Integrated care improves risk-factor modification after stroke: initial results of the Integrated Care for the Reduction of Secondary Stroke model

OBJECTIVE

Despite evidence demonstrating that risk-factor management is effective in reducing recurrent cerebrovascular disease, there are very few structured care programmes for stroke survivors. The aim was to implement and evaluate an integrated care programme in stroke.

METHODS

186 patients with stroke were randomised to either the treatment (integrated care) or control (usual care) group and were followed up over 12 months. The Integrated Care for the Reduction of Secondary Stroke (ICARUSS) model of integrated care involved collaboration between a specialist stroke service, a hospital coordinator and a patient's general practitioner. The primary aim was to promote the management of vascular risk factors through ongoing patient contact and education.

RESULTS

In the 12 months poststroke, systolic blood pressure (sBP) decreased in the treatment group but increased in controls. The group difference was significant, and remained so when age, sex, disability and sBP at discharge were accounted for (p = 0.04). Treatment patients also exhibited better modification of body mass index (p = 0.007) and number of walks taken (p<0.001) than controls. Rankin scores indicated significantly reduced disability in treatment patients relative to controls in the year poststroke (p = 0.003).

CONCLUSIONS

Through an integrated system of education, advice and support to both patient and GP, the ICARUSS model was effective in modifying a variety of vascular risk factors and therefore should decrease the likelihood or recurrent stroke or vascular event.

Guidelines and the adoption of 'lipid rescue' therapy for local anaesthetic toxicity

Gathering evidence from animal experiments, an editorial in this journal and published human case reports culminated in the Association of Anaesthetists of Great Britain and Ireland recommending in August 2007 that lipid emulsion be immediately available to all patients given potentially cardiotoxic doses of local anaesthetic drugs. This development offered an opportunity to track the adoption of an innovation by anaesthetists in the UK and to gauge the effects of guidelines. Two surveys, each of 66 NHS hospitals delivering acute care within London and its penumbra, examined the adoption of lipid emulsion therapy. After the publication of the editorial in autumn 2006, the spread of 'lipid rescue' was rapid. The timing of the adoption and the impetus for innovation varied substantially between the sampled hospitals. When the formal guidelines were published, approximately half of the hospitals surveyed did not have lipid rescue. Of those that subsequently adopted it, half attributed their decision to the guidelines. At the end of 2007, there remained a small number of hospitals that had yet to adopt lipid rescue. Lipid rescue's adoption by anaesthetists in the UK offers a rare example of swift uptake of an innovation. National guidelines accelerated the adoption of innovation by some hospitals.

An 8-yr follow-up of arthritis self-management programme participants

OBJECTIVES

To examine the pattern of scores on self-efficacy, health status and use of self-management techniques among a group of Arthritis Self-Management Programme (ASMP) participants over an 8-yr period, and to describe participants' perspectives of the ASMP and current use of self-management.

METHODS

Data from 125 participants who attended the ASMP as part of a randomized controlled trial and completed assessments at baseline, 4-month and 8-yr follow-ups were entered into the analysis. A sub-sample of 10 participants (five high- and five low self-efficacy) was interviewed.

RESULTS

The sample was 87% female; mean age 65 (s.d. 12) yrs; mean disease duration 19 (s.d. 11) yrs; 48% RA; 48% OA. The overall pattern of scores showed improvements between baseline and 4 months, which appeared to be maintained at 8-yr follow-up on self-efficacy, positive and negative affect, anxious and depressed moods, pain and fatigue, cognitive symptom management and communication with physician. The exception was HAQ, which was stable from baseline to 4 months (as expected), but had increased at 8 yrs indicating a decline in physical functioning. Sub-group analyses by RA and OA showed similar patterns of results. Interviews revealed that some participants continued to have problems with disease acceptance and highlighted the importance of pre-course expectations.

CONCLUSIONS

Long-term maintenance of self-efficacy, psychological well-being and self-management techniques may be possible following attendance on the ASMP. The need for additional psychological support for those who are having difficulty adjusting to their condition and its consequences is highlighted.

Parenting interventions and the prevention of unintentional injuries in childhood: systematic review and meta-analysis

OBJECTIVES

To evaluate the effectiveness of parenting interventions in preventing unintentional injury and increasing parental safety practices.

DATA SOURCES

A range of medical and social science electronic databases were searched. Abstracts from the first to seventh World conferences on injury prevention and control and the journal Injury Prevention were hand searched.

REVIEW METHODS

Randomized controlled trials (RCTs), non-randomized controlled trials (non-RCTs) and controlled before and after studies, providing parenting interventions to parents of children aged 0-18 years and reporting injuries, safety equipment or safety practices were included. Studies were selected, data extracted and quality appraised independently by two reviewers. Pooled relative risks were estimated using random effect models.

RESULTS

Fifteen studies (11 RCTs) were included, 11 of which were home visiting programmes and two of which were paediatric practice-based interventions. Thirteen studies recruited families at risk of adverse child health outcomes. Intervention arm families had a significantly lower risk of injury (RR 0.82, 95% CI 0.71-0.95), as measured by self-report of medically or non-medically attended injury. Several studies found fewer home hazards, a home environment more conducive to child safety, or a greater number of safety practices in intervention arm families.

CONCLUSIONS

Parenting interventions, most commonly provided within the home, using multi-faceted interventions appear to be effective in reducing unintentional child injury. Further research is required to explore the mechanisms by which parenting interventions reduce injury, the features of interventions that are necessary to reduce injury, and their generalizability to different population groups.

Estimation of the detection probability for Yangtze finless porpoises (Neophocaena phocaenoides asiaeorientalis) with a passive acoustic method

Yangtze finless porpoises were surveyed by using simultaneous visual and acoustical methods from 6 November to 13 December 2006. Two research vessels towed stereo acoustic data loggers, which were used to store the intensity and sound source direction of the high frequency sonar signals produced by finless porpoises at detection ranges up to 300 m on each side of the vessel. Simple stereo beam forming allowed the separation of distinct biosonar sound source, which enabled us to count the number of vocalizing porpoises. Acoustically, 204 porpoises were detected from one vessel and 199 from the other vessel in the same section of the Yangtze River. Visually, 163 and 162 porpoises were detected from two vessels within 300 m of the vessel track. The calculated detection probability using acoustic method was approximately twice that for visual detection for each vessel. The difference in detection probabilities between the two methods was caused by the large number of single individuals that were missed by visual observers. However, the sizes of large groups were underestimated by using the acoustic methods. Acoustic and visual observations complemented each other in the accurate detection of porpoises. The use of simple, relatively inexpensive acoustic monitoring systems should enhance population surveys of free-ranging, echolocating odontocetes.

