Inpatient electronic prescribing data can be used to identify 'lost' discharge codes for diabetes

AIM

Accurate assessment of missed discharge codes for diabetes is critical for effective planning of hospital diabetes services. We wished to estimate the frequency of missed discharge diagnostic codes for diabetes and the impact missed codes would have on diabetes-related payments to the hospital.

METHODS

We linked Patient Administration System data to the Prescribing Information and Communication System. We defined diabetes as those having a discharge code for diabetes in the Patient Administration System and those on anti-diabetic medication in the Prescribing Information and Communication System. Based on the two sources, we calculated the estimated missed discharge codes for diabetes using the capture-recapture technique. We generated the Healthcare Resource Group for a given admission before and after correction for the missed code to estimate the impact that correction would make on payments to the hospital.

RESULTS

Among the 171 067 admissions linked, 22 412 (13.1%) had a code for diabetes at discharge. An additional 2706 admissions were classified as having diabetes based on prescription data. The capture-recapture technique estimated there were 4588 (2.7% of all admissions) admissions with diabetes missed by current coding, of which 2706 (60%) would be obtained from prescription data. After adding a diabetes diagnostic code, 12.8% of the missed admissions with diabetes resulted in a change to the Healthcare Resource Group tariff code and payment.

CONCLUSION

The use of electronic prescription data is a simple solution to correct for missed discharge diagnostic codes.

Exposure to traumatic events and the behavioral health of children enrolled in an early childhood system of care

Children may be exposed to numerous types of traumatic events that can negatively affect their development. The scope to which studies have examined an array of events among young children has been limited, thereby restricting our understanding of exposure and its relationship to behavioral functioning. The current cross-sectional study describes traumatic event exposure in detail and its relationship to behavioral health among an at-risk sample of young children (N = 184), under 6 years of age, upon enrollment into an early childhood, family-based, mental health system of care. Caregivers completed home-based semistructured interviews that covered children's exposure to 24 different types of traumatic events and behavioral and emotional functioning. Findings indicated that nearly 72% of young children experienced 1 or more types of traumatic events. Multiple regression model results showed that exposure was significantly associated with greater behavioral and emotional challenges with children's age, gender, race/ethnicity, household income, and caregiver's education in the model. These findings highlight the prevalence of traumatic exposures among an at-risk sample of young children in a system of care and suggest that this exposure is associated with behavioral and emotional challenges at a young age.

Hypoglycaemia is associated with increased length of stay and mortality in people with diabetes who are hospitalized

AIM

To study the length of stay and inpatient mortality of patients with diabetes who had an episode of hypoglycaemia in a non critical care setting at University Hospital Birmingham, UK.

METHODS

Retrospective analysis of routinely available electronic data of 6374 admissions with a recording of either laboratory or point-of-care blood glucose value. Based on the lowest recorded blood glucose values, patients were categorized into a group without hypoglycaemia (> 3.9 mmol/l), a group with mild to moderate hypoglycaemia (2.3-3.9 mmol/l) and a group with severe hypoglycaemic (≤ 2.2 mmol/l). Length of stay and inpatient mortality were compared between the three groups, adjusting for age, gender, ethnicity, deprivation, admission type, use of insulin and modified Charlson co-morbidity score.

RESULTS

There were 148 admissions (2.3%) with severe hypoglycaemia (≤ 2.2 mmol/l), 500 admissions (7.8%) with mild to moderate hypoglycaemia (2.2-3.9 mmol/l) and 5726 admissions with no recorded hypoglycaemic episode (> 3.9 mmol/l). After adjustment, length of stay, when compared with those without a recorded hypoglycaemic episode, was 1.51 (95% CI 1.35-1.68) times higher in the group with blood glucose values of 2.3-3.9 mmol/l and 2.33 (95% CI 1.91-2.84) higher in the group with blood glucose values ≤ 2.2 mmol/l. Adjusted odds ratio of inpatient mortality when compared with the group without hypoglycaemia was 1.62 (95% CI 1.16-2.27) in the group with blood glucose values of 2.3-3.9 mmol/l and 2.05 (95% CI 1.24-3.38) in the group with blood glucose values ≤ 2.2 mmol/l.

CONCLUSION

Hypoglycaemia is associated with increased length of stay and inpatient mortality. Whilst causative evidence is lacking, our data are consistent with the need to avoid hypoglycaemia in our current and continued approach for optimal glycaemic control in people with diabetes admitted to hospital.

