast feeding, diet, and height and weight.

RESULTS

The mean body burden measured on lipid basis in ng/kg for the whole sample was: WHO-TEQ (PCDD/Fs): 29.9, 2378TCDD: 4.0, PCB 118:16200, PCB156: 13100. Body burdens were similar to others reported from industrialised countries, except that mean 2378TCDD was slightly higher. Mean ages, body mass index, and lifelong dietary patterns were similar in both zones. The authors found no significant difference in mean body burden levels between zones A and C before or after adjustment for covariates. All congener patterns were consistent with an urban background pattern, and there was no significant difference between congener compositions in the two zones. The TCDD body burden increased with age with accelerated increments above age 70.

CONCLUSION

Long term residency near heavy and chemical industry did not have an effect on women's body burden of PCDD/Fs and PCBs on Teesside, UK. The body burden of PCDD/F and PCBs was not a suitable biomarker for chronic, non-occupational exposure to industrial air pollution.

Cytochrome c oxidase deficient muscle fibres: Substantial variation in their proportions within skeletal muscles from patients with mitochondrial myopathy

Mitochondrial DNA (mtDNA) disease is a common cause of myopathy and the presence of histochemically demonstrated cytochrome c oxidase (COX) deficiency is an extremely useful diagnostic feature. However, there is currently no quantitative information regarding the variability of COX deficiency within or between muscles. This study addresses this issue by studying a number of skeletal muscle samples obtained at post-mortem from three patients with mitochondrial disease due to established mitochondrial DNA defects. COX deficient muscle fibres were enumerated in sections of these muscles and analysed according to patient, individual muscle, position within a particular muscle and sample size. Descriptive statistics were generated followed by an analysis of variance (ANOVA) to assess the effect of these parameters on the mean percentage of COX deficient fibres. We observed statistically significant variation in the percentage of COX deficient fibres within individual muscles from each patient for samples sizes of between 100 and 400 fibres. Our results have implications for the way in which biopsies of skeletal muscle are used for the assessment of disease severity, progression and response to treatment.

Clinical progression of mitochondrial myopathy is associated with the random accumulation of cytochrome c oxidase negative skeletal muscle fibres

We studied the accumulation of cytochrome c oxidase (COX)-negative skeletal muscle fibres in six patients with a myopathy due to a mitochondrial DNA (mtDNA) defect. Each patient was biopsied on two or more occasions over a period of 3-15 years. Progressive proximal weakness was associated with an increase in the proportion of COX-negative fibres. These fibres were arranged randomly, indicating that each fibre became COX negative independently of the status of neighbouring fibres. The clinical progression of mtDNA myopathy is therefore a consequence of a biochemical defect that develops independently within individual muscle fibres. It is likely that this is due to the clonal expansion of mutant mtDNA.

Children's respiratory health and daily particulate levels in 10 nonurban communities

We conducted a study to assess the association between the acute respiratory health of children and the levels of particulates in communities near and away from active opencast coal mines. The study enrolled children aged 1-11 years from the general population of five socioeconomically matched pairs of nonurban communities in northern England. Diaries of respiratory events were collected for 1405 children, and information was collected on the consultations of 2442 children with family/general practitioners over the 6-week study periods during 1996-1997, with concurrent monitoring of particulate levels. The associations found between daily PM(10) levels and respiratory symptoms were frequently small and positive and sometimes varied between communities. The magnitude of these associations were in line with those from previous studies, even though daily particulate levels were low, and the children were drawn from the general population, rather than from the population with respiratory problems. The associations among asthma reliever use, consultations with general practitioners, and daily particulate levels were of a similar strength but estimated less precisely. The strength of association between all respiratory health measures and particulate levels was similar in communities near and away from opencast coal mining sites.