Head-to-head comparison of oral contrast agents for cross-sectional enterography: small bowel distention, timing, and side effects

OBJECTIVE

To determine small bowel distention, scanning time, and side effects of commercially available oral contrast agents used in cross-sectional enterography.

METHODS

Ten healthy volunteers ingested 2000 mL of water, methylcellulose, polyethylene glycol (PEG), or 1350 mL of low-concentration barium (LCB) followed by 500 mL water on different days. Magnetic resonance imaging occurred every 10 minutes from 30 to 90 minutes after ingestion. Small bowel distention was compared between time points and agents. Volunteers ranked side effects, drinking difficulty, and preference.

RESULTS

By quantitative assessment, PEG and LCB distended small bowel loops better than water and methylcellulose (P < 0.0001). Time to optimal distention of the terminal ileum was from 51 to 72 minutes. Water and methylcellulose had the fewest side effects. Water was the most preferred contrast and PEG the least.

CONCLUSIONS

Polyethylene glycol and LCB distend small bowel better than water and methylcellulose. Polyethylene glycol was the most difficult to drink and least preferred agent.

Parenting programmes: a systematic review and synthesis of qualitative research

BACKGROUND

Parenting programmes are at the heart of intervention strategies for parents of children with emotional and behaviour problems. Systematic reviews and meta-analyses of randomized controlled trials have indicated that such programmes can improve many aspects of family life. However, there is currently a dearth of information concerning what it is that makes parenting programmes meaningful and helpful to parents. The aim of this paper was to examine parents' experience and perceptions of parenting programmes using the meta-ethnographic method, in order to sensitize policymakers and practitioners to the key factors that parents perceive to be of value.

METHODS

Systematic searches of a number of electronic databases were undertaken using key search terms. Critical appraisal of included studies was conducted using standardized criteria, and the reports were synthesized using meta-ethnographic methods.

RESULTS

Six reports were purposefully selected and critically appraised independently by two reviewers. Two were excluded. Based on the remaining four papers, five key concepts were identified as important when planning and delivering parenting programmes. A lines-of-argument synthesis was developed which suggests that the acquisition of knowledge, skills and understanding, together with feelings of acceptance and support from other parents in the parenting group, enabled parents to regain control and feel more able to cope. This led to a reduction in feelings of guilt and social isolation, increased empathy with their children and confidence in dealing with their behaviour.

CONCLUSION

This evaluation provides an indication of the components that parents perceive to be necessary in the provision of parenting programmes, independent of the particular type of programme being provided. It may therefore aid policymakers in decisions about which programmes to provide.

Parenting interventions for the prevention of unintentional injuries in childhood

BACKGROUND

Parent education and training programmes can improve maternal psychosocial health, child behavioural problems and parenting practices. This review assesses the effects of parenting interventions for reducing child injury.

OBJECTIVES

To assess the effects of parenting interventions for preventing unintentional injury as well as increasing possession and use of safety equipment and parental safety practices.

SEARCH STRATEGY

We searched CENTRAL, MEDLINE, EMBASE, Biological Abstracts, Psych INFO, Sociofile, Social Science Citation Index, CINAHL, Dissertation Abstracts, ERIC, DARE, ASSIA, Web of Science, SIGLE and ZETOC. We also handsearched abstracts from the World Conferences on Injury Prevention & Control and the journal Injury Prevention. The searches were conducted in May 2005.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), non-randomised controlled trials (non-RCTs) and controlled before and after studies (CBAs), which evaluated parenting interventions administered to parents of children aged 18 years and under, and reported outcome data on injuries (unintentional or unspecified intent), and possession and use of safety equipment or safety practices. Parenting interventions were defined as those with a specified protocol, manual or curriculum aimed at changing knowledge, attitudes or skills covering a range of parenting topics.

DATA COLLECTION AND ANALYSIS

Studies were selected, data were extracted and quality appraised independently by two authors. Pooled relative risks (RR) were estimated using random effect models.

MAIN RESULTS

Fifteen studies were included in the review: 11 RCTs (one included a CBA within the same study), one non-RCT, one study contained both randomised and non-randomised arms and two CBAs. Two provided solely educational interventions. Thirteen provided interventions comprising parenting education and other support services; 11 of which were home visiting programmes and two of which were paediatric practice-based interventions. Thirteen studies recruited families at risk of adverse child health outcomes. Nine RCTs were included in the primary meta-analysis, which indicated that intervention families had a significantly lower risk of injury (RR 0.82, 95% CI 0.71 to 0.95). Several studies found fewer home hazards, a home environment more conducive to child safety, or a greater number of safety practices in intervention families.

AUTHORS' CONCLUSIONS

Parenting interventions, most commonly provided within the home using multi-faceted interventions may be effective in reducing child injury. The evidence relates mainly to interventions provided to families at risk of adverse child health outcomes. Further research is required to explore mechanisms by which these interventions reduce injury, the features of parenting interventions that are necessary or sufficient to reduce injury and the generalisability to different population groups.

Massage intervention for promoting mental and physical health in infants aged under six months

BACKGROUND

Infant massage is increasingly being used in the community for low-risk babies and their primary care givers. Anecdotal claims suggest benefits for sleep, respiration, elimination and the reduction of colic and wind. Infant massage is also thought to reduce infant stress and promote positive parent-infant interaction.

OBJECTIVES

The aim of this review was to assess the effectiveness of infant massage in promoting infant physical and mental health in population samples.

SEARCH STRATEGY

Searches were undertaken of CENTRAL 2005 (Issue 3), MEDLINE (1970 to 2005), PsycINFO (1970 to 2005), CINAHL (1982 to 2005), EMBASE (1980 to 2005), and a number of other Western and Chinese databases.

SELECTION CRITERIA

Studies in which babies under the age of six months were randomised to an infant massage or a no-treatment control group, and utilising a standardised outcome measuring infant mental or physical development.

DATA COLLECTION AND ANALYSIS

Weighted and standardised mean differences and 95% confidence intervals are presented. Where appropriate the results have been combined in a meta-analysis using a random effects model.

MAIN RESULTS

Twenty-three studies were included in the review. One was a follow-up study and thirteen were included in a separate analysis due to concerns about the uniformly significant results and the lack of dropout. The results of nine studies providing primary data suggest that infant massage has no effect on growth, but provides some evidence suggestive of improved mother-infant interaction, sleep and relaxation, reduced crying and a beneficial impact on a number of hormones controlling stress. Results showing a significant impact on number of illnesses and clinic visits were limited to a study of Korean orphanage infants. There was no evidence of effects on cognitive and behavioural outcomes, infant attachment or temperament. The data from the 13 studies regarded to be at high risk of bias show uniformly significant benefits on growth, sleep, crying and bilirubin levels.