A pragmatic randomised controlled trial of the effectiveness and cost-effectiveness of screening older women for the prevention of fractures: rationale, design and methods for the SCOOP study

SCOOP is a UK seven-centre, pragmatic, randomised controlled trial with 5-year follow-up, including 11,580 women aged 70 to 85 years, to assess the effectiveness and cost-effectiveness of a community-based screening programme to reduce fractures. It utilises the FRAX algorithm and DXA to assess the 10-year probability of fracture. Introduction Osteoporotic, or low-trauma, fractures present a considerable burden to the National Health Service and have major adverse effects on quality of life, disability and mortality for the individual. Methods Given the availability of efficacious treatments and a risk assessment tool based upon clinical risk factors and bone mineral density, a case exists to undertake a community-based controlled evaluation of screening for subjects at high risk of fracture, under the hypothesis that such a screening programme would reduce fractures in this population. Results This study is a UK seven-centre, unblinded, pragmatic, randomised controlled trial with a 5-year follow-up period. A total of 11,580 women, aged 70 to 85 years and not on prescribed bone protective therapy will be consented to the trial by post via primary care providing 90% power to detect an 18% decrease in fractures. Conclusions Participants will be randomised to either a screening arm or control. Those undergoing screening will have a 10-year fracture probability computed from baseline risk factors together with bone mineral density measured by DXA in selected subjects. Individuals above an age-dependent threshold of fracture probability will be recommended for treatment for the duration of the trial. Subjects in the control arm will receive 'usual care'. Participants will be followed up 6 months after randomisation and annually by postal questionnaires with independent checking of hospital and primary care records. The primary outcome will be the proportion of individuals sustaining fractures in each group. An economic analysis will be carried out to assess cost-effectiveness of screening. A qualitative evaluation will be conducted to examine the acceptability of the process to participants.

Clinical decision support systems in the care of inpatients with diabetes in non-critical care setting: systematic review

BACKGROUND

Computerized clinical decision support systems have been claimed to reduce prescription errors and improve patient care. They may play an important role in the care of hospitalized patients with diabetes.

AIM

To collate evidence for the use of clinical decision support systems in improving the care of hospitalized patients with diabetes in a non-critical care setting and to assess their effectiveness.

METHODS

We searched four databases from 1980 to 2010 without language restrictions. All types of studies other than case reports were included. Data extraction and quality assessment were carried out based on the Centre for Review and Dissemination guidance. A narrative synthesis was conducted.

RESULTS

Fourteen studies met the inclusion criteria, including two cluster randomized controlled trials, eight before-and-after studies and four other descriptive studies. Generally, the quality of the studies was not very high. Nine out of 10 studies reported reduction in mean blood glucose or similar measures (patient-day-weighted mean blood glucose) during inpatient stay. The reduction using computerized physician order entry system in patient-day-weighted mean blood glucose ranged from 0.6 to 0.8 mmol/l (10.8-15.6 mg/dl). Other beneficial effects during inpatient stay included reduced use of sliding scale insulin and greater use of basal-bolus insulin regimen. Only one study found a significant increase in hypoglycaemic events.

CONCLUSIONS

Clinical decision support systems have been used, often as part of a complex programme, to improve the care of hospitalized patients with diabetes. There is some evidence that they may have a beneficial effect, but this needs further confirmation.

Impact of metabolic syndrome on ischemic heart disease - a prospective cohort study in an Iranian adult population: Isfahan Cohort Study

BACKGROUND

The impact of the metabolic syndrome among populations in the Middle East region is unknown; we therefore examined the association between the syndrome and the risk of ischemic heart disease (IHD) in an Iranian population.

METHODS AND RESULTS

The Isfahan Cohort Study (ICS) prospectively followed 6146 Iranian people (51.8% women, aged 35-75 years) from three cities and their rural districts who were initially free of ischemic heart disease. During the 5 year follow-up, 209 (56% men) cases of ischemic heart disease were detected. The metabolic syndrome was defined by the modified criteria of the National Cholesterol Education Program Adult Treatment Panel III (NCEP/ATPIII). End points were defined as fatal and nonfatal myocardial infarction, sudden cardiac death and unstable angina. A clear dose-response relationship was found between the number of metabolic risk factors and the incidence of IHD, with the hazard ratios increasing dose-dependently from 1.72 (95% CI 0.86-3.46) for only one to 1.97 (1.00-3.90), 2.85 (1.45-5.58) and 4.44 (2.25-8.76) for 2, 3 and ≥4 metabolic syndrome component respectively, relative to those with no component. The adjusted hazard ratio (95% CI) associated with the metabolic syndrome was 1.58 (1.06-2.35) in men and 1.72 (1.08-2.74) in women for IHD. The contribution of metabolic syndrome to the IHD risk was particularly strong among smokers although there was no significant interaction.