Upper aerodigestive tract cancers in former employees at an iron and steel works

Local concern about numbers of laryngeal cancer cases led to an investigation of the incidence of upper aerodigestive tract (UAT) cancer in an industrial cohort. Males (n = 11 470) who had been directly employed at an iron and steel works in northern England at any time between January 1960 and site closure in September 1983 were followed up for UAT cancers until December 1998. The incidence of UAT and laryngeal cancer was compared to the general population of the region via indirect standardization. Fifty-two members of the cohort developed a UAT cancer during 1960-1998. There were no more UAT cancers than expected [standardized incidence ratio = 97, 95% confidence interval (CI) = 72-127], but slightly more laryngeal cancers than expected (standardized incidence ratio = 118, 95% CI = 78-171), although this estimate was less precise. The lack of complete work histories meant that relationships between cancer incidence and length of service or job categories could not be explored.

Consultations of children living near open-cast coal mines

Because of local concerns, general practitioner consultation rates in children living in communities close to and away from open-cast mines were compared. Information on consultations was collected on 2,442 children 1-11 years of age living in five socioeconomically matched pairs of open-cast and control communities in northern England. The data collection periods were 6 weeks each during 1996-1997 and the 52-week periods preceding these weeks. Consultations were categorized as respiratory, skin and eye conditions (possibly exacerbated by particulate matter), or other conditions. Over the 6-week periods, children in 4/5 pairs of open-cast and control communities had similar consultation rates for all conditions combined [2.7 vs. 2.4 per person-year; odds ratio (OR) = 1.1; 95% confidence interval (CI), 0.96-1.3). Consultations were higher in the open-cast communities for respiratory, skin, and eye conditions (2.1 vs. 1.5 per person-year; OR = 1.4; 95% CI, 1.2-1.7), and respiratory conditions alone (1.5 vs. 1.1 per person-year; OR = 1.5; 95% CI, 1.2-1.8). However, increases in consultation rates in open-cast communities were generally not seen over the portions of the 52-week periods when the open-cast sites were either active or inactive.

Prevalence of asthma and other respiratory symptoms in children living near and away from opencast coal mining sites

BACKGROUND

Public concern about respiratory conditions prompted the investigation of asthma and other respiratory diseases in children living near and away from opencast coal mining sites.

METHODS

We selected all 4860 children aged 1--11 years from five socioeconomically matched pairs of communities close to (OC) and away from (CC) active opencast sites. A postal questionnaire collected data on health and lifestyle. Outcomes were the cumulative and period prevalence (2 and 12 months) of wheeze, asthma, bronchitis and other respiratory symptoms.

RESULTS

The cumulative prevalence of wheeze varied from 30% to 40% across the ten communities, it was 36% in OC and 37% in CC. The cumulative prevalence of asthma was 22% in both OC and CC, varying between 12% and 24%. We found little evidence for associations between living near an opencast site and an increased prevalence of respiratory illnesses, or asthma severity. Some outcomes such as allergies, hayfever, or cough varied little across the study communities. Others, such as the use of asthma medication, the number of severe wheezing attacks in the past year or tonsillitis showed large variation. These similarities and variations were not explained by differences in lifestyle factors or differences in health services delivery and remain unexplained.

CONCLUSIONS

There was little evidence of an association between residential proximity to opencast mining sites and cumulative or period prevalence of respiratory illness, or asthma severity. Some variations in health outcomes between communities remained unexplained.

Identifying industrial sites with potential for residential exposure to asbestos

BACKGROUND

Non-occupational exposure to asbestos has been of increasing interest, but residential exposure to asbestos often focuses on a few high-profile asbestos users. This study aimed to identify industrial sites producing asbestos goods in a given area and time period.

METHODS

A search of trade directories was carried out for industrial sites in West Yorkshire, England, where asbestos may have been used this century.

RESULTS

A large number of factories with potential for residential exposure were found. A total of 269 factories in West Yorkshire used asbestos between 1900 and 1979, many for short periods only.

CONCLUSIONS

Identification of potential sources of residential exposure to asbestos would have greatly underestimated their number if either only high-profile users or existing official listings had been used. Any consideration of asbestos use should aim to identify all users, not just the high-profile manufacturers.