AUTHORS' CONCLUSIONS

The only evidence of a significant impact of massage on growth was obtained from a group of studies regarded to be at high risk of bias. There was, however, some evidence of benefits on mother-infant interaction, sleeping and crying, and on hormones influencing stress levels. In the absence of evidence of harm, these findings may be sufficient to support the use of infant massage in the community, particularly in contexts where infant stimulation is poor. Further research is needed, however, before it will be possible to recommend universal provision.

Improving child protection: a systematic review of training and procedural interventions

AIM

To synthesise published evidence regarding the effectiveness of training and procedural interventions aimed at improving the identification and management of child abuse and neglect by health professionals.

METHODS

Systematic review for the period 1994 to 2005 of studies that evaluated child protection training and procedural interventions. Main outcome measures were learning achievement, attitudinal change, and clinical behaviour.

RESULTS

Seven papers that examined the effectiveness of procedural interventions and 15 papers that evaluated training programmes met the inclusion criteria. Critical appraisal showed that evaluation of interventions was on the whole poor. It was found that certain procedural interventions (such as the use of checklists and structured forms) can result in improved recording of important clinical information and may also alert clinical staff to the possibility of abuse. While a variety of innovative training programmes were identified, there was an absence of rigorous evaluation of their impact. However a small number of one-group pre- and post-studies suggest improvements in a range of attitudes necessary for successful engagement in the child protection process.

CONCLUSION

Current evidence supports the use of procedural changes that improve the documentation of suspected child maltreatment and that enhance professional awareness. The lack of an evidence based approach to the implementation of child protection training may restrict the ability of all health professionals to fulfil their role in the child protection process. Formal evaluation of a variety of models for the delivery of this training is urgently needed with subsequent dissemination of results that highlight those found to be most effective.

Individual and group-based parenting programmes for the treatment of physical child abuse and neglect

BACKGROUND

Child physical abuse and neglect are important public health problems and recent estimates of their prevalence suggest that they are considerably more common than had hitherto been realised. Many of the risk factors for child abuse and neglect are not amenable to change in the short term. Intervening to change parenting practices may, however, be important in its treatment. Parenting programmes are focused, short-term interventions aimed at improving parenting practices in addition to other outcomes (many of which are risk factors for child abuse e.g. parental psychopathology, and parenting attitudes and practices), and may therefore be useful in the treatment of physically abusive or neglectful parents.

OBJECTIVES

To assess the efficacy of group-based or one-to-one parenting programmes in addressing child physical abuse or neglect.

SEARCH STRATEGY

A range of biomedical and social science databases were searched including MEDLINE, EMBASE, CINAHL, PsychINFO, Sociofile, Social Science Citation Index, ASSIA, the Cochrane Library, Campbell Library (including SPECTR and CENTRAL), National Research Register (NRR) and ERIC, from inception to May 2005.

SELECTION CRITERIA

Only randomised controlled trials or randomised studies that compared two treatments were included. Studies had to include at least one standardised instrument measuring some aspect of abusive or neglectful parenting. In the absence of studies using objective assessments of child abuse, studies reporting proxy measures of abusive parenting were included. Only studies evaluating the effectiveness of standardised group-based or one-to-one parenting programmes aimed at the treatment of physical child abuse or neglect were included. Studies were also only eligible for inclusion if they had targeted parents of children aged 0-19 years who had been investigated for physical abuse or neglect.

DATA COLLECTION AND ANALYSIS

The treatment effect for each outcome in each study was standardised by dividing the mean difference in post-intervention scores for the intervention and treatment group by the pooled standard deviation, to obtain an effect size. The results for each outcome in each study have been presented, with 95% confidence intervals. It was not possible to combine any results in a meta-analysis.

MAIN RESULTS

A total of seven studies of variable quality were included in this review. Only two studies assessed the effectiveness of parenting programmes on the incidence of child abuse or number of injuries. One study showed that there were no reports of abuse in the intervention group compared with one report of abuse in the control group. In the second study the small number of injuries sustained precluded the possibility of statistical analysis. Data were also extracted on over fifty outcomes that are used as proxy measures of abusive parenting. These were on the whole diverse and measured a range of aspects of parenting (e.g. parental child management, discipline practices, child abuse potential and mental health), child health (e.g. emotional and behavioural adjustment) and family functioning, thereby precluding the possibility of undertaking a meta-analysis for most outcomes for which data were extracted. While none of the programmes were effective across all of the outcomes measured, many appeared to have improved some outcomes for some of the participating parents, although many failed to achieve statistical significance.

AUTHORS' CONCLUSIONS

There is insufficient evidence to support the use of parenting programmes to treat physical abuse or neglect (i.e. such as the incidence of child abuse using reports of child abuse/linjuries or children on the children protection register). There is, however, limited evidence to show that some parenting programmes may be effective in improving some outcomes that are associated with physically abusive parenting. There is an urgent need for further rigorous evaluation of the effectiveness of parenting programmes that are specifically designed to treat physical abuse and neglect, either independently or as part of broader packages of care. Such evaluation should include the use of objective measures of outcome such as independent assessments of parenting and the number of instances of physical abuse. In order to do this, future studies need to include long-term follow-up.

Transition-state Complex of the Purine-specific Nucleoside Hydrolase of T.vivax: Enzyme Conformational Changes and Implications for Catalysis

Nucleoside hydrolases cleave the N-glycosidic bond of ribonucleosides. Crystal structures of the purine-specific nucleoside hydrolase from Trypanosoma vivax have previously been solved in complex with inhibitors or a substrate. All these structures show the dimeric T. vivax nucleoside hydrolase with an "open" active site with a highly flexible loop (loop 2) in its vicinity. Here, we present the crystal structures of the T. vivax nucleoside hydrolase with both soaked (TvNH-ImmH(soak)) and co-crystallised (TvNH-ImmH(co)) transition-state inhibitor immucillin H (ImmH or (1S)-1-(9-deazahypoxanthin-9-yl)-1,4-dideoxy-1,4-imino-D-ribitol) to 2.1 A and 2.2 A resolution, respectively. In the co-crystallised structure, loop 2 is ordered and folds over the active site, establishing previously unobserved enzyme-inhibitor interactions. As such this structure presents the first complete picture of a purine-specific NH active site, including leaving group interactions. In the closed active site, a water channel of highly ordered water molecules leads out from the N7 of the nucleoside toward bulk solvent, while Trp260 approaches the nucleobase in a tight parallel stacking interaction. Together with mutagenesis results, this structure rules out a mechanism of leaving group activation by general acid catalysis, as proposed for base-aspecific nucleoside hydrolases. Instead, the structure is consistent with the previously proposed mechanism of leaving group protonation in the T. vivax nucleoside hydrolase where aromatic stacking with Trp260 and an intramolecular O5'-H8C hydrogen bond increase the pKa of the N7 sufficiently to allow protonation by solvent. A mechanism that couples loop closure to the positioning of active site residues is proposed based on a comparison of the soaked structure with the co-crystallized structure. Interestingly, the dimer interface area increases by 40% upon closure of loop 2, with loop 1 of one subunit interacting with loop 2 of the other subunit, suggesting a relationship between the dimeric form of the enzyme and its catalytic activity.

