Defocus image contrast in hexagonally-ordered mesoporous material

A transmission electron microscope was used to characterize a powder form of hexagonally-ordered mesoporous silica material. The structural symmetry built into this amorphous material allowed one to obtain three characteristic images, i.e. a hexagonal honey-comb structure and wide/narrow parallel lines. These images were found to originate primarily from phase contrast, which changed sensitively with defocusing. To further understand the contrast behaviour of these images, an analytical form of the defocus contrast theory was developed and applied to the simulation of the characteristic wide/narrow parallel line images. The simulation was found to be in good qualitative agreement with experiments, where changes in focus conditions and specimen thickness were predicted to alter the contrast in the resulting parallel-line type images.

Alcohol and drug use in the context of anal sex and other factors associated with sexually transmitted infections: results from a multi-city study of high-risk men who have sex with men in the USA

Men who have sex with men (MSM) who use alcohol and drugs are at especially high risk for sexually transmitted infections (STIs); more information is needed about associated factors to improve risk reduction. We assessed reported STIs and demographic and event-level alcohol and drug use characteristics associated with STIs in a diverse, multi-city study in the USA of MSM who use substances. Improved risk reduction efforts are needed for this group as well as some initiatives tailored to men who are HIV positive, younger and use drugs (not alcohol) in the context of anal sex.

A fistful of UDAs

One year in and we are now starting to see the truth behind the new contract, which was hailed as the saviour of NHS dentistry. Despite words of comfort and reassurance from the CDO, the majority of dentists seem ill at ease with their lot. There are mutterings in the ranks; there are concerned whispers about UDA values and 2009. They huddle in their surgeries, worrying about the financial implications of their underperformance. PCTs, short of money are only now being given the data by the BSA about how well their dentists have done. Many are not happy with what they see. This article looks at where we are now, and gives a personal view on how we got here.

Quantitative TEM analysis of a hexagonal mesoporous silicate structure

TEM analysis of mesoporous materials is generally undertaken to give qualitative results. Accurate quantitative analysis is demonstrated in this study. A systematic image analysis of a powder form of a hexagonal mesoporous material known as KIT-6 is conducted using a transmission electron microscope (TEM). Three types of image contrast typically appear in this material (a hexagonal honeycomb structure, wide and narrow parallel lines). The honeycomb face is used to characterise this material in terms of a conventional 2-D hexagonal structure and the d-spacings for the (100) and (110) planes are experimentally measured in varying focus conditions. A tilting experiment is conducted to determine how the angle of tilt affects the line spacing and their visibility. Tilting has very little effect on the line spacing, whereas it affects the visibility of both the wide and narrow lines by limiting an angle range of visibility. The hexagonal lattice structure parameter determined by TEM method is found to be approximately 7% lower than that calculated by low-angle X-ray diffraction. Thus we conclude that TEM data can be used to determine the geometry and dimensions of hexagonal mesoporous silica materials, with a small error in the hexagonal lattice parameter.

Social aggregation by thick-tailed geckos (Nephrurus milii, Gekkonidae): does scat piling play a role?

Communal deposition of faeces into scat piles plays a role in pheromonal communication among group members in many ‘social’ vertebrates, including the scincid lizard Egernia stokesii. How general is this apparent link between scat piling and sociality? Thick-tailed geckos (Nephrurus milii, Gekkonidae) are large nocturnally active lizards that are widely distributed across southern Australia. They spend the daylight hours inactive inside retreat sites, typically rock crevices or burrows. Unusually among geckos, these animals often form groups of several individuals at these times. Our observations of captive N. milii showed that they also form discrete scat piles. However, habitat-selection experiments suggested that adding scats to a crevice did not modify the lizards’ probability of using that crevice. Thus, although Nephrurus milii scat pile (at least in captivity), communal faeces deposits do not appear to serve a social role in this taxon.