An exploratory population-based case-control study of primary biliary cirrhosis

Primary biliary cirrhosis (PBC) is a disease of unknown etiology, with unexplained geographical variation. Various exposures have been suggested as triggers for disease development-possibly in susceptible individuals, but the evidence was not always well founded. We therefore conducted a population-based case-control study in Northeast England to investigate these and other exposures. All cases incident during 1993 to 1995 in a defined area of Northeast England were identified, and age- and sex-matched population controls were identified from primary care population registers. Cases and controls were sent postal self-completion questionnaires covering medical history and lifestyle. Information was received from 100 cases and 223 controls. The familial tendency of PBC was found to be less marked than has been claimed: Only weak associations were found with other autoimmune diseases. Among factors considered previously, no significant associations were found with surgical procedures, events in pregnancy, past infections, vaccinations, and medications. No significant associations were found for previously unconsidered lifestyle factors (drinking alcohol, previous pets, or stressful events), but there was an unexpected association with past smoking (ever smoked: 76% in cases vs. 57% in controls, odds ratio 2.4; smoked for 20 years or more: 64% vs. 35%, odds ratio 3.5). There were also unexpected significant associations with psoriasis (13% in cases vs. 3% in controls, odds ratio 4.6) and eczema (3% in cases vs. 11% in controls, odds ratio 0. 13). These findings merit further investigation.

Living near opencast coal mining sites and children's respiratory health

OBJECTIVES

To answer the question whether living near opencast coal mining sites affects acute and chronic respiratory health.

METHODS

All 4860 children aged 1-11 from five socioeconomically matched pairs of communities close to active opencast sites and control sites away from them were selected. Exposure was assessed by concentrations of particulate matter with aerodynamic diameter < 10 microns (PM10), residential proximity to active opencast sites, and particle composition. PM10 was monitored and sampled for 6 weeks in four pairs, and for 24 weeks in one pair. A postal questionnaire collected data on health and lifestyle. Daily health information was collected by a symptom diary (concurrently with PM10 monitoring) and general practitioner (GP) records were abstracted (concurrently with PM10 monitoring and 52 weeks before the study). Outcomes were the cumulative and period prevalence (2 and 12 months) of wheeze, asthma, bronchitis, and other respiratory symptoms, and the prevalence and incidence of daily symptoms and GP consultations.

RESULTS

Patterns of the daily variation of PM10 were similar in opencast and control communities, but PM10 was higher in opencast areas (mean ratio 1.14, 95% confidence interval (95% CI) 1.13 to 1.16, geometric mean 17.0 micrograms/m3 v 14.9 micrograms/m3). Opencast sites were a measurable contributor to PM10 in adjacent areas. Little evidence was found for associations between living near an opencast site and an increased prevalence of respiratory illnesses, asthma severity, or daily diary symptoms, but children in opencast communities 1-4 had significantly more respiratory consultations (1.5 v 1.1 per person-year) than children in control communities for the 6 week study periods. Associations between daily PM10 concentrations and acute health events were similar in opencast and control communities.

CONCLUSIONS

Children in opencast communities were exposed to a small but significant amount of additional PM10 to which the opencast sites were a measurable contributor. Past and present respiratory health of children was similar, but GP consultations for respiratory conditions were higher in opencast communities during the core study period.

Cancer risk in primary biliary cirrhosis: a study in northern England

BACKGROUND

Suggestions that breast cancer may be more common in patients with primary biliary cirrhosis (PBC) have been challenged. It has recently been proposed that total cancer rates may be higher in patients with PBC, as well as liver cancers.

AIMS

To investigate these proposals on a strictly defined case series.

SUBJECTS

A total of 769 prevalent or incident PBC patients with "definite" or "probable" disease detected in a defined area of the north-east of England during 1987-94.

METHODS

Cancer events and deaths were identified by obtaining information from one or more of the following sources: Office for National Statistics (ONS) Central Registers, Regional Cancer Registry, and clinical case records. Standardised cancer incidence (SIR) and mortality ratios (SMR) were calculated using the local region as the standard population.