The effectiveness and cost-effectiveness of parent training/education programmes for the treatment of conduct disorder, including oppositional defiant disorder, in children

OBJECTIVES

To assess the clinical and cost-effectiveness of parent training programmes for the treatment of children with conduct disorder (CD) up to the age of 18 years.

DATA SOURCES

Electronic databases.

REVIEW METHODS

For the effectiveness review, relevant studies were identified and evaluated. A quantitative synthesis of behavioural outcomes across trials was also undertaken using two approaches: vote counting and meta-analysis. The economic analysis consisted of reviewing previous economic/cost evaluations of parent training/education programmes and the economic information within sponsor's submissions; carrying out a detailed exploration of costs of parent training/education programmes; and a de novo modelling assessment of the cost-effectiveness of parent training/education programmes. The potential budget impact to the health service of implementing such programmes was also considered.

RESULTS

Many of the 37 randomised controlled trials that met the review inclusion and exclusion criteria were assessed as being of poor methodological quality. Studies were clinically heterogeneous in terms of the population, type of parent training/education programme and content, setting, delivery, length and child behaviour outcomes used. Both vote counting and meta-analysis revealed a consistent trend across all studies towards short-term effectiveness (up to 4 months) of parent training/education programmes (compared with control) as measured by a change in child behaviour. Pooled estimates showed a statistically significant improvement on the Eyberg Child Behaviour Inventory frequency and intensity scales, the Dyadic Parent-Child Interaction Coding System and the Child Behaviour Checklist. No studies reported a statistically significant result favouring control over parent training/education programmes. There were few statistically significant differences between different parent training/education programmes, although there was a trend towards more intensive interventions (e.g. longer contact hours, additional child involvement) being more effective. The cost of treating CD is high, with costs incurred by many agencies. A recent study suggested that by age 28, costs for individuals with CD were around 10 times higher than for those with no problems, with a mean cost of 70,019 pounds sterling. Criminality incurs the greatest cost, followed by educational provision, foster and residential care and state benefits. Only a small proportion of these costs fall on health services. Using a 'bottom-up' costing approach, the costs per family of providing parent training/education programmes range from 629 pounds sterling to 3839 pounds sterling depending on the type and style of delivery. Using the conservative assumption that there are no cost savings from treatment, a total lifetime quality of life gain of 0.1 would give a cost per quality-adjusted life-year of between 38,393 pounds sterling and 6288 pounds sterling depending on the type of programme delivery and setting.

CONCLUSIONS

Parent training/education programmes appear to be an effective and potentially cost-effective therapy for children with CD. However, the relative effectiveness and cost-effectiveness of different models (such as therapy intensity and setting) require further investigation. Further research is required on the impact of parent training/education programmes on the quality of life of children with CD and their parents/carers, as well as on longer term child outcomes.

The Citizenship Safety Project: a pilot study

The Government White Paper Saving Lives: Our Healthier Nation (1999) provides a clear indication that accidents are a serious public health problem and have been targeted by the Department of Health as a key area for prevention over the next 10 years. School-based injury prevention programmes have been identified as one of the key settings for the implementation of the White Paper's heath promotion strategies. The Citizen Safety Project (CSP) is a peer-delivered injury prevention programme for Year 10 students (14-15 years) and Year 2 pupils (6-7 years). This paper summarizes the findings of a pilot study that assessed the feasibility of implementing the CSP in schools and of conducting a larger study. Working as part of their Personal Social Health Education lessons, 11 pairs (n = 22) of Year 10 students developed a project to take one accident prevention theme of their choice into a primary school to teach small groups of five or six Year 2 pupils (n = 55). A formative evaluation was conducted, based on interviews with Year 2 and Year 10 teachers (n = 2), and the diaries of Year 10 students. Knowledge of accident prevention and risk awareness was measured in Year 2 pupils using the Draw and Write technique, and impact on Year 10 students was measured using self-esteem and locus of control inventories. Using both statistical and thematic analysis the study concludes that the CSP is well accepted, improves knowledge in Year 2 pupils and boosts confidence in Year 10 students, while concurrently achieving key stage attainment targets. Implications of the study are discussed in terms of future research, as are recommendations with regard to modifications to the project.

Preventing emotional and behavioural problems: the effectiveness of parenting programmes with children less than 3 years of age

BACKGROUND

Emotional and behavioural problems in children under 3 years of age have a high prevalence, and parenting practices have been shown to be strongly associated with their development. A number of recent systematic reviews have shown that group-based parenting programmes can be effective in improving the emotional and behavioural adjustment of older children (aged 3-10 years). The aim of this review was to establish whether there is evidence from controlled trials that group-based parenting programmes are effective in improving the emotional and behavioural adjustment of children less than 3 years of age, and their role in the primary prevention of emotional and behavioural problems.

METHODS

English and non-English language articles published between January 1970 and July 2001 were retrieved using a keyword search of a number of electronic databases.

RESULTS

Five studies were included and two meta-analyses were conducted, the first combining data from parent reports and the second combining data from independent observations of children's behaviour. The combined parent reports showed a non-significant difference favouring the intervention group, while the combined independent observations showed a significant difference favouring the intervention group.

CONCLUSION

It is concluded that this review points to the potential of parenting programmes to improve the emotional and behavioural adjustment of children less than 3 years of age, but that there is insufficient evidence from controlled trials to assess whether the short-term benefit is maintained over time, or the role that such programmes might play in the primary prevention of emotional and behavioural problems. This review points to the need for further primary preventive research on this important public health issue.

