Polybrominated diphenyl ethers in two species of marine top predators from England and Wales

During an earlier study, polybrominated diphenyl ethers were detected at high concentrations in fish and sediments downstream of a manufacturing site in NE England. We have now undertaken analysis of 14 tri- to heptabromodiphenyl ether congeners in tissues of two species of marine top predators exposed to these compounds through their consumption of fish. In this paper we report data for 47 cormorants and 60 harbour porpoises from England and Wales, sampled during the period 1996-2000. Concentrations of the summed congeners ranged from 1.8 to 140 microg kg(-1) wet weight in cormorant livers, and from not detected to 6900 microg kg(-1) wet weight in porpoise blubber. The major congeners present were generally BDE47, BDE99 and BDE100. There was little correlation between concentrations of chlorobiphenyls (as the sum of 25 individual congeners) and the sum of the 14 BDE congeners determined, particularly for the porpoises.

The psychosocial needs of cancer patients: findings from an observational study

The objectives of this study were to identify the prevalence of psychosocial need, and the contributory factors to need, among cancer patients, using a descriptive cross-sectional questionnaire survey of adult cancer patients. The participants were 1,000 patients from four hospitals in the north west of England with the following characteristics: tumour type (breast, colorectal, lymphoma, lung), being 1 month from a 'critical moment' in the cancer journey (i.e. (i) diagnosis, (ii) end of first treatment, (iii) recurrence, (iv) move from active treatment to palliative care), and aged over 18 years. The main outcome measure was a psychosocial needs inventory comprising seven needs categories (48 need items). A sample of 402 was achieved (40% response rate). Psychosocial needs relating to the need categories 'health professionals', 'information' and 'support networks' are commonly expressed and strongly felt by cancer patients. Needs relating to 'identity', 'emotional and spiritual' issues and 'practical' issues are less commonly expressed but are also strongly felt. Particular needs are related to tumour type, illness 'critical moment', age, gender, health status, socioeconomic and other social factors. This information should increase awareness among cancer care professionals about a range of psychosocial needs and may help them target particular patient groups for particular support interventions.

Associations between adverse events in childhood and chronic widespread pain in adulthood: are they explained by differential recall?

OBJECTIVE

Clinic based studies suggest that adverse events in childhood may predispose to chronic pain in adult life. These have been conducted on highly selected groups, and it is unknown whether these relationships hold in the general population and to what extent the increased rate of adverse childhood events in persons with pain is an artefact of differential reporting. We examined the hypothesis that chronic widespread pain was associated with reports of adverse experiences in childhood and whether any observed relationships could be explained by differential recall.

METHODS

A cross sectional population based screening survey was conducted. Subjects completed a questionnaire that included assessments of pain and psychological state. In total, 296 subjects who had demonstrated psychological distress were randomly selected and had a detailed interview, which included an assessment of 14 adverse childhood experiences. Medical records relating to childhood were also examined for those subjects.

RESULTS

The prevalence of self-reported adverse childhood experiences was greatest in adult subjects with current chronic widespread pain. Exposure to illness in family members, parental loss, operations, and abuse were all associated with increased, but nonsignificant, odds of having chronic widespread pain versus those without such exposures. However the only statistically significant association was with childhood hospitalizations. From medical record information the associations of hospitalizations (OR 5.1, 95% CI 2.0-13.0) and operations (OR 3.0, 95% CI 1.2-7.2) with pain previously noted were partly explained by differential recall between subjects with and without pain: hospitalizations, OR 2.2, 95% CI 0.9-5.5; operations, OR 1.2, 95% CI 0.5-3.4.

CONCLUSION

Although several reported adverse events in childhood were observed to be associated with chronic widespread pain in adulthood, only reports of hospitalizations were significantly associated. Validation of self-reported exposures suggests that there was differential recall of past events among those with and without pain, and this differential recall explained the association between hospitalizations and current chronic pain. Such differential recall may explain other observations of an association between reports of adverse childhood events and chronic pain in adulthood.

Temperature, housing, deprivation and their relationship to excess winter mortality in Great Britain, 1986-1996

OBJECTIVES

To examine the associations between temperature, housing, deprivation and excess winter mortality using census variables as proxies for housing conditions.

DESIGN

Small area ecological study at electoral ward level. Setting Great Britain between 1986 and 1996.