On-site treatment of a motorway service area wastewater using a package sequencing batch reactor (SBR)

A sequencing batch reactor (SBR) treating the effluent of a motorway service station in the south of England situated on a major tourist route was investigated. Wastewater from the kitchens, toilets and washrooms facilities was collected from the areas on each side of the motorway for treatment on-site. The SBR was designed for a population equivalent (p.e.) of 500, assuming an average flow of 100 m3/d, influent biochemical oxygen demand (BOD) of 300 mg/l, and influent suspended solids (SS) of 300 mg/l. Influent monitoring over 8 weeks revealed that the average flow was only 65 m3/d and the average influent BOD and SS were 480 mg/l and 473 mg/l respectively. This corresponded to a high sludge loading rate (F:M) of 0.42 d(-1) which accounted for poor performance. Therefore the cycle times were extended from 6 h to 7 h and effluent BOD improved from 79 to 27 mg/l.

Acetyl-L-carnitine for dementia

BACKGROUND

Dementia is a common mental health problem affecting 5% of those over 65. Various pathological processes are linked to memory impairment in dementia, particularly those affecting the cholinergic neurotransmitter system. Acetyl-l-carnitine (ALC) is derived from carnitine and is described as having several properties which may be beneficial in dementia. This includes activity at cholinergic neurons, membrane stabilization and enhancing mitochondrial function. Work on the effects of ALC has been ongoing since the 1980s yet the efficacy of ALC in cognitive decline remains unclear. Early studies suggested a beneficial effect of ALC on cognition and behaviour in aging subjects. However, later, larger studies have not supported these findings. Some of the difficulties lie in the early and later studies differing widely in methodology and assessment tools used, and are therefore difficult to compare. ALC is not currently in routine clinical use.

OBJECTIVES

The objective of this review is to establish whether Acetyl-l-carnitine is clinically effective in the treatment of people with dementia.

SEARCH STRATEGY

The trials were identified from a search of the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group on 8 January 2003 using the terms acetyl-l-carnitine, l-carnitine acetyl ester, acetylcarnitine.

SELECTION CRITERIA

All double-blind, randomized, trials involving people with dementia in which treatment with ALC was compared with a placebo group

DATA COLLECTION AND ANALYSIS

Data were extracted by a reviewer (SH) and entered into Revman 4.1 software. Where possible intention-to-treat data were used, but most of the analyses were of completers (people who completed the study).

MAIN RESULTS

There are 11 included trials, all of which had restricted the participants to people with Alzheimer's disease. All trials assessed the cognitive effects of ALC and in addition six considered severity of dementia, six considered functional ability and six considered clinical global impression. There were statistically significant treatment effects in favour of ALC at 12 and 24 weeks for the numbers showing improvement as determined by Clinical Global Impression, [OR 2.33, 95% CI 1.25 to 4.35, P<0.01] and [OR 3.91, 95% CI 1.32 to 11.54, P=0.01] but not as determined by the CIGIC at 52 weeks. There was no evidence of benefit for ALC in the areas of cognition, severity of dementia, functional ability or Clinical Global Impression as a continuous measure. Various adverse events were reported, but from the meta-analyses there were no statistically significant differences between treated and placebo groups.

REVIEWER'S CONCLUSIONS

There is evidence for benefit of ALC on clinical global impression, but there was no evidence using objective assessments in any other area of outcome. Given the large number of comparisons made, the statistically significant result may be due to chance. At present there is no evidence to recommend its routine use in clinical practice. Although the intention of the review was to access ALC for the treatment of all dementias, the included trials had confined themselves to participants with Alzheimer's disease. Individual patient data may add to the findings, as would trials including other types of dementia and other outcomes (e.g. mood and caregiver quality of life). However, the evidence does not suggest that ALC is likely to prove an important therapeutic agent. More work on the pharmacokinetics of ALC in humans is also required.

Structural characteristics and properties of the regenerated silk fibroin prepared from formic acid

Structural characteristics and thermal and solution properties of the regenerated silk fibroin (SF) prepared from formic acid (FU) were compared with those of SF from water (AU). According to the turbidity and shear viscosity measurement, SF formic acid solution was stable and transparent, no molecular aggregations occurred. The sample FU exhibited the beta-sheet structure, while AU random coil conformation using Fourier transform infrared (FTIR), X-ray diffraction (XRD), and differential scanning calorimetry. The effects of methanol treatment on samples were also examined. According to the measurement of crystallinity (XRD) and crystallinity index (FTIR), the concept of long/short-range ordered structure formation was proposed. Long-range ordered crystallites are predominantly formed for methanol treated SF film while SF film cast from formic acid favors the formation of short-range ordered structure. The relaxation temperatures of SF films measured by dynamic thermomechanical analysis supported the above mechanism due to the sensitivity of relaxation temperature on the short-range order.