Introduction to the DAPPLE Air Pollution Project

The Dispersion of Air Pollution and its Penetration into the Local Environment (DAPPLE) project brings together a multidisciplinary research group that is undertaking field measurements, wind tunnel modelling and computer simulations in order to provide better understanding of the physical processes affecting street and neighbourhood-scale flow of air, traffic and people, and their corresponding interactions with the dispersion of pollutants at street canyon intersections. The street canyon intersection is of interest as it provides the basic case study to demonstrate most of the factors that will apply in a wide range of urban situations. The aims of this paper are to introduce the background of the DAPPLE project, the study design and methodology for data collection, some preliminary results from the first field campaign in central London (28 April-24 May 2003) and the future for this work. Updated information and contact details are available on the web site at http://www.dapple.org.uk.

Evidence-based recommendations for the role of exercise in the management of osteoarthritis of the hip or knee--the MOVE consensus

OBJECTIVES

Exercise is an effective and commonly prescribed intervention for lower limb osteoarthritis (OA). Many unanswered questions remain, however, concerning the practical delivery of exercise therapy. We have produced evidence-based recommendations to guide health-care practitioners.

METHODS

A multidisciplinary guideline development group was formed from representatives of professional bodies to which OA is of relevance and other interested parties. Each participant contributed up to 10 propositions describing key clinical points regarding exercise therapy for OA of the hip or knee. Ten final recommendations were agreed by the Delphi technique. The research evidence for each was determined. A literature search was undertaken in the Medline, PubMed, EMBASE, PEDro, CINAHL and Cochrane databases. The methodological quality of each retrieved publication was assessed. Outcome data were abstracted and effect sizes calculated. The evidence for each recommendation was assessed and expert consensus highlighted by the allocation of two categories: (1) strength of evidence and (2) strength of recommendation.

RESULTS

The first round of the Delphi process produced 123 propositions. This was reduced to 10 after four rounds. These related to aerobic and strengthening exercise, group versus home exercise, adherence, contraindications and predictors of response. The literature search identified 910 articles; 57 intervention trials relating to knee OA, 9 to hip OA and 73 to adherence. The evidence to support each proposition is presented.

CONCLUSION

These are the first recommendations for exercise in hip and knee OA to clearly differentiate research evidence and expert opinion. Gaps in the literature are identified and issues requiring further study highlighted.

Impact of a general practice based group parenting programme: quantitative and qualitative results from a controlled trial at 12 months

AIMS

To test the effectiveness at one year of the Webster Stratton Parents and Children Series group parenting programme in a population sample of parents.

METHODS

In a multicentre block randomised controlled trial, parents of children aged 2-8 years in 116 families who scored in the upper 50% on a validated behaviour inventory, took part in Webster-Stratton's 10 week parenting programme led by trained and supervised health visitors. The following outcome measures were used: Eyberg Child Behaviour Inventory, Goodman Strengths and Difficulties Questionnaire, General Health Questionnaire, Parenting Stress Index, Rosenberg Self Esteem Scale.

RESULTS

The intervention significantly reduced child behaviour problems and improved mental health at immediate and 6 month follow ups. One year differences between control and intervention groups were not significant. Qualitative results suggest that these findings might be attributable in part to either Hawthorne effects or contamination of control group. At interview parents described ways in which the programme had improved their mental health. They reported gains in confidence and feeling less stressed. Some also reported beneficial changes in their own and their children's behaviour and improved relationships with their children. Some spoke of a need for further sessions to support the behaviour changes they had managed to make, and some the desire for attendance by both parents.

CONCLUSIONS

Parenting programmes have the potential to promote mental health and reduce social inequalities, but further work is needed to improve long term effectiveness.

[Effect of tea polyphenol on the demineralization and remineralization of enamel in vitro]

OBJECTIVE

To investigate the effect of tea polyphenol (TP) on the mineralization behaviour of enamel in two sterile, in vitro systems.

METHODS

In the demineralization study, sound enamel sections were pH-cycled. Treatments were 2000 mg/L TP, 200 mg/L TP, 2000 mg/L TP + 100 mg/L fluoride, 100 mg/L fluoride, and deionized water. In the remineralization study, surface-softened enamel was used and pH-cycled as above. Test treatments were 2000 mg/L TP, 2000 mg/L TP + 250 mg/L fluoride, 250 mg/L fluoride, and deionized water. The acidic buffers were retained for calcium analysis. The enamel was analysed before and after pH-cycling by microhardness.

RESULTS

In the demineralization study, the calcium depletion rates(CDR) were (0.43 +/- 0.05), (0.49 +/- 0.006), (0.21 +/- 0.02), (0.21 +/- 0.03) and (0.50 +/- 0.11) microgram/(mm2.h) respectively. The Knoop hardness values(KHV) percent reduction were 94.19 +/- 3.50, 96.62 +/- 0.63, 74.74 +/- 4.09, 77.79 +/- 3.11 and 97.32 +/- 4.03 respectively. There were no significant differences within either the TP-only groups or the fluoride groups, but the fluoride groups were significantly more efficacious than the TP-only groups (P < 0.05). In the remineralization study, the KHV percent increase were -11.96 +/- 10.1, -21.32 +/- 11.3, -49.52 +/- 24.6 and -4.24 +/- 8.51 respectively. Notably more remineralization was observed in the fluoride group. There were no significant differences between the other groups (P > 0.05).

CONCLUSION

The data of this in vitro study suggest that TP has no effect on de/remineralization of enamel blocks and there is no synergetic action of TP and fluoride in a sterile system. This finding supports the proposition that tea polyphenols exert an anti-caries effect via an anti-microbial mode-of-action.

Parent-training programmes for improving maternal psychosocial health

BACKGROUND

Mental health problems are common and there is evidence to suggest that the origins of such problems lie in infancy and childhood. In particular, there is evidence from a range of studies to suggest that maternal psychosocial health can have a significant effect on the mother-infant relationship, and that this in turn can have consequences for both the short and long-term psychological health of the child. The use of parenting programmes is increasing in the UK and elsewhere and evidence of their effectiveness in improving outcomes for children has been provided. Evidence is now required of their effectiveness in improving outcomes for mothers.

OBJECTIVES

The objective of this review is to address whether group-based parenting programmes are effective in improving maternal psychosocial health including anxiety, depression, and self-esteem.

SEARCH STRATEGY

A range of biomedical, social science, educational and general reference electronic databases were searched including MEDLINE, EMBASE CINAHL, PsychLIT, ERIC, ASSIA, Sociofile and the Social Science Citation Index. Other sources of information included the Cochrane Library (SPECTR, CENTRAL), and the National Research Register (NRR).