RESULTS

There were 97 cancer events during 1987-96. SIR from cancer registrations for all cancers was 1.7 (95% confidence interval (CI) 1.3 to 2.2), for liver cancer was 74 (95% CI 32 to 146), and for breast cancer was 1.1 (95% CI 0.4 to 2.4). SMR for all cancers was 1. 8 (95% CI 1.4 to 2.4), for liver cancer was 39 (95% CI 20 to 68), and for breast cancer was 0.4 (95% 0.1 to 1.6). The results were similar after excluding the first year of follow up after PBC diagnosis.

CONCLUSIONS

There was some evidence of a small increase in overall cancer incidence and mortality in PBC patients. With the exception of liver cancer, it is unlikely that there is a high excess incidence for PBC patients from any cancer at a particular site, and specifically breast cancer.

The Newcastle exercise project: a randomised controlled trial of methods to promote physical activity in primary care

OBJECTIVE

To evaluate the effectiveness of combinations of three methods to promote physical activity.

DESIGN

Randomised controlled trial. Baseline assessment with post-intervention follow up at 12 weeks and 1 year.

SETTING

One urban general practice, 1995-7.

PARTICIPANTS

523 adults aged 40 to 64 years, randomised to four intervention groups and a control group.

INTERVENTIONS

Brief (one interview) or intensive (six interviews over 12 weeks) motivational interviewing based on the stages of change model of behaviour change, with or without financial incentive (30 vouchers entitling free access to leisure facilities).

MAIN OUTCOME MEASURES

Physical activity score; sessions of moderate and vigorous activity in the preceding four weeks.

RESULTS

Response rate was 81% at 12 weeks and 85% at one year. More participants in the intervention group reported increased physical activity scores at 12 weeks than controls (38% v 16%, difference 22%, 95% confidence interval for difference 13% to 32%), with a 55% increase observed in those offered six interviews plus vouchers. Vigorous activity increased in 29% of intervention participants and 11% of controls (difference 18%, 10% to 26%), but differences between the intervention groups were not significant. Short term increases in activity were not sustained, regardless of intensity of intervention.

CONCLUSIONS

The most effective intervention for promoting adoption of exercise was the most intensive. Even this did not promote long term adherence to exercise. Brief interventions promoting physical activity that are used by many schemes in the United Kingdom are of questionable effectiveness.

Primary biliary cirrhosis once rare, now common in the United Kingdom?

There is a widespread impression that the number of patients with the autoimmune liver disease primary biliary cirrhosis (PBC) is increasing, although its incidence and prevalence vary widely. Using thorough case-finding methods and rigorous definitions to assess changes in incidence and prevalence with time and to explore the symptomatology and mortality of the disease in a large group of unselected patients, we performed a descriptive epidemiological study of PBC in a well defined population over a fixed period of time using established diagnostic criteria and with clinical follow-up of all cases. In a population of 2.05 million in northern England 770 definite or probable PBC cases were identified. Prevalence rose from 201.9 per 10(6) in the adult population and 541. 4 per 10(6) women over 40 in 1987 to 334.6 per 10(6) adults and 939. 8 per 10(6) women over 40 in 1994. Incidence was 23 per 10(6) in 1987 and 32.2 per 10(6) in 1994. Three hundred patients died in median follow-up of 6.27 years (141 liver deaths); the standardized mortality ratio was 2.85. At presumed diagnosis, 60.9% had no symptoms of liver disease. By June 1994 62% of prevalent patients had liver symptoms. PBC is apparently increasing. It is still unclear whether this is because of a true increase, case finding, or increased disease awareness. The study draws attention to (1) high mortality from liver disease and non-liver-related causes even in patients initially with no liver symptoms and (2) apparently poor diagnostic awareness of the disease.