CONCLUSIONS

The metabolic syndrome by NCEP/ATPIII definition is a major determinant of ischemic heart disease in this middle-aged Iranian population, especially among smokers.

Insecure attachment and frequent attendance in primary care: a longitudinal cohort study of medically unexplained symptom presentations in ten UK general practices

BACKGROUND

In primary care frequent attenders with medically unexplained symptoms (MUS) pose a clinical and health resource challenge. We sought to understand these presentations in terms of the doctor-patient relationship, specifically to test the hypothesis that such patients have insecure emotional attachment.

METHOD

We undertook a cohort follow-up study of 410 patients with MUS. Baseline questionnaires assessed adult attachment style, psychological distress, beliefs about the symptom, non-specific somatic symptoms, and physical function. A telephone interview following consultation assessed health worry, general practitioner (GP) management and satisfaction with consultation. The main outcome was annual GP consultation rate.

RESULTS

Of consecutive attenders, 18% had an MUS. This group had a high mean consultation frequency of 5.24 [95% confidence interval (CI) 4.79-5.69] over the follow-up year. The prevalence of insecure attachment was 28 (95% CI 23-33) %. A significant association was found between insecure attachment style and frequent attendance, even after adjustment for sociodemographic characteristics, presence of chronic physical illness and baseline physical function [odds ratio (OR) 1.96 (95% CI 1.05-3.67)]. The association was particularly strong in those patients who believed that there was a physical cause for their initial MUS [OR 9.52 (95% CI 2.67-33.93)]. A possible model for the relationship between attachment style and frequent attendance is presented.

CONCLUSIONS

Patients with MUS who attend frequently have insecure adult attachment styles, and their high consultation rate may therefore be conceptualized as pathological care-seeking behaviour linked to their insecure attachment. Understanding frequent attendance as pathological help seeking driven by difficulties in relating to caregiving figures may help doctors to manage their frequently attending patients in a different way.

[Introduction to preventive and predictive medicine: past experience and future reality]

The active practical introduction of the achievements of genomics, proteomics, metabolomics, and bioinformatics brought about a fundamental change in views on the role and place of medicine in the structure of healthcare at the turn of the 1980s-1990s, by giving impetus to the development of the radically new health care area--preventive, predictive, and personalized medicine (PPPM).

Cardiovascular screening for men at high risk in Heart of Birmingham Teaching Primary Care Trust: the 'Deadly Trio' programme

BACKGROUND

The Deadly Trio programme offered cardiovascular health checks to men over 40 in inner-city Birmingham. The aim was to increase diagnosis of diabetes, cardiovascular and kidney disease among this deprived and ethnically diverse population. Either patients' own general practitioners (GPs) were paid to provide health checks or patients were invited to an alternative provider.

METHODS

Routine data were sought from 68 participating practices. Logistic regression analysis was undertaken to determine the patient and practice factors associated with being screened and with being added to a disease register.

RESULTS

Data were obtained from 58 practices; 5871 (24.3%) of 24 166 eligible men were screened. Screening uptake was higher in those with a recorded phone number, South Asians and Blacks but lower in smokers. Compared to the alternative provider, uptake was higher among men registered with single-handed (but not multi-partner) GPs paid to provide health checks. South Asian, older and screened men were more often added to disease registers. Men with missing information and GP-screened men were less likely to be added to registers.

CONCLUSIONS

The programme achieved higher screening uptake and diagnosis of disease among minority ethnic men. Single-handed GPs paid to provide screening (and their patients) were more responsive than multi-partner practices.

Electronic Transport Properties of ZnSe Layers on GaAs

The electronic transport properties of ZnSe layers grown by MBE on GaAs sub- strates are studied by small-signal ac admittance, dc current-voltage, and Hall effect measurements. This work is supplemented by a study of TEM and x-ray rocking curve data. We find that the transport characteristics are strongly affected by the proper- ties of the ZnSe/GaAs interface. From the dc and ac measurements, we determine the total barrier height at the interface of thick (1-6 µm) ZnSe layers on n+-GaAs, and find that it is in general voltage dependent. While some samples are found to have a very high peak mobility (> 10,000cm2 /Vsec), an anomalous reduction in the mobility in a large fraction of the samples is found, and attributed to the presence of non- uniform space charge regions.

