Validation of a home safety questionnaire used in a randomised controlled trial

OBJECTIVE

To measure the validity of self reported safety practices from a questionnaire, completed by families participating in a home safety randomised controlled trial.

METHODS

The postal questionnaire was used to measure secondary outcomes in a randomised controlled trial. The answers to 26 questions that could be assessed by observation were checked by a home visit. Families were invited to take part in a "home safety check"; they were not told that the visit was part of a validation study. At the time of the visit the researcher was blind to the self reports in the questionnaires.

RESULTS

Sixty four questionnaires were validated by visits to 64 households. Percentage agreement ranged from 58% to 100%. Sensitivity was high (68% or above) for most safety practices. The positive predictive value was also high for most safety practices (78% or above for 15 of the 16 practices).

CONCLUSIONS

This study found a fairly high degree of consistency between self reported data and actual observations. The findings from this relatively small study need confirmation from larger studies.

Bayesian latent variable models for median regression on multiple outcomes

Often a response of interest cannot be measured directly and it is necessary to rely on multiple surrogates, which can be assumed to be conditionally independent given the latent response and observed covariates. Latent response models typically assume that residual densities are Gaussian. This article proposes a Bayesian median regression modeling approach, which avoids parametric assumptions about residual densities by relying on an approximation based on quantiles. To accommodate within-subject dependency, the quantile response categories of the surrogate outcomes are related to underlying normal variables, which depend on a latent normal response. This underlying Gaussian covariance structure simplifies interpretation and model fitting, without restricting the marginal densities of the surrogate outcomes. A Markov chain Monte Carlo algorithm is proposed for posterior computation, and the methods are applied to single-cell electrophoresis (comet assay) data from a genetic toxicology study.

Development of a disease specific questionnaire to supplement a generic tool for QoL in colorectal cancer

The need for disease-specific quality of life measures is highlighted in the literature. The psychometric properties of a supplementary disease-specific quality of life questionnaire developed for use with a generic Quality of Life tool in colorectal cancer patients are explored. Originally developed and tested in a German sample, the English translation was tested on a cohort of UK colorectal cancer patients. Relevance and acceptability was previously established in Germany. A rigorous factor analysis ascertained the underlying structure of two factors with a number of single items that were retained as clinically important symptom indicators. In considering validity, four conditions were assessed: Reliability using Cronbach's alpha; Construct validity by comparing patient subgroups; Clinical Validity, by testing the hypothesis that some patient subgroups experience worse quality of life; Construct Reliability using second order factor analysis with the EORTC QOLQ-C30 scales, confirming that the factors retained provide an excellent measure of physical discomfort and a good measure of physical well being. Two other such questionnaires were developed in parallel with this one and reported in the literature (FACT-C and QOLQ-CR38). However, this questionnaire provides a useful alternative tool for use in clinical trials of colorectal cancer treatments alongside a core QoL questionnaire especially when brevity is an important consideration.

Type 2 diabetes presenting as diabetic ketoacidosis in adolescence

We report two black adolescent subjects who presented with diabetic ketoacidosis, but who lacked autoimmune markers and demonstrated clinical and biochemical characteristics more typical of Type 2 diabetes, including obesity, acanthosis nigricans, positive family history for Type 2 diabetes, and Type 2 diabetic dyslipidaemia. Subsequent to acute presentation, insulin was discontinued in both subjects and excellent glycaemic control was achieved with metformin therapy alone. Four months following acute presentation, both had adequate C-peptide responses to intravenous glucagon. Type 2 diabetes can present as diabetic ketoacidosis in obese adolescent subjects.

Balancing autonomy and responsibility: the ethics of generating and disclosing genetic information

Using data obtained during a retrospective interview study of 30 women who had undergone genetic testing-BRCA1/2 mutation searching-this paper describes how women, previously diagnosed with breast/ovarian cancer, perceive their role in generating genetic information about themselves and their families. It observes that when describing their motivations for undergoing DNA testing and their experiences of disclosing genetic information within the family these women provide care based ethical justifications for their actions. Finally, it argues that generating genetic information and disclosing this information to kin raise different types of ethical issues. The implications of these findings for ethical debates about informed choice in the context of genetic testing are discussed.