Equity in the diagnosis of chest pain: race and gender

OBJECTIVE

To explore gender and racial equity in emergency room treatment of chest pain.

METHODS

Three hundred seventy-nine patient records were analyzed, taking into account effects of age, clinic, comorbid status, and insurance status.

RESULTS

Analysis of covariance and logistic regression revealed statistically significant differences between races but not between genders for time to first EKG and percent of patients receiving cardiac catheterization and echocardiography. Blacks waited longer than whites for an EKG and were less likely to receive cardiac catheterizations but more likely to receive echocardiography.

CONCLUSION

This study demonstrates a lack of equity by race in treatment of chest pain emergencies.

Specificity of preformed alloantibodies causing B cell positive flow crossmatch in renal transplantation

The specificity of alloantibodies (alloAb) and their clinical significance in association with T-/B+ flow cytometry crossmatch (FCXM) in kidney transplantation are not clearly defined. This study was undertaken to examine the HLA specificity and clinical relevance of Ab causing B+ FCXM in pre-transplant (final XM) recipients' serum samples. Final FCXM serum samples were analyzed from 457 renal transplant patients followed for 10 months post-transplantation. Two hundred and sixty patients had T-/B+ final FCXM. The control group included 197 recipients with T-/B- FCXM at time of transplantation. Class I/class II PRA and specificity of anti-HLA class I and class II Ab in final FCXM serum samples were analyzed by FlowPRA Class I Screening Test and FlowPRA Class II Screening Test. We found no correlation between graft outcome and pre-transplant T-/B- and T-/B+ FCXM status. Additionally, we observed no clinical relevance of B+ FCXM in retransplant patients. However, MCS > or =200 in B+ FCXM retransplant recipients was associated with anti-class II Ab to previous mismatches in regrafted patients (n = 46). This finding was confirmed by specificity analysis of anti-DR/DQ Ab in patients with high ( > or =15%) class II PRA. In 63% (12 of 19) of retransplants having T-/B+ FCXM, we defined the specificity of alloAb to first graft mismatched class II antigens. In contrast, anti-class II Ab was detected in only 5.7% (2 of 35) of single-graft recipients with different PRA values. Significantly greater MCS (240 +/- 61 vs. 163 +/- 48; p = 0.022) was observed in retransplant patients having short ( < or =5 m) previous graft survival time (PGST) than in those with long PGST ( > or =5 m). Only 2% of retransplant recipients with B + FCXM had non-HLA Ab. In contrast, the overwhelming majority of primary recipients had no detectable alloAbs. No significant difference in class I PRA was found between B- and B+ FCXM recipients. However, class II PRA was significantly higher in patients having B + FCXM (p = 0.028). Collectively, these data show that MCS intensity is not always a reliable criterion for anti-HLA Ab detection because of the presence of non-HLA Ab. These results can be explained by low titers of anti-class II Ab, at which concentration these Ab cannot produce a deleterious effect. FlowPRA and Flow screen beads appeared to be reliable and sensitive methods for detection and specificity analysis of anti-class II alloAb.

Older people and laxative use: literature review and pilot study report

This study explored older adults' perceptions of constipation, and the measures taken if they believed themselves to be afflicted by this condition. The paper provides an overview of the current literature surrounding laxative use, followed by a discussion of the pilot study and its findings. The objectives of the pilot study were to establish older people's definitions of the term 'constipation'; identify prescribed laxatives, over-the-counter laxatives, and home remedies used by older people to manage constipation; produce a detailed account of when these products are used; identify the older person's belief system underpinning their concepts of constipation, and their consequent use of laxative products; and produce information which will inform nursing practice, with a particular focus on nurses in community practice. People who identified themselves as being constipated were interviewed on a one to one basis. Participants shared their stories of loneliness, social isolation and anxiety related to constipation and the need to use laxatives on a daily basis, and described persistent unpleasant and often painful physical symptoms such as bloating, urges, excessive flatus, nausea and cramps, commonly associated with laxative ingestion. Nurses are challenged to work with older people within a 'wellness' framework, helping clients to maintain their bowel function, rather than fall back on short-term options, which provide only brief relief of symptoms, while ignoring the underlying causes.