PARTICIPANTS

Men and women aged 65 and over.

MAIN OUTCOME MEASURES

Deaths from all causes (International Classification of Diseases, Ninth Revision [ICD-9] codes 0-999), coronary heart disease (ICD-9 410-414), stroke (ICD-9 430-438) and respiratory diseases (ICD-9 460-519). Odds of death occurring in winter period of the four months December to March compared to the rest of the year.

RESULTS

During the study period (excluding the influenza epidemic year of 1989/90), a total of 1,682,687 deaths occurred in winter and 2,825,223 deaths occurred during the rest of the year among people aged > or =65 (around 30,000 excess winter deaths per year). A trend of higher excess winter mortality with age was apparent across all disease categories (P < 0.01). There was a significant association between winter mortality and temperature with a 1.5% higher odds of dying in winter for every 1 degrees C reduction in 24-h mean winter temperature. The amount of rain, wind and hours of sunshine were inversely associated with excess winter mortality. Selected housing variables derived from the English House Condition Survey showed little agreement with census-derived variables at electoral ward level. For all-cause mortality there was little association between deprivation and excess winter mortality, although lack of central heating was associated with a higher risk of dying in winter (odds ratio [OR] = 1.016, 95% CI : 1.009-1.022).

CONCLUSIONS

Excess winter mortality continues to be an important public health problem in Great Britain. There was a strong inverse association with temperature. Lack of central heating was associated with higher excess winter mortality. Further work is needed to disentangle the complex relationships between different indicators of housing quality and other measures of socioeconomic deprivation and their relationship to the high number of excess winter deaths in Great Britain.

Markers of low level arsenic exposure for evaluating human cancer risks in a US population

Epidemiologic studies conducted in the US have not previously detected an association between regional drinking water arsenic concentrations and corresponding cancer occurrence or mortality rates. To improve our estimation of cancer risk and arsenic exposure in the USA, we have investigated the reliability of several exposure markers. In the current study, we specifically evaluated the long-term reproducibility of tap water and toenail concentrations of arsenic, and the relation between water, toenail, and urinary measurement. Subjects included 99 controls in our case-control study on whom we requested a household tap water sample and toenail clipping three to five years apart. Additionally, participants were asked to provide a first morning void sample at the second interview. Tap water arsenic concentrations ranged from undetectable (<0.01 microg/L) to 66.6 microg/L. We found a significant correlation between both replicate water and toenail samples (intraclass correlation coefficient = 0.85, 95% confidence interval = 0.79-0.89 for water, and intraclass correlation coefficient = 0.60, 95% confidence interval = 0.48-0.70 for toenails). The inter-method correlations for water, urinary and toenail arsenic were all statistically significant (r = 0.35, p = 0.0024 for urine vs water; r = 0.33, p = 0.0016 for toenail vs water and r = 0.36, p = 0.0012 for urine vs toenails). Thus, we found both toenail and water measurements of arsenic reproducible over a three- to five-year period. Our data suggest that biologic markers may provide reliable estimates of internal dose of low level arsenic exposure that can be used to assess cancer risk.

Determination of DDT and its metabolites in cattle dip soil available in aqueous phase after remediation

Soil taken from a former cattle tick dip site in NSW Australia, was remediated with a chemical leaching technology. The pre- and post-remediated soil (20g) was dispersed in water (100mL) and subjected to passive diffusion using polymeric membranes. The remediation reduced tDDT from 1174.3 microg/g to 102.9 microg/g (ash weight basis), which was further reduced to 43.2 microg/g with composting. The membranes accumulated 41.3 microg tDDT/g from the dip soil, 49.2 microg tDDT/g from the chemically leached soil and 3.1 microg tDDT/g from the leached composted soil. The chemical leaching removed over 90% of the tDDT, but released soil bound DDT, which was converted to DDE, while 2.99 microg/g was accumulated by the membranes from dip soil, 37.52 microg/g was accumulated from remediated soil. Composting, however, almost eliminated the availability for passive diffusion by the membranes from 50-60 microg/g in remediated soil to 3 -3.5 microg/g in composted soil. Variability studies of the membranes using eight replicates demonstrated that the accumulation by the membranes was reproducible with an average relative error of 20.3% for p,p'-DDT in soil type two, whilst the lowest average relative error for p,p'-DDE was 4.3%, suggesting that triplicate analyses will achieve acceptable accuracy.