Genetic testing for women previously diagnosed with breast/ovarian cancer: examining the impact of BRCA1 and BRCA2 mutation searching

This study sought to investigate the impact of BRCA1 and BRCA2 mutation searching on women previously diagnosed with breast or ovarian cancer. In-depth interviews were undertaken with 30 women who had undergone a BRCA1 and BRCA2 mutation search within the clinical setting. The main reasons reported for undergoing mutation searching were: to provide genetic information for other family members, general altruism, curiosity about the aetiology of cancer, and to provide information to facilitate risk management decisions. In the main, the process of undergoing genetic testing was not experienced as anxiety provoking. The benefit of receiving a result confirming the presence of a genetic mutation was seen as an end to uncertainty, whereas the costs included difficulties in disclosing information to kin and potentially increased anxiety about one's own or others' cancer risks. Women receiving an inconclusive test result reported a range of emotional reactions. There was evidence that some women misunderstood the meaning of this result, interpreting it as definitive confirmation that a cancer-predisposing mutation was not present within the family. It is concluded that women with cancer who participate in BRCA1 and BRCA2 testing need to receive clear information about the meaning and implications of the different types of test results. Some recommendations for clinical practice are discussed.

Protective role of appendicectomy on onset and severity of ulcerative colitis and Crohn's disease

BACKGROUND AND AIMS

Recent studies on appendicectomy rates in ulcerative colitis and Crohn's disease have generally not addressed the effect of appendicectomy on disease characteristics. The aims of this study were to compare appendicectomy rates in Australian inflammatory bowel disease patients and matched controls, and to evaluate the effect of prior appendicectomy on disease characteristics.

METHODS

Patients were ascertained from the Brisbane Inflammatory Bowel Disease database. Controls matched for age and sex were randomly selected from the Australian Twin Registry. Disease characteristics included age at diagnosis, disease site, need for immunosuppression, and intestinal resection.

RESULTS

The study confirmed the significant negative association between appendicectomy and ulcerative colitis (odds ratio (OR) 0.23, 95% confidence interval (CI) 0.14-0.38; p<0.0001) and found a similar result for Crohn's disease once the bias of appendicectomy at diagnosis was addressed (OR 0.34, 95% CI 0.23-0.51; p<0.0001). Prior appendicectomy delayed age of presentation for both diseases and was statistically significant for Crohn's disease (p=0.02). In ulcerative colitis, patients with prior appendicectomy had clinically milder disease with reduced requirement for immunosuppression (OR 0.15, 95% CI 0.02-1.15; p=0.04) and proctocolectomy (p=0.02).

CONCLUSIONS

Compared with patients without prior appendicectomy, appendicectomy before diagnosis delays disease onset in ulcerative colitis and Crohn's disease and gives rise to a milder disease phenotype in ulcerative colitis.

Psychological impact of genetic testing in women from high-risk breast cancer families

Psychological adjustment in 90 women (30 carriers and 60 non-carriers) who had undergone genetic testing for mutations in BRCA1 and BRCA2 breast/ovarian cancer susceptibility genes was compared with that of 53 women who were not offered genetic testing. Women were assessed prior to genetic testing and 7-10 days, 4 and 12 months after carrier status disclosure using self-administered questionnaires. Compared with women not offered testing, mutation carriers had significantly higher breast cancer distress 7-10 days (t=2.80, P=0.005) and 12 months (t=2.01, P=0.045) post-notification. Non-carriers showed a significant decrease in state anxiety 7-10 days post-notification (t=2.27, P=0.024) and in depression 4 months post-notification (t=2.26, P=0.024), compared with women not offered testing. These data show that non-carriers derive psychological benefits from genetic testing. Women testing positive may anticipate a sustained increase in breast cancer distress following disclosure, although no other adverse psychological outcomes were observed in this group.