The Isfahan cohort study: rationale, methods and main findings

A 10-year longitudinal population-based study, entitled the Isfahan Cohort Study (ICS) is being conducted. The ICS commenced in 2001, recruiting individuals aged 35+ living in urban and rural areas of three counties in central Iran, to determine the individual and combined impact of various risk factors on the incidence of cardiovascular events. After 24379 person-years of follow-up with a median follow-up of 4.8 years, we documented 219 incident cases of ischemic heart disease (IHD) (125 in men and 94 in women) and 57 incident cases of stroke (28 in men and 29 in women). The absolute risk of IHD was 8.9 (7.8-10.2) per 1000 person-years for all participants, 10.6 (8.8-12.5) per 1000 person-years for men and 7.4 (6.0-9.0) per 1000 person-years for women. The respective risk of ischemic stroke was 2.3 (1.7-3.0), 2.3 (1.6-3.3) and 2.3 (1.5-3.2) per 1000 person-years. The risk of IHD was approximately 3.5-fold higher in the presence of hypertension, followed by diabetes mellitus and hypercholesterolemia with near 2.5- and twofold higher risk, respectively. This cohort provides confirmatory evidence of the ethnic differences in the magnitude of the impact of various risk factors on cardiovascular events. The differences may be due to varying absolute risk levels among populations and the existing ethnic disparities for using western risk equations to local requirements.

A pilot double-blind randomised placebo-controlled trial of the effects of fixed-dose combination therapy ('polypill') on cardiovascular risk factors

AIM

Our objective was to investigate the effects and tolerability of fixed-dose combination therapy on blood pressure and LDL in adults without elevated blood pressure or lipid levels.

METHODS

This was a double-blind randomised placebo-controlled trial in residents of Kalaleh, Golestan, Iran. Following an 8-week placebo run-in period, 475 participants, aged 50 to 79 years, without cardiovascular disease, hypertension or hyperlipidaemia were randomised to fixed-dose combination therapy with aspirin 81 mg, enalapril 2.5 mg, atorvastatin 20 mg and hydrochlorothiazide 12.5 mg (polypill) or placebo for a period of 12 months. The primary outcomes were changes in LDL-cholesterol, systolic and diastolic blood pressure and adverse reactions. Analysis was by intention-to-treat basis.

RESULTS

At baseline, there were differences in systolic blood pressure (6 mmHg). Taking account of baseline differences, at 12 months, polypill was associated with statistically significant reductions in blood pressure (4.5/1.6 mmHg) and LDL-cholesterol (0.46 mmol/l). The study drug was well tolerated, but resulted in the modest reductions in blood pressure and lipid levels.

CONCLUSION

The effects of the polypill on blood pressure and lipid levels were less than anticipated, raising questions about the reliability of the reported compliance. There is a case for a fully powered trial of a polypill for the prevention of cardiovascular disease.

Effectiveness of microsatellite and SNP markers for parentage and identity analysis in species with low genetic diversity: the case of European bison

The European bison (Bison bonasus) has recovered successfully after a severe bottleneck about 90 years ago but has been left with low genetic variability that may substantially hinder parentage and identity analysis. According to pedigree analysis, over 80% of the genes in the contemporary population descend from just two founder animals and inbreeding coefficients averaged almost 0.5, whereas microsatellite heterozygosity does not exceed 0.3. We present a comparison of the effectiveness of 17 microsatellite and 960 single nucleotide polymorphism (SNP) markers for paternity and identity analysis in the European bison. Microsatellite-based paternity and identity analysis was unsuccessful because of low marker heterozygosity and is not a practical approach in this species. Simulations using SNP markers suggest that 80-90 randomly selected loci, or just 50-60 of the most heterozygous loci, would be sufficient to ensure successful paternity and identity analysis in this species. For the purpose of standardizing future analysis, a panel of 50-60 bovine SNPs characterized by high heterozygosity and an even distribution in the genome could be selected. This panel of markers could be typed using VeraCode (Illumina) or similar SNP genotyping systems. The low cost of these SNP genotyping methods compared with a 16 locus microsatellite survey means that off-the-shelf SNP genotyping systems developed for domestic species represent powerful tools for genetic analysis in related species, and can be effective even in bottlenecked species in which heterozygosity of other markers such as microsatellites may be very low.

Menopausal symptoms in women treated for breast cancer: the prevalence and severity of symptoms and their perceived effects on quality of life

OBJECTIVES

To determine, first, the prevalence and severity of various symptoms related to estrogen deficiency in women within a few years of receiving treatment for breast cancer, second, how women perceive the effects of these symptoms on their quality of life and, third, what measures have been taken to relieve vasomotor symptoms.

METHODS

Two hundred women (aged 29-65 years) who had received treatment for breast cancer within the last 5 years were included in this cross-sectional survey. Information was collected about their breast cancer treatment, menopausal symptoms (Menopausal Rating Scale), the perceived effects of menopausal symptoms on their and their partner's quality of life and any treatments they were receiving for hot flushes.