Risk of adverse birth outcomes in populations living near landfill sites

OBJECTIVE

To investigate the risk of adverse birth outcomes associated with residence near landfill sites in Great Britain.

DESIGN

Geographical study of risks of adverse birth outcomes in populations living within 2 km of 9565 landfill sites operational at some time between 1982 and 1997 (from a total of 19 196 sites) compared with those living further away.

SETTING

Great Britain.

SUBJECTS

Over 8.2 million live births, 43 471 stillbirths, and 124 597 congenital anomalies (including terminations).

MAIN OUTCOME MEASURES

All congenital anomalies combined, some specific anomalies, and prevalence of low and very low birth weight (<2500 g and <1500 g).

RESULTS

For all anomalies combined, relative risk of residence near landfill sites (all waste types) was 0.92 (99% confidence interval 0.907 to 0.923) unadjusted, and 1.01 (1.005 to 1.023) adjusted for confounders. Adjusted risks were 1.05 (1.01 to 1.10) for neural tube defects, 0.96 (0.93 to 0.99) for cardiovascular defects, 1.07 (1.04 to 1.10) for hypospadias and epispadias (with no excess of surgical correction), 1.08 (1.01 to 1.15) for abdominal wall defects, 1.19 (1.05 to 1.34) for surgical correction of gastroschisis and exomphalos, and 1.05 (1.047 to 1.055) and 1.04 (1.03 to 1.05) for low and very low birth weight respectively. There was no excess risk of stillbirth. Findings for special (hazardous) waste sites did not differ systematically from those for non-special sites. For some specific anomalies, higher risks were found in the period before opening compared with after opening of a landfill site, especially hospital admissions for abdominal wall defects.

CONCLUSIONS

We found small excess risks of congenital anomalies and low and very low birth weight in populations living near landfill sites. No causal mechanisms are available to explain these findings, and alternative explanations include data artefacts and residual confounding. Further studies are needed to help differentiate between the various possibilities.

Ecology and behavior of Gecarcoidea natalis, the Christmas Island red crab, during the annual breeding migration

The terrestrial crab Gecarcoidea natalis is endemic to the forests of Christmas Island but must migrate each year to the coast to breed. During 1993 and 1995, radio-tracking, mark and recapture, and counting methods were used to establish the routes, walking speeds, direction of travel, and destinations of migrating crabs, as well as crab numbers and distribution. The density of crabs ranged from 0.09 to 0.57 crabs per square meter, which gave a population estimate of 43.7 million adult crabs on the island. During the dry season the crabs were relatively inactive but on arrival of the wet season immediately began their migration. The crabs generally walked in straight lines, and most crabs from around the Island traveled toward the northwest shore instead of simply walking toward the nearest shore. The maximum recorded distance walked by a red crab in one day was 1460 m, but the mean was 680 m per day in 1993 and 330 m in 1995. Comparing the 1993 and 1995 study seasons, there was a 3-week difference in the timing of the start of the migration, but the spawning date was fixed by the lunar phase and took place 17 to 18 days after mating. In 1993, late rain prompted a "rushed" migration and crabs walked directly to their shore destinations; in contrast, in 1995 most crabs made stops of 1 to 7 days during the downward migration. By giving the crabs a chance to feed along the way and minimizing the time that the population was concentrated near the shore, these stops may be important in ensuring that the animals have enough food after the long dry season. Furthermore, this behavior implies that the crabs are able to judge how far away they are from the shore during the migration.

Metabolic status and respiratory physiology of Gecarcoidea natalis, the Christmas Island red crab, during the annual breeding migration