SELECTION CRITERIA

Only randomised controlled trials were included in which participants had been randomly allocated to an experimental and a control group, the latter being a waiting-list, no-treatment or a placebo control group. Studies had to include at least one group-based parenting programme, and one standardised instrument measuring maternal psychosocial health.

DATA COLLECTION AND ANALYSIS

A systematic critical appraisal of all included studies was undertaken using a modified version of the Journal of the American Medical Association (JAMA) published criteria. The treatment effect for each outcome in each study was standardised by dividing the mean difference in post-intervention scores for the intervention and treatment group, by the pooled standard deviation, to produce an effect size. Where appropriate the results were then combined in a meta-analysis using a fixed-effect model, and 95% confidence intervals were used to assess the significance of the findings.

MAIN RESULTS

A total of 23 studies were included in the original review which was increased to 26 at the first udate (2003). Of these 20 provided sufficient data to calculate effect sizes. The 20 studies provided a total of 64 assessments of outcome on a range of aspects of psychosocial functioning including depression, anxiety, stress, self-esteem, social competence, social support, guilt, mood, automatic thoughts, dyadic adjustment, psychiatric morbidity, irrationality, anger and aggression, mood, attitude, personality, and beliefs. Data sufficient to combine in a meta-analysis existed for only five outcomes (depression; anxiety/stress; self-esteem; social support; and relationship with spouse/marital adjustment). The results of the meta-analyses show statistically significant results favouring the intervention group for depression; anxiety/stress; self-esteem; and relationship with spouse/marital adjustment. The meta-analysis of the social support data showed no evidence of effectiveness. Of the remaining data that it was not possible to combine in a meta-analysis, approximately 22% of the outcomes measured, showed significant differences between the intervention group and the control group. A further 40% showed non-significant differences favouring the intervention group. Approximately one-third of outcomes showed no evidence of effectiveness.A meta-analysis of the follow-up data on three outcomes was also conducted - depression, self-esteem and relationship with spouse/marital adjustment. The results show that there was a continued improvement in self-esteem, depression, and marital adjustment at follow-up, although the latter two findings were not statistically significant. This review has been updated (2003) with the addition of 3 new included studies. A number of additional excluded studies have also been added. There is one additional study awaiting 03) with the addition of 3 new included studies. A number of additional excluded studies have also been added. There is one additional study awaiting assessment and 2 ongoing studies listed for inclusion at a future update of this review. The size of effect for the main outcomes has not been substantially altered by this update. Additional sensitivity analyses to assess the impact of quasi randomised studies on the result have also been added. Where the quasi randomised studies are excluded from the analysis, the result was found to be slightly more conservative.

REVIEWER'S CONCLUSIONS

It is suggested that parenting programmes can make a significant contribution to the short-term psychosocial health of mothers. However, there is currently a paucity of evidence concerning whether these results are maintained over time, and the limited follow-up data which are available show equivocal results. This points to the need for further evidence concerning the long-term effectiveness of parenting programmes on maternal mental health. Whilst the results of this review are positive overall, some studies showed no effect. Further research is needed to assess which factors contribute to successful outcomes in these programmes with particular attention being paid to the quality of delivery.These results suggest that parenting programmes have a potential role to play in the promotion of mental health.

Services for pre-school children with behaviour problems in a Midlands city

OBJECTIVES

To study the services for pre-school children with behaviour problems in a Midlands city and the level of co-ordination and co-operation between providers.

SETTING

A socially and ethnically diverse Midlands city in the UK.

METHODS

Survey methods were employed with city health visitors in order to determine their role and identify service providers. Service providers from different agencies were interviewed and data collected related to service offered, materials used, theoretical basis of interventions, referrals to and from the service, inclusion and exclusion criteria and co-ordination and co-operation with other providers. Themes were identified related to the content and process of the services using qualitative data analysis methods. Frequencies of themes were estimated for different provider groups.

RESULTS

Health visitors and nursery nurses working in the primary care services were the primary point of contact for children with pre-school behaviour problems. Nursery nurses were one of the major sources of referral for children with pre-school behaviour problems and a significant majority of these providers had not received any specific training for this role. The majority of the providers used evidence-based programmes but few adhered strictly to a particular programme and instead used a mixture of materials drawn from different programmes. Many health service providers in particular offered interventions to parents on a one-to-one basis only. Most providers used behaviour modification approaches. While many providers claimed to have knowledge of other local providers and have good links, there was little evidence of co-ordination within and between agencies.

CONCLUSIONS

While there appears to be high levels of activity by providers from both statutory and voluntary sectors in providing services for pre-school children with behaviour problems, there is evidence to suggest that some of the main providers of services are not being adequately prepared and supported in the role. There is a lack of co-ordination within and between services, and indication that evidence-based programmes are being modified and used in an ad hoc manner. It is concluded that surveys of this nature may be an important preliminary step in establishing co-ordinated services for the primary and secondary prevention of pre-school behaviour problems.

Cluster analysis of symptoms and health seeking behaviour differentiates subgroups of patients with severe irritable bowel syndrome

BACKGROUND

Irritable bowel syndrome (IBS) is a heterogeneous condition which is diagnosed according to specific bowel symptom clusters. The aim of the present study was to identify subgroups of IBS subjects using measures of rectal sensitivity and psychological symptoms, in addition to bowel symptoms. Such groupings, which cross conventional diagnostic approaches, may provide greater understanding of the pathogenesis of the condition and its treatment.

METHOD

A K means cluster analysis was used to group 107 clinic patients with IBS according to physiological, physical, and psychological parameters. All patients had severe IBS and had failed to respond to usual medical treatment. Twenty nine patients had diarrhoea predominant IBS, 26 constipation predominant, and 52 had an alternating bowel habit.

RESULTS

The clusters were most clearly delineated by two variables: "rectal perceptual threshold (volume)" and "number of doctor visits". Three subgroups were formed. Group I comprised patients with low distension thresholds and high rates of psychiatric morbidity, doctor consultations, interpersonal problems, and sexual abuse. Group II also had low distension thresholds but low rates of childhood abuse and moderate levels of psychiatric disorders. Group III had high distension thresholds, constipation or alternating IBS, and low rates of medical consultations and sexual abuse.

CONCLUSION

The marked differences across the three groups suggest that each may have a different pathogenesis and respond to different treatment approaches. Inclusion of psychosocial factors in the analysis enabled more clinically meaningful groups to be identified than those traditionally determined by bowel symptoms alone or rectal threshold.