The safety and efficacy of a two-dose daclizumab (zenapax) induction therapy in liver transplant recipients

BACKGROUND

Induction therapy with daclizumab has been shown to be efficacious in the prevention of acute rejection in kidney transplant patients. The routine use of antibody induction therapy in liver transplantation has not gained widespread acceptance, except in the cases of renal insufficiency. The recent approval of daclizumab prompted us to initiate this pilot study using induction therapy in those patients at risk for developing posttransplant renal insufficiency.

METHODS

This nonrandomized study examined the use of daclizumab in 39 of the last 97 liver transplants performed at the University of Alabama in Birmingham. The daclizumab group received 2 mg/kg intravenously before organ engraftment, and 38 of the 39 received 1 mg/kg intravenously on postoperative day 5. The control group consisted of the remaining 58 contemporary patients. Additional immunosuppression consisted of steroids, tacrolimus, or microemulsion cyclosporine in all patients and mycophenolate mofetil in selected patients.

RESULTS

Pretransplant demographics were not significantly different between the groups. In the induction group there were significantly fewer males, 14 (36%) vs. 34 (59%) (P=0.03). They had greater renal insufficiency at the time of transplant, serum creatine 1.9+/-0.37 mg/dl vs. 0.8+/-0.5; P=0.0009, and more patients were at higher acuity (status 1 and 2A): 12 (31%) vs. 3 (5%) P=0.0006 than in the noninduction group. By postoperative day 7, renal function improved in the induction group such that it was not significantly different from the noninduction group and remained similar throughout the rest of the follow-up. The induction group also experienced significantly less acute rejection, 7 (18%) vs. 23 (40%) (P=0.02) than in the noninduction group in the first 6 months. The 1-, 3-, and 6-month patient survival rates were similar in the induction group, 97.4%, 97.4%, and 97.4%, vs. non-induction 94.8%, 93.0%, and 93% (P=NS). The incidence of cytomegalovirus, in the first 6 months, in the induction group was four (10%) vs. five (9%) (P=NS) in the noninduction group.

CONCLUSION

In the pilot study, induction therapy with daclizumab was safe, facilitated improvement in renal function, and appeared to reduce the incidence of acute rejection. Combination therapy with daclizumab may be an important adjunct in immunosuppressive strategies for liver transplant recipients.

Care of the patient with oesophageal varices

Practice profiles are reflective pieces written by nurses in practice and based on continuing professional development articles. This week Suzanne Hudson discusses Oesopahgeal varices. CPD article NS 17. McArdle J (1999) Understanding oesophageal varices.

Renal retransplantation at the University of Alabama at Birmingham: incidence and outcome

Only half the patients who lost a renal allograft either returned to the waiting list (32%) or were retransplanted (17%). One fifth died soon after allograft loss. Patients did not return to the waiting list for multiple reasons including patient choice, worsened medical condition and most commonly, interest but non-referral. Diabetics had a significantly diminished chance for survival on dialysis after graft loss. African-Americans had a better chance of survival after graft loss but a much worse opportunity to be retransplanted. The use of CellCept in triple immunosuppressive therapy, along with a flow cytometry crossmatch, has improved retransplant allograft survival commensurate with primary graft outcome. The incidence of retransplantation is decreasing at our institution even though the number of potential candidates for retransplantation remains stable.

The prevention of playground injuries

Playground accidents are the most common cause of injury to children in school. As the health professional who attends to these injured children, school nurses should be aware of safety practices that can help eliminate the risks that children encounter. The National Program for Playground Safety has identified four areas that can reduce the level of risk on school playgrounds: supervision, age-appropriate design of the play area, fall surfaces under and around playground equipment, and equipment and surface maintenance. The article discusses each of these, and recommends leadership methods and practices that nurses can implement that will eliminate or reduce risk factors. In addition, a comprehensive playground risk model is described, and suggestions for policy areas are outlined. Policy areas include assessment, education, and enforcement in relation to each of the risk factors.