The pH and titratable acidity of a range of diluting drinks and their potential effect on dental erosion

OBJECTIVES

To investigate, in vitro, the potential dental effects of diluting juices by measuring their acidity levels and to examine the effect dilution has on the potential erosive properties of the drinks.

METHODS

Four commonly available diluting drinks were assessed for both pH and titratable acidity at a variety of dilutions, reflecting the range of concentrations over which such drinks may be consumed. Predetermined dilutions of citric acid and hydrochloric acid, with similar pH values to those of the drinks, were used as positive control acidic solutions. The pH measurements throughout the study were made using a pH electrode connected to an Orion EA940 IonAnalyser.

RESULTS

All four drinks demonstrated a high degree of resistance to a rise in pH, indicating high intrinsic buffering capacity. The measured pH changed very little with increasing dilution ratio when compared to the citric and hydrochloric acid controls, even when considered extremely dilute. In contrast, the titratable acidity of each of the drinks reduced proportionally with increasing dilution, thereby reducing considerably its erosive potential.

CONCLUSIONS

While dilution had very little effect on the measured pH values, the titratable acidity reduced as the drink became more dilute. Since there appears to be a direct relationship between dilution and titratable acidity, the erosive potential of diluting juices may be reduced substantially by the addition of water. It remains unlikely, however, that the drinks would ever be consumed at a 'safe' level of dilution due to diminished taste and colour.

Baseline quality of life predicts survival in patients with advanced colorectal cancer

The aim of this study was to investigate the influence of baseline quality of life (QoL) on survival in patients with advanced colorectal cancer. From 1992 to 1998, four randomised clinical trials in advanced colorectal cancer were conducted at this institution. The European Organization for Research and Treatment of Cancer-Quality of Life Core 30 (EORTC-QLQ-C30) questionnaire was completed prior to the commencement of chemotherapy. Analyses were performed on median-dichotomised baseline Quality of Life (QoL) and clinical prognostic factors. Baseline QoL questionnaires were completed by 501 patients. One-year survival was 38.3 and 72.5% (P<0.0001) for patients with global QoL scores below and above the median (67), respectively. Other than cognitive functioning, fatigue, appetite, constipation, diarrhoea and financial domains, all QoL scales were significant independent predictors of survival (P<0.035). In the final model, the global QoL score remained highly significant as an independent predictor of survival (P<0.0001). Baseline QoL is a strong independent predictor of survival in patients with advanced colorectal cancer. Measurements should be routinely recorded in clinical trials to stratify cohorts and aid in trial comparison.

Staphylococcus aureus bacteraemia in children: a 5-year retrospective review

OBJECTIVE

The clinical presentation of Staphyloccocus aureus bacteraemia has been well described in adults, but there is a paucity of published data on the presentation of S. aureus bacteraemia in children. This review sought to compare the presentation of S. aureus in children with that of adults.

METHODS

We conducted a 5-year retrospective chart review of S. aureus bacteraemia at the Royal Alexandra Hospital for Children between 1994 and 1998.

RESULTS

Of the 140 episodes of S. aureus bacteraemia, 53% were community acquired and 47% nosocomially acquired. The clinical presentation of S. aureus bacteraemia in the children in the present study differed significantly from published studies of adult patients. Of children with community-acquired bacteraemia without pre-existing medical conditions, 59% had a bone or joint infection, which is higher than adult series. Endocarditis has been associated with up to 30% of community-acquired bacteraemia in adults but was much less frequent (1.4%) in the present study. Despite the infrequent use of empiric antibiotic therapy (34% of episodes), the case fatality rate (1.4%) was significantly lower than the published literature relating to adults (11-32%).

CONCLUSION

The present study highlights the differences between S. aureus bacteraemia in adults and children.