Higher stromal expression of transforming growth factor-beta type II receptors is associated with poorer prognosis breast tumors

Transforming growth factor-beta (TGFB) is a potent inhibitor of normal epithelial cell proliferation, and may be one of the regulatory factors that are perturbed during tumor development. While many tumor cell lines no longer respond to the inhibitory effects of TGFB due to a reduction or absence of the type II receptor (TGFBR2), the role of TGFBR2 in tumors from patients with breast cancer is less clear. The objective of this study was to screen human breast tumors to determine if there was a TGFBR2 mutation and/or altered expression of TGFBR2 protein. Using 10 unique primers, SSCP-PCR was used to detect heterozygosity in the complete coding sequence from 72 tumors and normal DNA from 20 individuals. One region of the promoter was also examined. Expression of TGFBR2 in the same breast tumors was examined by immunohistochemistry. Sequence variations were identified among normal and tumor tissue samples by SSCP-PCR within coding regions of exon 4 (1/72 samples) and within non-coding regions of intron 2 (1/72), intron 3 (72/72), and intron 6 (1/72). A new polymorphism was identified in intron 3. Observed allele frequencies were consistent with Hardy-Weinberg equilibrium in both the tumors and normal DNA. TGFBR2 was expressed in the epithelium and stroma of tumor tissue. The percentage of cells expressing TGFBR2 in stroma was higher in patients that had a positive lymph node status and/or negative estrogen and progesterone receptor expression. There was no relationship between TGFBR2 expression in the epithelium and these variables.

Group-based parent-training programmes for improving emotional and behavioural adjustment in 0-3 year old children

BACKGROUND

Emotional and behavioural problems in children are common. Research suggests that parenting has an important role to play in helping children to become adjusted, and that the first few months and years of a child's life are especially important in establishing patterns of emotional, cognitive and social functioning which will in turn influence the child's future development and in particular, their mental health. Parenting programmes may therefore have a role to play in improving the emotional and behavioural adjustment of infants and toddlers.

OBJECTIVES

The objectives of this review are as follows: a) To establish whether group-based parenting programmes are effective in improving the emotional and behavioural adjustment of children less than three years of age b) To assess the role of parenting programmes in the primary prevention of emotional and behavioural problems.

SEARCH STRATEGY

A range of biomedical and social science databases were searched including MEDLINE, EMBASE, CINAHL, PsychLIT, Sociofile, Social Science Citation Index, ASSIA, the Cochrane Library including SPECTR, CENTRAL, National Research Register (NRR) and ERIC.

SELECTION CRITERIA

Only randomised controlled trials of group based parenting programmes were included, and studies that had used at least one standardised instrument to measure emotional and behavioural adjustment.

DATA COLLECTION AND ANALYSIS

The treatment effect for each outcome in each study was standardised by dividing the mean difference in post-intervention scores for the intervention and treatment group by the pooled standard deviation, to obtain an effect size. The results for each outcome in each study have been presented, with 95% confidence intervals. Where appropriate the results have been combined in a meta-analysis using a random effect model.

MAIN RESULTS

Five studies were included in the review, and there was sufficient data from five studies to combine the results in a meta-analysis. Meta-analyses were conducted for both parent-reports and independent assessments of children's behaviour. The result for parent reports shows a non-significant result favouring the intervention group (ES -0.5, CI -1.06 to 0.08). The result for independent observations of children's behaviour shows a significant result favouring the intervention group (ES -0.54, CI -0.84 to -0.23). A meta-analysis of the limited follow-up data available shows a small non-significant result favouring the intervention group (ES -0.24, CI -0.56 to 0.09).

REVIEWER'S CONCLUSIONS

The findings of this review provide some support for the use of group-based parenting programmes to improve the emotional and behavioural adjustment of children under the age of 3 years. There is, however, insufficient evidence to reach any firm conclusions regarding the role that such programmes might play in the primary prevention of such problems. Furthermore, there is limited data available concerning the long-term effectiveness of these programmes, and the results from the two studies for which data was available produced borderline insignificant findings. Further research is required.

Improving mental health through parenting programmes: block randomised controlled trial

AIMS

To assess the effectiveness of a parenting programme, delivered by health visitors in primary care, in improving the mental health of children and their parents among a representative general practice population.

METHODS

Parents of children aged 2-8 years who scored in the upper 50% on a behaviour inventory were randomised to the Webster-Stratton 10 week parenting programme delivered by trained health visitors, or no intervention. Main outcome measures were the Eyberg Child Behaviour Inventory and the Goodman Strengths and Difficulties Questionnaire to measure child behaviour, and the General Health Questionnaire, Abidin's Parenting Stress Index, and Rosenberg's Self Esteem Scale to measure parents' mental health. These outcomes were measured before and immediately after the intervention, and at six months follow up.

RESULTS

The intervention was more effective at improving some aspects of the children's mental health, notably conduct problems, than the no intervention control condition. The Goodman conduct problem score was reduced at immediate and six month follow up, and the Eyberg Child Behaviour Inventory was reduced at six months. The intervention also had a short term impact on social dysfunction among parents. These benefits were seen among families with children scoring in the clinical range for behaviour problems and also among children scoring in the non-clinical (normal) range.

CONCLUSION

This intervention could make a useful contribution to the prevention of child behaviour problems and to mental health promotion in primary care.

Need and demand for parenting programmes in general practice

AIMS

To establish the prevalence of behaviour problems and the level of interest in parenting programmes in a population sample of parents of children aged 2-8 years, and to assess to what extent they are associated with socioeconomic factors.

METHODS

Postal survey of parents of children aged 2-8 years registered with three general practitioner surgeries; 70% response rate.

RESULTS

One fifth of parents from this population sample were experiencing difficulties with their children's behaviour. While behaviour problems were more prevalent in the manual social classes, "need" was high across all social groups. Just under a fifth of parents reported prior attendance at a parenting programme and 58% expressed interest in attending in the future. Interest in attending a parenting programme was not class related, but was predicted by the age of the eldest child and the existence of behaviour problems.

CONCLUSION

Behaviour problems are an important public health issue. Findings support the use of a non-selective approach to the provision of parenting programmes in the UK.

Hip protector compliance among older people living in residential care homes

OBJECTIVES

To estimate the compliance rates for the use of hip protectors among people living in residential care homes. Population/setting: People aged 65 years and over living in residential care homes with 20 or more beds in East Kent, south east England.

METHODS

Seventeen homes with the highest historical frequency of hip fractures were selected. All residents were offered SAFEHIP hip protectors. Care staff recorded daily hip protector compliance on diary cards over six months. Compliance rates were estimated from the number of sessions (morning, afternoon, evening, night) that a person wore hip protectors.