Career structures for South Australian nurses: developing a research agenda

Career structure models are central to the organisation of the work of professionals like nurses, to their remuneration and other forms of recognition, and for the organisation of employing institutions. It has been little more than a decade since the implementation of a career structure model for nurses in South Australia in 1986-7. Since that time a number of changes to the profession, and to the health care system more generally, have resulted in ad hoc adaptations to, and sometimes an erosion of, the career structure as originally envisioned. As we approach the new millennium, an assessment and evaluation of the efficacy of the SA career structure in meeting the professional needs of nurses and their employing organisations is both timely and necessary. This paper provides the historical background to the development of the SA career structure, and highlights some of the major issues that have emerged as problematic since implementation. The paper then identifies some issues that might contribute towards guiding a more systematic approach to the re-appraisal of nurses' career structures.

Reentry using naltrexone: one anesthesia department's experience

The responsibilities of administrative managers may include dealing with the practitioner who is seeking to reenter the workplace while recovering from drug or alcohol addiction. The following article offers assistance when considering the development of a policy for reintroducing and monitoring these individuals in an anesthesia department. In this instance, naltrexone was found useful in facilitating reentry into anesthesia practice after inpatient treatment and while following a comprehensive aftercare program. The AANA Peer Assistance Advisors have compiled a model policy and reentry contract. For copies of policies, video resources, or other additional information, contact AANA staff member Susan Burger at (847) 692-7050, extension 3011.

From compliance to concordance: a challenge for contraceptive prescribers

In 1997 the Royal Pharmaceutical Society of Great Britain published a report entitled From Compliance to Concordance: Achieving Shared Goals in Medicine Taking. This article applies this new model--of doctors and patients working together towards a shared goal--to the prescribing of hormonal forms of contraception. It begins by critically evaluating the current dominant model of contraceptive prescribing. It claims that this model tends to stereotype all women, but particularly young, poor and black women, as unreliable and ill-informed contraceptors who need to be advised and even controlled by much more knowledgeable and socially responsible family planning experts. The article then suggests how a much more egalitarian model of contraceptive prescribing might be put into practice, whilst acknowledging the existence of many serious obstacles to such a radical shift within family planning services. In conclusion, the article suggests that until contraceptive prescribers begin to take women's experiences of, and concerns about, hormonal contraceptives seriously they will fail to develop a potentially much more effective and liberating model of family planning.

Operative treatment of tertiary hyperparathyroidism: a single-center experience

OBJECTIVE

To review the experience with the operative treatment of tertiary hyperparathyroidism (TH) from a single renal transplant center.

SUMMARY BACKGROUND DATA

Most patients with chronic renal failure show evidence of secondary hyperparathyroidism by the time maintenance hemodialysis begins. Persistent secondary hyperparathyroidism (i.e., TH) requiring surgical intervention is uncommon in the authors' experience.

METHODS

Charts of patients who underwent parathyroidectomy for TH were reviewed retrospectively. Information obtained included demographics, laboratory data, symptoms, operative procedure (including morbidity and mortality rates), and pathology. Comparisons of demographic data and allograft survival were made between the transplant population as a whole and a matched cohort group of patients.

RESULTS

Thirty-eight patients from 4344 renal transplant procedures during a 29-year period required parathyroidectomy for TH. All patients had hypercalcemia; 20 were asymptomatic and 18 had varying symptoms. Mean time from renal transplantation to parathyroidectomy was 997 +/- 184 days, with a mean preoperative calcium level of 12.2 +/- 0.14 mg/dl. Total parathyroidectomy with parathyroid autograft was performed in 26 of 34 primary procedures. There were no deaths. The operative morbidity rate was 6% (wound separation and vocal cord hemiparesis, one each). Pathology was reported in all patients and recently reviewed in 28 patients. Twenty-four had diffuse hyperplasia and nine had nodular hyperplasia; one had an adenoma. Parathyroid glands diagnosed as nodular hyperplasia were significantly larger by total mass than those with diffuse hyperplasia. Comparison of allograft survival between the study group and a matched cohort group of patients revealed no difference in long-term graft survival.

CONCLUSIONS

Operative intervention is recommended in patients with an asymptomatic increase in serum calcium to >12.0 mg/dl persisting for >1 year after the transplant, acute hypercalcemia (calcium >12.5 mg/dl) in the immediate posttransplant period, and symptomatic hypercalcemia.