RESULTS

All but one woman reported at least one symptom related to the menopause (95.9% vasomotor; 83.3% psychological; 89.7% somatic). Current treatment with tamoxifen or previous chemotherapy did not influence the prevalence or the severity of hot flushes. Current antidepressant treatment was, however, significantly associated with a higher prevalence and severity of most menopausal symptoms, including hot flushes and sweats (p = 0.008). The severity of hot flushes and sweats was significantly correlated with self-assessed effects on overall quality of life (r(s) = 0.47); 56.4% of the respondents believed that menopausal symptoms had affected their partner's quality of life, the strongest correlations being with severity of sexual symptoms (r(s) = 0.56) and vaginal dryness (r(s) = 0.5). Only 21% of women experiencing hot flushes were receiving any treatment for hot flushes, with most women describing no knowledge or poor knowledge of treatment options.

CONCLUSIONS

The majority of women receiving treatment for breast cancer report menopausal symptoms, which negatively correlate, not only with their own, but also with their partner's quality of life. Most women experiencing hot flushes are not receiving treatment due to lack of both awareness and confidence in the existing treatment options.

Performance of FASTPlaqueTB and a modified protocol in a high HIV prevalence community in South Africa

Modifications in the FASTPlaqueTB test protocol have resulted in an increase in the analytical limits of detection. This study investigated whether the performance of a modified prototype was able to increase the detection of smear-negative, culture-positive sputum samples as compared to the first generation FASTPlaqueTB test. Modifications to the FASTPlaqueTB did result in increased detection of smear-negative samples, but this was associated with a decrease in the specificity of the test. Before the FASTPlaqueTB can be considered as a viable replacement for smear microscopy and culture for the identification of tuberculosis, further work is required to resolve the performance issues identified in this study.

Professional assistance during birth and maternal mortality in two Indonesian districts

OBJECTIVE

To examine determinants of maternal mortality and assess the effect of programmes aimed at increasing the number of births attended by health professionals in two districts in West Java, Indonesia.

METHODS

We used informant networks to characterize all maternal deaths, and a capture-recapture method to estimate the total number of maternal deaths. Through a survey of recent births we counted all midwives practising in the two study districts. We used case-control analysis to examine determinants of maternal mortality, and cohort analysis to estimate overall maternal mortality ratios.

FINDINGS

The overall maternal mortality ratio was 435 per 100,000 live births (95% confidence interval, CI: 376-498). Only 33% of women gave birth with assistance from a health professional, and among them, mortality was extremely high for those in the lowest wealth quartile range (2303 per 100,000) and remained very high for those in the lower middle and upper middle quartile ranges (1218 and 778 per 100,000, respectively). This is perhaps because the women, especially poor ones, may have sought help only once a serious complication had arisen.

CONCLUSION

Achieving equitable coverage of all births by health professionals is still a distant goal in Indonesia, but even among women who receive professional care, maternal mortality ratios remain surprisingly high. This may reflect the limitations of home-based care. Phased introduction of fee exemption and transport incentives to enable all women to access skilled delivery care in health centres and emergency care in hospitals may be a feasible, sustainable way to reduce Indonesia's maternal mortality ratio.

A complex orbit

Wegener's Granulomatosis (WG) in its limited form can be a challenging diagnosis. ANCA, radiological investigations and histology should be interpreted in light of clinical findings. A delay in diagnosis can have profound visual consequences. Immunosuppressive therapy and co-morbidities can mask signs of orbital sepsis. A low threshold for further exploration and biopsy should be maintained if an orbital abscess is suspected. This report describes a complex case of WG that illustrates the diagnostic and therapeutic challenges inherent in this form of orbital inflammatory disease.

A reproducibility study of a TDI-based method to calculate indices of arterial stiffness

The aim of the study was to investigate the reproducibility of estimation of Young's modulus E and pressure strain elastic modulus Ep, derived from a tissue Doppler imaging (TDI) wall motion technique. Healthy subjects had their arteries insonated at the same sitting by two different observers and at two different sittings by the same observer. From 32 subjects in the reproducibility study, within-scan coefficient of variation (CV) was 4.5%. Intraobserver between-scan CV for E was 12.7% and for Ep 11.0%. Interobserver CVs were 8.3% and 9.3%, respectively. TDI is a reproducible, valid and highly sensitive direct assessment of arterial wall parameters. It is at least as reproducible as other ultrasound based methods for assessing arterial stiffness and also provides increased information about the arterial distension waveform.