Impact of clinical practice guidelines on clinicians' behaviour: tonsillectomy in children

OBJECTIVE

This study was conducted to assess the extent to which developing and implementing clinical practice guidelines for listing children for tonsillectomy (with or without adenoidectomy) influenced the behaviour of participating ENT surgeons.

METHOD

A before and after study in which the intervention (the development and dissemination of local practice guidelines) was introduced sequentially into different hospitals and surgical practice. The study was conducted in four ear, nose, and throat surgical services in the North of England, with 16 consultant ENT surgeons and their junior staff on 1190 children aged 0 to 14 years who were judged, prior to consultation with an ENT surgeon, to have been referred for throat-related problems for which tonsillectomy was one possible treatment option were included in the study. Decision reached by surgeons and proportion of decisions that complied with new guidelines.

RESULTS

Of the clinical decisions to list children for tonsillectomy taken before introduction of locally agreed guidelines, 73% (486/660) conformed to the criteria in the subsequent guidelines, 15% (97/660) did not, and in 12% (77/660), it was impossible to judge. After the intervention, the corresponding figures were 73% (386/530), 14% (73/53), and 13% (71/530), respectively. When decisions were taken to break the guidelines, this was more often to list for tonsillectomy when it was not indicated--83% (141/170)--than to withhold tonsillectomy when it was indicated--17% (29/170). The aspects of guidelines that were breached in decisions to carry out tonsillectomy were: the age of the child was younger than the guidelines recommended--54% (75/141); there had been fever attacks of tonsillitis than the guidelines recommended--22% (32/141); and there were "significant" symptoms not included in the guidelines--20% (29/141).

CONCLUSIONS

In spite of strong evidence to the contrary, local guidelines were formulated at a level that the majority of surgeons already attained. Guideline development and implementation, therefore, had very little impact on clinical practice. The process of local formulation of guidelines was not sufficient to achieve change toward evidence-based practice; clinical preference proved to be quite intractable. There is a need to enhance the ability of clinicians in the assessment and interpretation of research evidence. Previous work has emphasized the need to explore factors that influence clinical behaviour toward evidence-based practice. Our study suggests the need for more research into why clinicians continue to follow clinical preference even when invited to base agreed local clinical policies on evidence.

Mineral fibre analysis and routes of exposure to asbestos in the development of mesothelioma in an English region

OBJECTIVES

To compare the concentrations of inorganic fibres in the lungs in cases of mesothelioma and controls: to determine whether concentrations of retained asbestos fibres differ with the different exposures identified from interview; and to investigate the existence of a cut off point in concentrations of asbestos fibres that indicates occupational exposure.

METHODS

Case-control study; 147 confirmed cases of mesothelioma and 122 controls identified from deaths occurring in four districts of Yorkshire between 1979 and 1991. Surviving relatives were interviewed to determine lifetime exposure history to asbestos. Mineral fibre analysis was carried out on lung tissue from postmortem examinations.

RESULTS

Odds on high concentrations of retained asbestos fibres were greater in cases than controls. After excluding subjects with occupational and paraoccupational exposure, the odds on high concentrations were still greater in cases than controls, but only significantly so for amphiboles. There was only a weak relation between probability of occupational exposure to asbestos and concentrations of retained asbestos fibres, and no significant difference in fibre concentrations was found between subjects who had been exposed to asbestos through different routes: these comparisons were only based on small groups. There was considerable overlap in concentrations of retained asbestos fibres between cases and controls with and without histories of occupational exposure.

CONCLUSIONS

The study has confirmed previous results of higher concentrations of asbestos fibres in cases than controls, and has shown that this is still found in subjects with little evidence of occupational and para-occupational exposure. The overlap in concentrations of retained asbestos for different groups of subjects did not suggest a clear cut of value.

Computer simulation to estimate the effectiveness of carotid endarterectomy

OBJECTIVES

To investigate the benefit of carotid endarterectomy relative to medical treatment, by comparing the outcome for different groups of patients following transient ischaemic attacks.