Predictive testing for BRCA1/2: attributes, risk perception and management in a multi-centre clinical cohort

The aim of this multi-centre UK study is to examine the attributes of a cohort offered predictive genetic testing for breast/ovarian cancer predisposition. Participants are adults unaffected with cancer from families with a known BRCA1/2 mutation. This is the first large multi-centre study of this population in the UK. The study evaluates mental health, perceived risk of developing cancer, preferred risk management options, and motivation for genetic testing. Participants were assessed when coming forward for genetic counselling prior to proceeding to genetic testing. Three hundred and twelve individuals, 76% of whom are female, from nine UK centres participated in the study. There are no gender differences in rates of psychiatric morbidity. Younger women (<50 years) are more worried about developing cancer than older women. Few women provide accurate figures for the population risk of breast (37%) or ovarian (6%) cancer but most think that they are at higher risk of developing breast (88%) and ovarian (69%) cancer than the average woman. Cancer related worry is not associated with perceived risk or uptake of risk management options except breast self-examination. The findings indicate that younger women may be particularly vulnerable at the time of the offer of a predictive genetic test.

Deletion of the NF2 region in both meningioma and juxtaposed meningioangiomatosis: case report supporting a neoplastic relationship

We report a case of juxtaposed atypical meningioma and meningioangiomatosis (MA) in an 8-year-old boy with no clinical stigmata or family history of neurofibromatosis. We studied the proliferative activity and genetic changes in the two lesions in an attempt to define their biologic and pathogenetic relationships. The MIB-1 index was 11% in the meningioma and <1% in the MA, indicating increased proliferative activity in the meningioma. Fluorescence in situ hybridization was done for two chromosomal regions commonly deleted in meningiomas. There was loss of the neurofibromatosis 2 locus (22q12) in both the meningioma and MA. Conversely, the region of 1p32 was not deleted. Our results indicate that both the meningioma and MA arose from the same clonal process, with the meningioma probably undergoing additional, but undefined, genetic alterations that confer upon it a more proliferative potential. This loss of 22q12 in the MA raises doubt about the presumed hamartomatous nature of MA.

Discotic mesogens with potential electron carrier properties

A new family of discotic liquid crystals, potentially electron carriers, has been synthesised, some members of which exhibit a particularly rich thermotropic behaviour.

Guidelines and educational outreach visits from community pharmacists to improve prescribing in general practice: a randomised controlled trial

OBJECTIVES

To evaluate the effectiveness of guidelines with or without one-to-one educational outreach visits by community pharmacists in improving general practice prescribing for non-steroidal anti-inflammatory drugs (NSAIDs).

METHODS

Cluster randomised trial of 20 general practices within Avon, England. Practices were randomised to three groups: control; mailed guidelines; mailed guidelines plus educational outreach visits. General practitioners (GPs) in the latter group received two one-to-one outreach visits from community pharmacists. Changes in prescribing were measured using outcomes derived from prescribing analysis and cost (PACT) data. The primary outcome measure was change in the volume of prescribing for ibuprofen, diclofenac and naproxen as a percentage of total NSAID prescribing. Six secondary outcomes included other measures of prescribing quality and volume. A cost-benefit analysis was performed.

RESULTS

No significant differences were observed for the primary outcome measure: practices receiving outreach visits prescribed only 2.1% [95% confidence interval (CI): -0.8 to 5.0] more of the three recommended NSAIDs than the control practices did and 1.6% (95% CI: -1.4 to 4.7) more than practices that received guidelines only. Following adjustment for multiple comparisons, only one secondary outcome showed a statistically significant difference between the groups: the proportion of prescribing of the five most frequently used drugs was 2.2% (95% CI: 0.9 to 3.6) higher in the educational outreach group compared with the control group. A net increase in costs was shown with both interventions.

CONCLUSIONS

Although good prescribing at baseline in the participating practices limited the capacity for improvement, this trial provides no evidence that guidelines with or without educational outreach visits from community pharmacists lead to substantial improvements in prescribing behaviour.