With the arrival of the monsoonal rains and after months of inactivity during the dry season, the terrestrial crab Gecarcoidea natalis embarks on its annual breeding migration to the coast. The physiological demands of the migration were assessed by determining respiratory gases in the hemolymph, key metabolites, and energy stores in G. natalis during two migratory seasons. At the end of each day of migration the pulmonary hemolymph PO2 decreased by 1-2.5 kPa, but the hemocyanin remained saturated with O2 and the venous reserve was largely unchanged (O2 > 0.4 mmol x l(-1)). The breeding migration of red crabs was accomplished without recourse to anaerobiosis, even though at times walking speeds (up to 6.2 +/- 0.5 m x min(-1)) exceeded those that promoted anaerobiosis in non-migrating crabs and in crabs exercised in the laboratory. In contrast to all previous studies, at the end of each day of migrating, red crabs experienced an alkalosis (up to 0.1 pH units) rather than any acidosis. This alkalosis was removed overnight when the crabs were inactive. Although there were seasonal fluctuations in the glycogen, glucose, and triglyceride stores, crabs engaging in the migration did not draw on these stores and must have fed along the way. In contrast, crabs returning from breeding activities on the shore terraces had significantly depleted glycogen stores. Additionally, in 1993, the male crabs returning from the breeding activities on the terraces were dehydrated and experienced a decrease in muscle tissue water of 11%. In contrast to the breeding migration per se, fighting for burrows in which breeding occurs produced severe anaerobiosis in males, especially the victors: after 135 s of combat, the maximum L-lactate concentration in the hemolymph was 35 mmol x l(-1). It appears that burrowing, courtship, and mating are more demanding than the migration itself. Furthermore, the data provide evidence that the metabolic responses of migrating individuals of G. natalis might be different from those at other times of the year.

Use of a behavioural programme in the first 3 months to prevent infant crying and sleeping problems

OBJECTIVE

To assess the effectiveness of a behavioural programme introduced in the first 3 months of age in preventing infant crying and sleeping problems. Two issues were addressed: (i) which elements of the behavioural programme would parents implement; and (ii) whether the behavioural programme was more effective in reducing infant crying and encouraging night-time sleeping than an educational intervention or the routine services.

METHODOLOGY

Mothers and newborns were assigned at random to the behavioural programme (n = 205), educational intervention (n = 202), or control (n = 203) group. Behaviour diaries kept before randomization and at 3, 6, 9 and 12 weeks of age were used to measure implementation of the interventions and infant behaviour, including crying and sleeping. Crying and sleeping problems were followed up using questionnaire measures at 9 months of age.

RESULTS

The educational intervention did not change parental care behaviour. One element of the behavioural programme, a focal feed between 10 PM and midnight, was not implemented. A second element, stretching of interfeed intervals after 3 weeks of age, was implemented initially, but not maintained at older ages. The third element, which asked parents to emphasise day and night differences in the environment, and to settle their babies in the cot and minimise interaction at night, was carried out by more parents in the behavioural group than in the other groups. This led to an increase of around 10% in the number of babies who slept for 5 or more hours at night (a definition of sleeping through the night) at 12 weeks of age. Fewer behavioural programme parents sought help for crying and sleeping problems between 3 and 9 months of age.

CONCLUSION

The behavioural programme produced a modest increase in the number of infants who slept through the night by 12 weeks of age. The results are discussed in relation to other findings, which bear on the programme's adoption for routine health-care policy and practice.

The future of journals: where will electronic publishing take us?

Journals provide much that is of immense value to the researcher and practitioner. Yet the economics of journals are unsustainable; the amount of publishable research is increasing more rapidly than the funds available to buy it. Various alternative models are emerging, none of them without problems. The way forward is not clear, but change is inevitable.

Determination of enantiomeric purity of hyoscyamine from scopolia extract using HPLC-CD system without chiral separation

Enantiomeric ratio of hyoscyamine from Scopolia extract was determined by chiral HPLC-CD analysis. It was found that circular dichroism (CD) detection allowed the analysis of the sample without any special pretreatment whereas UV detection required an ammonia-ether extraction. To obtain a shorter analysis time for the determination, reversed-phase HPLC-CD analysis was applied by using a g-factor calibration curve (EE% vs. CD/UV). The analysis time was shortened from 35 to 18 min. EE% values obtained were consistent with those by chiral HPLC analysis.

Where are the economic guidelines coming from?

Economic guidelines recommend methods that should be employed in conducting economic evaluations of healthcare programs. The nature of the efficiency or equity goal underpinning economic guidelines is unclear. What is also unclear is how the methods recommended in the guidelines are linked to the underlying efficiency or equity goal being targeted. If it is unclear what efficiency/equity objectives are being pursued, then it is unlikely that even full implementation of economic guidelines will improve resource allocation.