The importance of anaemia in diagnosing colorectal cancer: a case-control study using electronic primary care records

Although anaemia is recognised as a feature of colorectal cancer, the precise risk is unknown. We performed a case–control study using electronic primary care records from the Health Improvement Network database, UK. A total of 6442 patients had a diagnosis of colorectal cancer, and were matched to 45 066 controls on age, sex, and practice. We calculated likelihood ratios and positive predictive values for colorectal cancer in both sexes across 1 g dl⁻¹ haemoglobin and 10-year age bands, and examined the features of iron deficiency.In men, 178 (5.2%) of 3421 cases and 47 (0.2%) of 23 928 controls had a haemoglobin <9.0 g dl⁻¹, giving a likelihood ratio (95% confidence interval) of 27 (19, 36). In women, the corresponding figures were 227 (7.5%) of 3021 cases and 58 (0.3%) of 21 138 controls, a likelihood ratio of 41 (30, 61). Positive predictive values increased with age and for each 1 g dl⁻¹ reduction in haemoglobin. The risk of cancer for current referral guidance was quantified. For men over 60 years with a haemoglobin <11 g dl⁻¹ and features of iron deficiency, the positive predictive value was 13.3% (9.7, 18) and for women with a haemoglobin <10 g dl⁻¹ and iron deficiency, the positive predictive value was 7.7% (5.7, 11). Current guidance for urgent investigation of anaemia misses some patients with a moderate risk of cancer, particularly men.

Estimating the proportion of young adults on antihypertensive treatment that have been correctly diagnosed

This paper aims to identify how many young adults on antihypertensive treatment have been misclassified as hypertensive. We identified subjects aged under 35 on antihypertensive treatment, from the Health Surveys for England, 1998-2004. Pretreatment systolic and diastolic blood pressures were calculated by adjusting on-treatment blood pressures for the effects of treatment. Treatment effects were derived from meta-analysis. Subjects were classified as hypertensive if pretreatment blood pressure was >or=160/100 mm Hg, or was >or=140/90 mm Hg in conjunction with high cardiovascular risk. We then identified the proportion of treated subjects on antihypertensive treatment who were truly eligible for treatment. From the survey data we identified 65 adults (25 men and 40 women) under 35 on diuretics, beta-blockers, angiotensin converting enzyme inhibitors, calcium blockers or other antihypertensives. Average pretreatment blood pressure was 164/100 mm Hg in those eligible for treatment, and 136/79 mm Hg in those not eligible. The analysis indicated that 29.2% of adults aged 16-34 (95% confidence interval (CI): 18.6-41.8%) were truly eligible for antihypertensive treatment: 32.0% (95% CI: 14.9-53.5%) of men and 25.0% (95% CI: 12.7-41.2%) of women. A total of 73.7% (14 of 19) of subjects eligible and 41.3% (19 of 46) of subjects not eligible for treatment either had a body mass index >30 kg m(-2) or kidney disease (chi(2)-test P=0.018). Because of biological variation in blood pressure, most young adults on treatment for hypertension have been misclassified as hypertensive. Most who have been correctly diagnosed are either clinically obese or have kidney disease.

The effects of maternal and infant vitamin A supplementation on vitamin A status: a randomised trial in Kenya

Postpartum vitamin A supplementation of mothers and infants is recommended, but the efficacy has been questioned. In this double-blind, placebo-controlled trial, Kenyan mother–infant pairs were randomised to maternal vitamin A (400 000 IU) or placebo < 24 h postpartum, and infant vitamin A (100 000 IU) or placebo at 14 weeks. Milk retinol was determined at weeks 4, 14 and 26, and maternal and infant serum retinol at weeks 14 and 26. Infant retinol stores were assessed at week 26, using a modified relative dose response (MRDR) test. Among 564 women, serum retinol at 36 weeks gestation was 0·81 (sd 0·21) μmol/l, and 33·3 % were < 0·7 μmol/l. Maternal serum retinol was not different between groups, but milk retinol was higher in the vitamin A group: (0·67 v. 0·60 μmol/l; 0·52 v. 0·44 μmol/l; 0·50 v. 0·44 μmol/l at 4, 14 and 26 weeks, respectively). When expressed per gram fat, milk retinol was higher in the vitamin A group only at 4 weeks. Infant serum retinol was not different between groups. However, although most infants had deficient vitamin A stores (MRDR>0·06 %) at 26 weeks, vitamin A to infants, but not mothers, resulted in a lower proportion of infants with deficient vitamin A stores (69 v. 78 %). High-dose postpartum vitamin A supplementation failed to increase serum retinol and infant stores, despite modest effects on milk retinol. Infant supplementation, however, increased stores. There is a need for a better understanding of factors affecting absorption and metabolism of vitamin A.