METHODS

A Markov model was used to describe the survival and quality of life of patients treated for a transient ischaemic attack. The benefit is measured in terms of quality adjusted life months (QALMs). The outcome was estimated using a computer simulation with parameters based on published studies on the probability of events following treatment. The benefit of carotid endarterectomy was explored using a baseline set of parameters and a sensitivity analysis.

RESULTS

The baseline scenario of a 65-year-old male patient with the model factors set at an intermediate level showed a benefit for surgery of 3 QALMs compared with medical treatment alone. The sensitivity analysis showed that the most favourable combination of factors had a benefit of 13.4 QALMs and the least favourable a loss of 2 QALMs. Of all 128 factor combinations, 79.9% showed a benefit for surgery, 5.5% showed equal benefit, and 15.6% showed a benefit for medical treatment.

CONCLUSIONS

Computer simulations have the potential for deriving estimates of benefit for different patient groups from the results of clinical trials. Combined with reliable information on costs, the technique could also demonstrate variations in cost-effectiveness for these groups. For patients following a transient ischaemic attack, the results from this simulation and limited cost information suggest that carotid endarterectomy is unlikely to be a cost-effective intervention in the UK for many patient groups despite a reduction in the risk of stroke.

Incidence and prevalence of primary biliary cirrhosis in the city of Newcastle upon Tyne, England

OBJECTIVE

To describe the incidence and prevalence of primary biliary cirrhosis in an urban population between 1987 and 1994, using stringent inclusion criteria and a well-defined study area and population.

DESIGN

Descriptive study based on a case register compiled by a retrospective and prospective case-finding exercise and examination of case notes.

SETTING

The city of Newcastle upon Tyne. MAIN INCLUSION CRITERIA: (1) Definite cases: fulfilling all three of the following diagnostic criteria: positive antimitochondrial antibody (AMA) > or = 1:40; cholestatic liver function tests (LFT); diagnostic or compatible liver histology. (2) Probable cases: fulfilling two of these criteria.

SUBJECTS

All cases of primary biliary cirrhosis identified by multiple case-finding methods, alive from 1 January 1987 to 31 December 1994, in the defined area.

MAIN OUTCOME MEASUREMENTS

Incidence and point prevalence rates by age and sex.

RESULTS

In all, 202 potential cases were identified, of whom 160 met at least two inclusion criteria. In definite cases annual incidence varied from 14 to 32 (mean 22) per million whole population (with no clear trend) and point prevalence rose from 180 per million in 1987 to 240 in 1994. Mean age at diagnosis in cases incident during the study period was 63.2 years (S.D. 11.1 years, range 39.8-85.7 years).

CONCLUSIONS

Primary biliary cirrhosis is much more common in Newcastle than has previously been reported anywhere in the world, and prevalence appears to be rising.

Routes of asbestos exposure and the development of mesothelioma in an English region

OBJECTIVES

To investigate the contribution of exposure to asbestos through different routes in the development of mesothelioma.

METHODS

Case-control study. 185 confirmed cases of mesothelioma and 160 controls were identified, when death had occurred between 1979 and 1991 in four health districts in Yorkshire. The surviving relatives were interviewed to ascertain lifetime exposure to asbestos. Adjusted odds ratios (ORs) of exposure to asbestos (through occupational, paraoccupational, and residential routes) were calculated for cases and were compared with controls.

RESULTS

Likely or possible occupational exposure to asbestos was more common in cases than in controls (OR 5.6, 95% confidence interval (95% CI) 3.1 to 10.1). After excluding those with likely or possible occupational exposure, likely or possible paraoccupational exposure was more common in cases than controls (OR 5.8, 95% CI 1.8 to 19.2). Only six cases of mesothelioma were identified as being solely exposed to asbestos through their residence, compared with nine controls. The OR for residential exposure to asbestos varied between 1.5 and 6.6, depending on which potential industrial sources were included, but the 95% CIs were so wide that slightly reduced or greatly increased odds comparing cases with controls could not be excluded.