Neuroendocrine regulation of osmoregulation and the evolution of air-breathing in decapod crustaceans

Gills are the primary organ for salt transport, but in land crabs they are removed from water and thus ion exchanges, as well as CO(2) and ammonia excretion, are compromised. Urinary salt loss is minimised in land crabs by redirecting the urine across the gills where salt reabsorption occurs. Euryhaline marine crabs utilise apical membrane branchial Na(+)/H(+) and Cl(−)/HCO(3)(−) exchange powered by a basal membrane Na(+)/K(+)-ATPase, but in freshwater crustaceans an apical V-ATPase provides for electrogenic uptake of Cl(−) in exchange for HCO(3)(−). The HCO(3)(−) is provided by carbonic anhydrase facilitating CO(2) excretion while NH(4)(+) can substitute for K(+) in the basal ATPase and for H(+) in the apical exchange. Gecarcinid land crabs and the terrestrial anomuran Birgus latro can lower the NaCl concentration of the urine to 5 % of that of the haemolymph as it passes across the gills. This provides a filtration-reabsorption system analogous to the vertebrate kidney. Crabs exercise hormonal control over branchial transport processes. Aquatic hyper-regulators release neuroamines from the pericardial organs, including dopamine and 5-hydroxytryptamine (5-HT), which via a cAMP-mediated phosphorylation stimulate Na(+)/K(+)-ATPase activity and NaCl uptake. Freshwater species utilise a V-ATPase, and additional mechanisms of control have been suggested. Crustacean hyperglycaemic hormone (CHH) has now also been confirmed to have effects on hydromineral regulation, and a putative role for neuropeptides in salt and water balance suggests that current models for salt regulation are probably incomplete. In a terrestrial crabs there may be controls on both active uptake and diffusive loss. The land crab Gecarcoidea natalis drinking saline water for 3 weeks reduced net branchial Na(+) uptake but not Na(+)/K(+)-ATPase activity, thus implying a reduction in diffusive Na(+) loss. Further, in G. natalis Na(+) uptake and Na(+)/K(+)-ATPase were stimulated by 5-HT independently of cAMP. Conversely, in the anomuran B. latro, branchial Na(+) and Cl(−) uptake and Na(+)/K(+)-ATPase are inhibited by dopamine, mediated by cAMP. There has been a multiple evolution of a kidney-type system in terrestrial crabs capable of managing salt, CO(2) and NH(3) movements.

Exposure of juvenile roach (Rutilus rutilus) to treated sewage effluent induces dose-dependent and persistent disruption in gonadal duct development

Wild roach (Rutilus rutilus) have been found with intersex gonads in rivers throughout the United Kingdom. The incidence of intersexuality is strongly correlated with discharges of estrogenic treated sewage effluent into those rivers, and this has led to the hypothesis that estrogenic chemicals in effluents are feminizing wild male fish. In this study, early-life stage roach (50 days post hatch, dph) were exposed for 150 days to a graded concentration (0%, 12.5%, 25%, 50%, and 100%) of treated sewage (primarily domestic) effluent to examine the effects of exposure on sexual differentiation and development. Measurement of steroid estrogens and alkylphenolic chemicals in the effluent and a resulting dose-dependent induction of vitellogenin (VTG; a female-specific, estrogen-dependent plasma protein) confirmed that the fish had been exposed and responded to "estrogen" in the effluent. Exposure to treated sewage effluent induced feminization of the reproductive ducts in "male" roach in a dose-dependent manner (in full-strength effluent, 100% of the fish had feminized ducts), indicating that the disruption of the gonad ducts seen in wild roach is the result of exposure to treated sewage effluents during early-life stages. There were no effects of treated sewage effluent exposure on germ cell development; therefore, no oocytes occurred in the testes of the feminized male roach. Subsequent, depuration of the effluent exposed fish in "clean" water for 150 days resulted in a reduction in plasma VTG but no alteration of the feminized ducts, indicating that the effect of the treated sewage effluent on reproductive duct development was permanent. The causality of oocytes in the testes of wild male roach therefore remains to be elucidated.

Reliability of measurements obtained with the Timed "Up & Go" test in people with Parkinson disease

BACKGROUND AND PURPOSE

The Timed "Up & Go" Test (TUG) is used to measure the ability of patients to perform sequential locomotor tasks that incorporate walking and turning. This study investigated the retest reliability, interrater reliability, and sensitivity of scores obtained with the TUG in detecting changes in mobility in subjects with idiopathic Parkinson disease (PD).