The effect of supervised exercise and cilostazol on coagulation and fibrinolysis in intermittent claudication: A randomized controlled trial

BACKGROUND

The prothrombotic, hypofibrinolytic state that develops in patients with intermittent claudication (IC) upon walking due to ischemia-reperfusion injury (IRI) of the leg muscles may contribute to the high incidence of life- and limb-threatening thrombotic events observed in this patient group. Treatments, such as angioplasty, that obtund the IRI also ameliorate the procoagulant diathesis. The effect on this diathesis of supervised exercise and cilostazol, both of which provide symptomatic benefit in IC, but without significantly obtunding IRI, is unknown.

METHODS

Thirty-four patients (27 men and 7 women; median age, 67 years; range, 63-72 years) were randomized to receive best medical therapy (BMT) plus supervised exercise (n = 9), BMT plus cilostazol (n = 9), BMT plus supervised exercise plus cilostazol (n = 7), or BMT alone (n = 9) in a 2 x 2 factorial design. Thrombin-antithrombin complex and prothrombin fragments 1 and 2, both markers of thrombin generation; plasminogen activator inhibitor antigen and tissue plasminogen activator antigen, both markers of fibrinolysis; ankle-brachial pressure index (ABPI); and initial and absolute claudication distance (ACD) were measured at baseline and then 3 and 6 months after randomization.

RESULTS

At 6 months, when compared with receiving BMT only, supervised exercise and cilostazol resulted in improvements in ABPI of 18% and 13% and in ACD of 40% and 64%, respectively. The effects on ABPI and ACD of combining supervised exercise and cilostazol were additive. Supervised exercise, cilostazol, and supervised exercise combined with cilostazol had no significant effect on any of the four hemostatic markers.

CONCLUSIONS

Treatment of IC by supervised exercise or cilostazol results in significant improvements in ABPI and ACD but has no demonstrable effect on the prothrombotic diathesis. This suggests that supervised exercise and cilostazol, unlike angioplasty, are unlikely to have a long-term beneficial effect on the thrombotic risks faced by these patients.

Predictors of patients' preferences for treatments to prevent heart disease

OBJECTIVES

To determine the relationship between expressed preferences for drug treatment to prevent coronary disease and several participant and general practitioner characteristics among patients attending coronary risk screening.

DESIGN

Face-to-face interviews with patients. At the first interview, a researcher asked participants to imagine six scenarios representing different levels of pretreatment five-year coronary risk. In each case they were asked whether they would choose treatment that would reduce their coronary risk by 30% of pretreatment risk. At the second interview participants were told their coronary risk and asked whether they would choose treatment. Sociodemographic variables were collected to investigate their relationship to patients' treatment preferences.

PARTICIPANTS

Patients identified as likely to be at high coronary risk were invited to attend for risk screening and to participate in the study.

SETTING

13 practices in the West Midlands.

RESULTS

Participants' preferences varied widely: at the first interview 112 (55.2%) of 203 participants preferred treatment at 3% five-year coronary risk but 31 (15.3%) preferred no treatment even at 30% five-year coronary risk. Age, sex, education and drug treatment history did not affect preferences, but lower social class was associated with preferring treatment at lower risk. Preferences expressed at the second interview were generally consistent with preferences at the first interview (kappa = 0.510, 95% CI 0.380 to 0.639).

CONCLUSIONS

Patients attending for coronary risk screening express stable preferences for drug treatment to prevent coronary heart disease. Their preferences vary widely and may be associated with social class.

Phase I/II trial of the prostate-specific membrane antigen (PSMA)-targeted immunoconjugate MLN2704 in patients (pts) with progressive metastatic castration resistant prostate cancer (CRPC)

4500

Background: MLN2704 is an immunoconjugate that utilizes the PSMA-targeted monoclonal antibody MLN591 to deliver the maytansinoid antimicrotubule agent DM1 directly to prostate cancer cells. This multicenter trial was designed to determine the tolerability, optimal dosing schedule and efficacy of MLN2704 in pts with progressive metastatic CRPC. Methods: Pts aged ≥18 yrs with progressive metastatic CRPC received MLN2704 i.v. over 2.5 hr q1wk, q2wks or q3wks for 12 wks, with additional doses permitted in responders. Doses within a given schedule were escalated in 40% increments in the absence of excessive dose-limiting toxicity (DLT). Results: 61 pts have been treated. The most common adverse events (AEs) were nausea, fatigue, and schedule-dependent neurotoxicity. The only DLT was gr 3 hepatic transaminitis in 1/6 pts at 330 mg/m2 q2wks; the only gr 4 AE was transient neutropenia, in 2 pts (330 mg/m2 q2wks and q3wks). Declines in PSA were most frequent at 330 mg/m2 q2wks ( table ), including 49–88% PSA declines in 4/6 pts. However, given the frequency of grade 2–3 peripheral neuropathy an additional cohort is being treated with 330mg/m2 on days 1 and 15 of a 6-wk cycle. Initial results with this 6-wk schedule indicate PSA declines with a lower incidence of gr 2–3 toxicities, particularly neuropathy. Conclusions: Accrual to the dose-escalation phase is complete. Dose-dependent antitumor effects were seen. Peripheral neuropathy has limited continuous dosing at higher dose levels prompting a schedule change. Accrual to the 6-wk schedule is continuing.