RESULTS

A total of 153 (51%) out of 299 residents agreed to wear hip protectors The 24 hour compliance rate for those who were issued with hip protectors and wore them at least once was 29%: 37% in the daytime and 3% at night. Daytime compliance rates reduced from 47% for the first month, to around 30% for months 5 and 6.

CONCLUSION

This study highlights the problems of persuading older people living in residential care homes to wear hip protectors. They have been shown to prevent hip fracture in nursing home (high risk) populations, and a recent trial showed their effectiveness in a mixed geriatric population. People living in residential care homes are also at greater risk of falling and fracturing than their counterparts living in the community. Initiatives to prevent hip fracture within residential care homes are also justified.

Treatment of sound errors in aphasia and apraxia of speech: Effects of phonological complexity

BACKGROUND: Recent research suggests that the complexity of treatment stimuli influences the effectiveness of treatment. However, no studies have examined the role of complexity on sound production treatment in adult individuals with sound production impairments. AIMS: This study examines effects of syllable complexity on treatment outcome in two patients with acquired sound production problems. Complexity is defined in terms of syllable structure: clusters are more complex than singletons. Using a single-subject multiple-baseline design, we address the question: Is treatment of complex syllables more effective than treatment of simple syllables? METHODS #ENTITYSTARTX00026; PROCEDURES: Two patients with aphasia and apraxia of speech were trained to produce complex or simple syllables (using modelling). Improvement was measured by percent correct on a word and nonword repetition test. OUTCOMES #ENTITYSTARTX00026; RESULTS: We found that both treatment on simple syllables and treatment on complex syllables led to improved production of simple syllables, while treatment of complex syllables also led to improvement on some complex syllables for one of the two patients. CONCLUSIONS: These results suggests that training complex items is more effective than training simple items, at least for some patients. Possible reasons for lack of stronger effects are discussed, as well as directions for future research.

How to use education as an intervention in osteoarthritis

Definitions of health education and patient education form the starting point for an overview of patient education interventions for people with osteoarthritis (OA). Recipients, tutors and the key messages that education can deliver are considered, followed by a review of the methods used and the typical content of current educational provision for OA. The theoretical and empirical basis for interventions is illustrated using examples from the somewhat limited field. The outcomes used to evaluate education and the evidence for effectiveness is presented. The issues of which patients benefit most, adherence, length of interventions, optimal timing and frequency are raised. The chapter concludes with a brief discussion of the best health care system is needed to underpin educational provision and suggestions for a research agenda that will go some way towards addressing the many questions that remain unanswered.

Volunteers' experiences of becoming arthritis self-management lay leaders: "It's almost as if I've stopped aging and started to get younger!"

OBJECTIVE

To determine whether undergoing training to become a lay leader and conducting an arthritis self-management course is associated with improvements in physical and psychological health status, arthritis self-efficacy, use of self-management techniques, and visits to the general practitioner. In addition, we aimed to describe the experiences of training and course delivery from the older volunteers' perspective.

METHODS

21 participants completed all assessments and had a median age of 58, median disease duration of 10 years, and either osteoarthritis (n = 13) or rheumatoid arthritis (n = 8). The study was a pretest-posttest design with qualitative data collected at 3 points in time: before training, 6 weeks after training, and 6 months after training. Quantitative data were collected through self-administered postal questionnaires at baseline and 6-month followup.

RESULT

Six months after training, participants reported small, significant increases in arthritis self-efficacy for pain (P = 0.002), cognitive symptom management (P = 0.004), and communication with their physician (P = 0.024) and a small, significant decrease in depressed mood (P = 0.04). Qualitative data supported these findings, with participants reporting more confidence, happiness, and a changed outlook on life in general. Volunteerism was associated with altruistic behavior and with filling the vocational void caused by retirement.

CONCLUSION

Findings support the value of volunteerism and training to become lay leaders in arthritis self-management programs. Volunteers reported positive changes both in themselves and in course participants. They enjoyed helping similar others and being involved in a worthwhile activity, and they valued their newly acquired status as lay leaders. Many had begun to apply their newfound knowledge about self-management to their own situation, reporting less pain and more willingness "to get on with life."

Relationships among somatic cell count, California mastitis test, impedance and bacteriological status of milk in goats and sheep in early lactation

The objectives of this trial were to evaluate and compare the test characteristics of a number of indirect tests of bacteriological status of the milk from goats and sheep and to assess the affect of varying levels of prevalence of infection on the performance of those tests.The somatic cell count, California mastitis test (CMT) score, electrical impedance and the bacteriological status of 220 and 262 milk samples from the glands of lactating dairy goats and sheep, respectively, were determined. The sensitivity and specificity of indirect tests in predicting the bacteriological status were compared by analyzing the areas under the receiver operating characteristic curve and calculating the likelihood ratio at various cut-off values.Bacteria were isolated from 17.7 and 4.6% of glands from goats and sheep, respectively. Somatic cell count was a better predictor of bacteriological status than either the CMT score or impedance in both goats and sheep. However, knowledge of the CMT score in both sheep and goats and the impedance in goats increases the likelihood of predicting the presence of a bacterial pathogen compared to no testing at all (P<0.05). Knowledge of the age and days postpartum of the animals at the time of testing did not increase the probability that infection status could be predicted. Variation in cut-off levels to predict infection status reported in the literature may be due to variation in the prevalence of infection in the populations studied. Use of likelihood ratio allows comparison of tests over a range of prevalence's as likelihood ratios are independent of prevalence. The prevalence of infection within a herd should be considered when selecting a cut-off value for indirect testing for the presence of bacteria in milk of small ruminants.

What is a dental access centre?

Few in dentistry can be unaware of the Prime Minister's pledge made at the September 1999 Labour Party conference in Bournemouth: “and working with the British Dental Association, everyone within the next two years will be able once again to see an NHS dentist just by phoning NHS Direct.” The recent NHS dental plan ‘Modernising NHS Dentistry’1,2 has announced a number of initiatives to work towards this goal, the deadline for which is rapidly approaching. Obviously, this is not going to be possible without some reversal, or at least a slow down, in the move away from the NHS by General Dental Practitioners and there are parts of the plan devoted to this objective. That said, equally it would appear that these may not in themselves be enough to ensure that people can access NHS dental care within a reasonable travelling distance, which leads us to consider the other part of the plan, Dental Access Centres (DACs), which are intended to supplement other services, not replace them. This paper attempts to explain just what they are, presents one particular DAC scheme as an example and discusses the challenges they face in the future.