Ethnicity and cancer outcomes: behavioral and psychosocial considerations

Cancer has been the subject of thousands of behavioral and psychosocial studies. The literature has focused largely on non-Hispanic Whites, despite the fact that cancer outcomes vary by ethnicity. This article provides a review of those studies that do consider the relations between ethnicity and cancer-related adherence behaviors, survival, and quality of life. The authors propose a mediational framework that links ethnicity and cancer outcomes through socioeconomic status, knowledge and attitudes, and access to medical care. They use this framework to organize the literature and to develop recommendations for future research.

Scenario analysis of the future of clinical pharmacy

The role of clinical pharmacy in the health care system is changing rapidly. This change is almost universal among different countries and is related to developments in medical technology, health economics, informatics, socio-economic status, and professional relations. Transitions to new systems of clinical pharmacy are difficult to anticipate. Even with well defined targets, it remains uncertain what the future of clinical pharmacy will bring us. The construction of plausible scenarios may help us better in preparing for the 'new world' ahead. At the annual congresses of ESCP in Prague 1995 (24th) and Lisbon 1996 (25th), a number of scenario analysis workshops with respect to the future of clinical pharmacy were organized. This paper gives a report of the results of these scenario sessions and reflects on the implications for future policy making. After we identified the driving forces behind the future of clinical pharmacy, various sets of assumptions were made and from them scenarios were constructed which are plausible: they 'could' happen. This analysis provided a logical framework in which we ultimately depicted three alternating stories of the future of clinical pharmacy, named 'CLERK', 'CONTROLLER' and 'CARE MANAGER'. These scenarios are intended to help clinical pharmacists to break free of familiar mental maps and to stimulate creative thinking on the future.

An association between the heat-humidity index and preterm labor and delivery: a preliminary analysis

OBJECTIVES

The goal of this study was to determine whether a relationship exists between heat-humidity indexes and rates of preterm labor and preterm delivery.

METHODS

Preterm labor and delivery rates were compared during the 2 summer and 2 winter weeks with the highest and lowest heat-humidity indexes for each season.

RESULTS

The rate of preterm labor increased consistently from 1.23% to 3.00% as the heat-humidity index rose. When preterm births were examined, the trend was similar but not statistically significant.

CONCLUSIONS

Given the public health import of preterm labor and the frequency with which pregnant women may be exposed to extremes of heat, studies designed to confirm or refuse our preliminary observations are warranted.

Relationship of the antispasticity effect of tizanidine to plasma concentration in patients with multiple sclerosis

BACKGROUND

Spasticity is a serious problem in multiple sclerosis (MS) and many patients do not achieve a satisfactory response to currently available oral antispasticity drugs. Tizanidine hydrochloride, an alpha 2-noradrenergic agonist, has been shown to have an antispasticity effect in single center trials of patients with MS.

OBJECTIVE

To compare plasma concentrations of tizanidine with objective measures of muscle tone in patients with MS with moderate to severe spasticity.

SETTING

Ten centers, all tertiary referral centers for the specialized treatment of patients with MS, in the United States and Canada.

DESIGN

A randomized, double-blind, placebo-controlled, dose-response study of tizanidine hydrochloride (8 or 16 mg).

PATIENTS

One hundred forty-two patients with spastic MS who were not taking any interfering medication, such as an antispasticity drug or other alpha-noradrenergic agonist, entered the trial.

RESULTS

Tizanidine treatment reduced muscle tone significantly, as shown by improved Ashworth scores and increased knee swing amplitude recorded by the pendulum test, both of which correlated significantly with plasma concentration. Placebo had no significant effect on muscle tone. Dizziness, drowsiness, dry mouth, and fatigue were reported most often in the group treated with tizanidine at peak plasma concentration.

CONCLUSIONS

Tizanidine reduces spasticity in MS, and both therapeutic effects and side effects are related to the plasma drug levels.

A descriptive analysis of children's playground injuries in the United States 1990-4

OBJECTIVES

To review playground injury statistics over a five year period in order to develop an awareness of how and where children in the United States are being injured.

METHODS

All data are based on the United States Consumer Product Safety Commission's National Electronic Injury Surveillance System (NEISS) for playground related injuries during 1990-4. The surveillance data includes injuries recorded in more than 90 hospital emergency departments located throughout the United States.