CONCLUSION

Study results support previous evidence that occupational and paraoccupational exposure to asbestos is associated with developing mesothelioma. Despite a rigorous search, purely residential exposure seemed to account for only 3% of identified cases. No firm conclusion can be drawn about the risks from residential exposure alone, as many of the study subjects could also have been occupationally or paraoccupationally exposed to asbestos.

Late-onset idiopathic scoliosis in children six to fourteen years old. A cross-sectional prevalence study

We performed a point-prevalence survey of 15,799 children, six to fourteen years old, who formed part of a prospective longitudinal study. Our purpose was to detect the prevalence of scoliosis and to investigate associated factors. On the basis of the initial screening, 934 children (5.9 per cent) were referred for additional clinical and radiographic examinations; 896 children returned for this second evaluation. A lateral spinal curve with a Cobb angle of more than 5 degrees was seen in 431 children (2.7 per cent of the 15,799 children). Only seventy-six children (0.5 per cent) had a curve that met our definition of idiopathic scoliosis (a curve of more than 10 degrees with concordant apical rotation). The point-prevalence rate was higher in girls, and it increased with age. The rate was 0.1 per cent (four of 5246) in the age-group of six to eight years, 0.3 per cent (sixteen of 5831) in the age-group of nine to eleven years, and 1.2 per cent (fifty-six of 4722) in the age-group of twelve to fourteen years old. With allowance for the fact that different definitions of idiopathic scoliosis have been used in earlier studies, our results suggest that the natural history of idiopathic scoliosis may be becoming more benign spontaneously.

Psychological morbidity and the availability of assisted conception: a group comparison study

BACKGROUND

Given its limited availability, it is worth while to explore the relationship between the non-availability of assisted conception and psychological morbidity among subfertile women, to see if those denied the procedure experience poorer health.

METHODS

A non-randomized group comparison study was carried out in Bradford Health Authority, England. Sixty-six women who had reached the point at which assisted conception was deemed appropriate, but for whom such treatments were not available, were compared with 49 parous women, and 73 newly diagnosed subfertile women. The General Wellbeing Index (GWI) was used to measure their psychological wellbeing.

RESULTS

Cases and subfertile controls have similar levels of wellbeing, whereas parous controls have significantly higher average levels than cases. This pattern is seen in the simple unadjusted comparison and also when adjustments are made for the distributions of age, life event score and social class.

CONCLUSIONS

Subfertile women experience poorer psychological health than similar parous women. Subfertile women, for whom assisted conception is an appropriate but unavailable treatment option, appear to have similar psychological health to those who are being investigated and treated by other means.

Statistical analysis of compositional data in anatomy

BACKGROUND

Variables which describe the composition, or relative size of components, of an organism need to be analysed in an appropriate manner.

METHODS

A few of the appropriate descriptive and inferential techniques have been described and applied to a number of anatomical data sets.

RESULTS

When applied to data on the composition of the vastus medialis in adults, a small but significant difference in average muscle fibre type distribution was demonstrated between males and females. There was little evidence for a relationship between fibre type distribution and age over the range considered.

CONCLUSIONS

Graphical displays via ternary diagrams are a simple way of illustrating compositional data simultaneously between and within groups. Numerical analysis is likely to involve transformation of original variables before standard univariate or multivariate statistical techniques can be used.

The health care experience and health behaviour of the Chinese: a survey based in Hull

Lack of knowledge about the health care experience and health behaviour of an important ethnic minority group prompted a study to inform the provision of health care and promote local action in Hull. Thirty Chinese 'takeaway' shops were randomly selected from the Yellow Pages of the Hull telephone directory, and all Chinese people working in them asked to complete a questionnaire. It contained questions on their knowledge, use and experience of primary health care and health promotion, together with aspects of their health behaviour. The same questionnaire in English was delivered to all workers in 30 fish and chip shops, to provide a White comparison group. Eighty (71 per cent) of the Chinese returned their questionnaire, and 73 (67 per cent) were returned from the chip-shop workers. The results indicate that the Chinese in Hull are not making optimal use of health services; they use some services inappropriately, whereas others, such as preventive health programmes, are under-used. One of the main reasons is identified as the language/communication difficulties faced by many Chinese. Other reasons are also highlighted and their implications discussed. The findings of this survey are in keeping with the mainly unpublished work undertaken elsewhere on this comparatively little researched ethnic minority group.