SUBJECTS

The performance of 12 people with PD was compared with that of 12 age-matched comparison subjects without PD.

METHODS

The subjects with PD completed 5 trials of the TUG after withdrawal of levodopa for 12 hours ("off" phase of the medication cycle) as well as an additional 5 trials 1 hour after levodopa was administered ("on" phase of the medication cycle). They were scored on the Modified Webster Scale at both sessions. The comparison subjects also performed 5 TUG trials. All trials were videotaped and timed by 2 experienced raters. The videotape was later rated by 3 experienced clinicians and 3 inexperienced clinicians.

RESULTS

For the subjects with PD, within-session performance was highly consistent, with correlations (r) ranging from.80 to.98 for the "off" phase and from.73 to.99 for the "on" phase. The performance of the comparison subjects across the 5 trials was also highly consistent (r=.90-.97). Comparisons showed differences between trials 1 and 2 on the TUG for both groups. Removal of data for trial 1 (the practice trial) further enhanced retest reliability. There was close agreement in TUG scores among raters despite different levels of experience (intraclass correlation coefficient [3,1]=.87-.99). Mean TUG scores were different between the "on" and "off" phases of the levodopa cycle and between subjects with PD and comparison subjects during the "on" phase.

CONCLUSION AND DISCUSSION

Retest reliability and interrater reliability of the TUG measurements were high, and the measurements reflected changes in performance according to levodopa use. The TUG can also be used to detect differences in performance between people with PD and elderly people without PD.

The DNA mismatch repair enzyme PMS1 is a myositis-specific autoantigen

OBJECTIVE

The specificity of the autoantibody response in different autoimmune diseases makes autoantibodies useful for diagnostic purposes. It also focuses attention on tissue- and event-specific circumstances that may select unique molecules for an autoimmune response in specific diseases. Defining additional phenotype-specific autoantibodies may identify such circumstances. This study was undertaken to investigate the disease specificity of PMS1, an autoantigen previously identified in some sera from patients with myositis.

METHODS

We used immunoprecipitation analysis to determine the frequency of autoantibodies to PMS1 in sera from patients with myositis, systemic lupus erythematosus, or scleroderma and from healthy controls. Additional antigens recognized by PMS1-positive sera were further characterized in terms of their susceptibility to cleavage by apoptotic proteases.

RESULTS

PMS1, a DNA mismatch repair enzyme, was identified as a myositis-specific autoantigen. Autoantibodies to PMS1 were found in 4 of 53 patients with autoimmune myositis (7.5%), but in no sera from 94 patients with other systemic autoimmune diseases (P = 0.016). Additional mismatch repair enzymes (PMS2, MLH1) were targeted, apparently independently. Sera recognizing PMS1 also recognized several other proteins involved in DNA repair and remodeling, including poly(ADP-ribose) polymerase, DNA-dependent protein kinase, and Mi-2. All of these autoantigens were efficiently cleaved by granzyme B, generating unique fragments not observed during other forms of cell death.

CONCLUSION

PMS1 autoantibodies are myositis specific. The striking correlation between an immune response to a group of granzyme B substrates (functioning in DNA repair and remodeling) and the myositis phenotype strongly implies that tissue- and event-specific biochemical events play a role in selecting these molecules for an autoimmune response. Understanding the role of granzyme B cleavage in this response is an important priority.

Hormonally impregnated intrauterine systems (IUSs), versus other forms of reversible contraceptives as effective methods of preventing pregnancy

OBJECTIVES

To assess the contraceptive efficacy, tolerability and acceptability of hormonally impregnated intrauterine systems (IUSs) in comparison to other reversible contraceptive methods.

SEARCH STRATEGY

Literature was identified through database searches, reference lists and individuals/organisations working in the field.

SELECTION CRITERIA

All randomised controlled trials comparing IUSs with other forms of reversible contraceptives and reporting on pre-determined outcomes in women of reproductive years. The primary outcomes were pregnancy due to method/user failure and continuation rate.