RESULTS

Each year there are roughly 211,000 preschool or elementary school-children in the United States who receive emergency department care for injuries associated with playground equipment. On average, 17 of these cases result in death. 70% of all injuries occur on public playgrounds, with nearly one third classified as severe. Swings, climbers, and slides are the pieces of playground equipment associated with 88% of all NEISS reported injuries. Falls to the surface are responsible for 70%.

CONCLUSIONS

NEISS playground injury statistics contribute to our understanding of playground injuries. By identifying where and how children are injured, suggestions can be made in an attempt to make playgrounds safer.

An evaluation of community pharmacy records in the development of pharmaceutical care in The Netherlands

An electronic patient database linking prescribes with a Dutch community pharmacy consortium was evaluated in a subset of the population of Noordwijk (11,760 patients out of a total of 25,600). The pharmacy database (a file of 41 disease contra-indications representing a subset of the prescribers' medical diagnosis) was studied in order to assess its value for the accurate discrimination of target patient groups within the community and for support to the pharmaceutical care of individual patients. The aim was to examine the application of the pharmacy records to pharmaceutical care, tested by measuring the accuracy of the pharmacy database to predict the community public health profile; and, more specifically, the accuracy to identify three potential target groups for pharmaceutical care. The records of patients with angina, chronic respiratory disease and diabetes (n = 1116), representing 65% of the total pharmacy morbidity records, were studied in detail and verified by the files and texts of the prescriber's individual patient records. From samples of patients (n = 273) from the three patient groups, the extent and nature of co-morbidity, polypharmacy (drug entities prescribed annually) and drug therapy instability (prescription changes to dose or dose form annually) were characterised. Angina patients showed the most comorbidity, 46% having three or more additional diseases; chronic respiratory disease patients showed most drug therapy instability; and insulin-dependent diabetic patients received most polypharmacy per disease. The pharmacy database predicted the prevalence of 10 of 23 relevant disease categories (representing 51% of the total morbidity on the medical records). However, the prevalences of eight categories were underestimated and of five categories overestimated. Of the three patient groups, 73% of patients appeared on both the pharmacy and the medical database. Of the total co-morbidity recorded for these patients, 68% of records were common to both databases. The database discrepancies (32%) were due to morbidity omitted (12%) and morbidity unverified (10%) on the pharmacy database, together with morbidity omitted from the medical database (10%). The current pharmacy database provides a limited view of morbidity. A strategic approach to pharmaceutical care requires pharmacists and prescribers to verify and share patient information if patient groups and individuals within a group are to be usefully targeted.

Strategies for weight control success in adults

Recent evidence demonstrates that only about 5% of individuals embarking on a weight loss program show lasting weight reduction. While many weight loss strategies have demonstrated poor results, some combinations of approaches have been successful. Empirical evidence demonstrates that certain conceptual approaches can contribute to the development of strategies to facilitate weight loss. This manuscript addresses three conceptual approaches that direct intervention strategies. Cognitive-behavioral strategies are directed toward modification of eating behaviors, and the social-contextual approach is directed toward the social and partnership approach to intervention. Biophysical strategies that have demonstrated success in weight loss include the effect of dietary restriction and exercise on weight loss. Using this synthesis of empirical evidence for success in weight loss, practitioners can develop individually tailored intervention strategies for their clients.

Are community health interventions evaluated appropriately? A review of six journals

OBJECTIVES

To determine if Randomized Controlled Trial (RCT) methodology was used appropriately in community health, we: (1) determined the proportion of non-randomized studies that should have been RCTs, and (2) assessed the quality of the RCTs.

METHODS

The 1992 issues of six community health journals were manually searched. Intervention studies were analyzed. Studies that did not use randomization were analyzed for feasibility and practicality of RCT methods; RCTs were analyzed for quality using a checklist. RCTs were compared with community health RCTs from The New England Journal of Medicine. The proportion of studies meeting each criterion was determined.

RESULTS

Fourteen percent of 603 studies were interventions and 4% were RCTs. Of those not using randomization, 42% should have. Mean RCT scores were significantly lower for the community health journals than for The New England Journal of Medicine. Many criteria important to quality scored poorly.

CONCLUSIONS

RCTs are underused and lack methodologic rigor in community health. Conclusions regarding the effectiveness of interventions are therefore suspect.