Prophylactic intravenous immunoglobulin in pre-term infants: a controlled trial

Sixty-six pre-term infants of less than 30 weeks gestation consecutively admitted to either of two neonatal intensive care units were randomized to receive routine intensive care only or prophylactic intravenous immunoglobulin, 200 mg/kg body weight at 3-weekly intervals in addition to routine intensive care. Eleven babies, 6 in the control group and 5 in the treatment group, were withdrawn from the trial due to early death from extreme prematurity (7 babies), early return to the referring hospital (3 babies), and elective treatment with intravenous immunoglobulin for severe congenital septicaemia (1 baby). Of the 55 who remained in the trial, significantly fewer babies in the treatment group had infection, 8 compared to 17 (p = 0.01). This difference was not significant when blood-culture-proven septicaemia only was considered, 8 compared to 14 (p = 0.09). Twenty-seven (84%) of 32 blood-culture-positive episodes of infection were caused by coagulase-negative staphylococci. Serum IgG was significantly higher with treatment and achieved levels comparable to those of normal full-term babies at the same post-natal age.

A test to detect clustering applied to muscle fibres

The random arrangement of a chosen uncommon element type within a mosaic has been assessed by the new statistics, 'Number of Clusters' and 'Mean Cluster Size'. Their distributions were obtained by simulation assuming the mosaic has a hexagonal arrangement. When this assumption was relaxed to allow mosaics nearer to those observed in nature, the results were little changed. This method was then applied to a set of muscle fibre data to test hypotheses about the likely targets in inflammatory muscle disorders.

Should maternal alpha-fetoprotein estimation be carried out in centers where ultrasound screening is routine? A sensitivity analysis approach

We describe a case of small, open spina bifida that was detected on the basis of maternal serum alpha-fetoprotein levels but consistently missed on careful ultrasound examination. This prompted us to reexamine the policy (adopted by an increasing number of departments) of relying exclusively on ultrasound examination for the detection of spinal lesions. In this article we therefore analyze the number of additional cases of spina bifida that could be detected by offering maternal serum alpha-fetoprotein screening in addition to a routine ultrasound examination. Our calculations are made on the basis of published assessments of the performance of these tests and on the assumptions about test independence. We test our conclusions against a wide variety of test performance values in a detailed sensitivity analysis. The final decision to carry out maternal serum alpha-fetoprotein testing is a value judgment, but this decision should be based on realistic numeric estimates of the potential benefits and hazards of this procedure.

Spatial distribution of muscle necrosis in biopsies from patients with inflammatory muscle disorders

Muscle biopsies from 56 patients with polymyositis (PM), juvenile dermatomyositis (JDM) and adult dermatomyositis (ADM) were investigated using a range of quantitative histological techniques. The objective was to present data on the extent and distribution of muscle fibre degeneration in these patients and to determine whether these data were compatible with postulated mechanisms of fibre injury. Atrophy of one or more of the major fibre types was found in 45/56 biopsies but there was no evidence that particular patterns of type-specific atrophy were characteristic of any individual disease group. However, selective atrophy and/or necrosis of perifascicular fibres was much more common in JDM patients than in ADM or PM groups. In virtually all biopsies where abnormalities of the microvasculature were apparent (7/8 JDM biopsies, 4/13 ADM biopsies and 5/33 PM biopsies) the distribution of acute muscle necrosis was found to be non-random (clustered). However, a substantial proportion of biopsies in the PM group showed clustering of necrotic fibres in the absence of evidence of vascular involvement. This finding suggests that non-random targetting of muscle fibres by effector cells may occur.