DATA COLLECTION AND ANALYSIS

The quality assessment of studies and data extraction were completed independently by two blinded reviewers. A quality checklist was designed to identify general methodological and contraceptive specific factors which could bias results. Events per women months and single decrement life table rates were extracted where possible for pregnancy, continuation, adverse events and reasons for discontinuation. Events per total number of women at follow up were collected for hormonal side effects and menstrual disturbance. When appropriate, data were pooled at the same points of follow up to calculate rate ratios in order to determine the relative effectiveness of one method compared to another. For the single decrement life table rates, the rate differences were pooled to determine the absolute difference in effectiveness of one method compared to another. Interventions were only combined if the contraceptive methods were similar. Non-hormonal IUDs were divided into three categories for the purpose of comparison with IUSs: IUDs >250mm2 (i.e. CuT 380A IUD and CuT 380 Ag IUD), IUDs <=250mm2 (i.e. Nova-T, Multiload, CuT 200 and CuT 220 IUDs) and non-medicated IUDs.

MAIN RESULTS

Nineteen RCTs comparing hormonally impregnated IUSs to a reversible contraceptive method met the inclusion criteria and it was possible to include eight of these in the meta-analyses, four comparing LNG-20 IUSs with non-hormonal IUDs, one comparing the LNG-20 IUS with Norplant-2 and three comparing Progestasert with non-hormonal IUDs. No significant difference was observed between the pregnancy rates for the LNG-20 users and those for the IUD >250mm2 users. However, women using the LNG-20 IUS were significantly less likely to become pregnant than those using the IUD <=250mm2. Women using the LNG-20 IUS were more likely to experience amenorrhoea and device expulsion than women using IUDs >250mm2. LNG-20 users were significantly more likely than all the IUD users to discontinue because of hormonal side effects and menstrual disturbance, which on further breakdown of the data was due to amenorrhoea. When the LNG-20 IUS was compared to Norplant-2, the LNG-20 users were significantly more likely to experience amenorrhoea and oligomenorrhoea, but significantly less likely to experience prolonged bleeding and spotting. No other significant differences were observed. Progestasert users were significantly less likely to become pregnant and less likely to continue on the method than non-medicated IUD users after one year, but no significant differences was noted for these two outcomes when Progestasert users were compared to IUD<=250mm2 users. The only other significant differences found in the meta-analyses were that Progestasert users were less likely to expel the device and more likely to discontinue the method because of menstrual bleeding and pain than users of IUDs <=250mm2.

REVIEWER'S CONCLUSIONS

Current evidence suggests LNG-20 IUS users are no more or less likely to have unwanted pregnancies than IUD >250mm2 and Norplant-2 users. The LNG-20 IUS was more effective in preventing either intrauterine or extrauterine pregnancies than IUDs <=250mm2. The contraceptive effectiveness of Progestasert was significantly better than non-medicated IUDs, but no difference was observed when compared to IUDs<=250mm2. Continuation of LNG-20 IUS use was similar to continuation of the non-hormonal IUDs and Norplant-2. Amenorrhoea was the main reason for the discontinuation for the LNG-20 IUS and women should be informed of this prior to starting this method.

Economic evaluation of strategies for managing crying and sleeping problems

AIMS

To estimate the financial cost to the NHS of infant crying and sleeping problems in the first 12 weeks of age and to assess the cost effectiveness of behavioural and educational interventions aimed at reducing infant crying and sleeping problems relative to usual services.

METHODS

A cost burden analysis and cost effectiveness analysis were conducted using data from the Crying Or Sleeping Infants (COSI) Study, a three armed prospective randomised controlled trial that randomly allocated 610 mothers to a behavioural intervention (n = 205), an educational intervention (n = 202), or existing services (control, n = 203). Main outcome measures were annual total cost to the NHS of infant crying and sleeping problems in the first 12 weeks, and incremental cost per interruption free night gained for behavioural and educational interventions relative to control.

RESULTS

The annual total cost to the NHS of infant crying and sleeping problems in the first 12 weeks was 65 pound sterling million (US$104 million). Incremental costs per interruption free night gained for the behavioural intervention relative to control were 0.56 pound sterling (US$0.92). For the educational intervention relative to control they were 4.13 pound sterling (US$6.80).

CONCLUSIONS

The annual total cost to the NHS of infant crying and sleeping problems is substantial. In the cost effectiveness analysis, the behavioural intervention incurred a small additional cost and produced a small significant benefit at 11 and 12 weeks of age. The educational intervention incurred a small additional cost without producing a significant benefit.