[Table: see text]

[Table: see text]

Caesarean section and subsequent fertility in sub-Saharan Africa

OBJECTIVE

To determine the impact of caesarean section on fertility among women in sub-Saharan Africa.

DESIGN

Analysis of standardised cross-sectional surveys (Demographic and Health Surveys).

SETTING

Twenty-two countries in sub-Saharan Africa, 1993-2003.

SAMPLE

A total of 35 398 women of childbearing age (15-49 years).

METHODS

Time to subsequent pregnancy was compared by mode of delivery using Cox proportional hazards regression models.

MAIN OUTCOME MEASURES

Natural fertility rates subsequent to delivery by caesarean section compared with natural fertility rates subsequent to vaginal delivery.

RESULTS

The natural fertility rate subsequent to delivery by caesarean section was 17% lower than the natural fertility rate subsequent to vaginal delivery (hazard ratio = 0.83, 95% CI 0.73-0.96, P < 0.01; controlling for age, parity, level of education, urban/rural residence and young age at first intercourse). Caesarean section was also associated with prior fertility and desire for further children: among multiparous women, an interval > or =3 versus <3 years between the index birth and the previous birth was associated with higher odds of caesarean section at the index birth (OR = 1.4, 95% CI 1.1-1.7, P= 0.005); among all women, the odds of desiring further children were lower among women who had previously delivered by caesarean section (OR = 0.67, 95% CI 0.54-0.84, P < 0.001). Caesarean section did not appear to increase the risk of a subsequent pregnancy ending in miscarriage, abortion or stillbirth.

CONCLUSIONS

Among women in sub-Saharan Africa, caesarean section is associated with lower subsequent natural fertility. Although this reflects findings from developed countries, the roles of pathological and psychological factors may be quite different because a much higher proportion of caesarean sections in sub-Saharan Africa are emergency procedures for maternal indication.

The constitutive procoagulant and hypofibrinolytic state in patients with intermittent claudication due to infrainguinal disease significantly improves with percutaneous transluminal balloon angioplasty

BACKGROUND

Patients with intermittent lower limb claudication (IC) exhibit a prothrombotic diathesis that is acutely exacerbated by exercise. This may occur because of ischemia/reperfusion injury within the leg muscles during walking and may contribute to the increased risk of thrombotic vascular events in this group of patients. This randomized study compared the effect of lower limb revascularization by percutaneous transluminal balloon angioplasty (PTA), supervised exercise, and best medical therapy (BMT) alone on this prothrombotic state.

METHODS

Twenty-three patients (16 men and 7 women; median age, 67 years; range, 57-77 years) with IC due to infrainguinal disease were randomized to receive BMT alone (n = 7), BMT plus PTA (n = 9), or BMT plus supervised exercise (n = 7) as part of the Health Technology Assessment-funded EXercise vs Angioplasty in Claudication Trial (EXACT). Patients were assessed at baseline and at 3 and 6 months. Thrombin-antithrombin complex (TAT) was determined as a marker of thrombin generation, and plasminogen activator inhibitor (PAI) antigen was determined as a marker of fibrinolysis. Increased TAT indicates a procoagulant state, and increased PAI antigen indicates a hypofibrinolytic state.

RESULTS

At 6 months, subjects randomized to BMT plus PTA demonstrated a significant improvement in ankle-brachial pressure index (P = .013) and maximal walking distance (P = .008), a significant decline in resting thrombin generation (median [interquartile range] TAT, 6.4 microg/L [2.7-13.5 microg/L] to 1.5 microg/L [0.3-2.9 microg/L]; P = .038), and an improvement in resting fibrinolysis (median [interquartile range] PAI-1, 10.0 ng/mL [1.0-20.5 ng/mL] to 1.0 ng/mL [1.0-14.8 ng/mL]; P = .043). There was no significant change in any of these parameters in patients randomized to BMT plus supervised exercise or to BMT alone.

CONCLUSIONS

The addition of lower limb revascularization by PTA to BMT in patients with IC due to infra-inguinal disease results in a medium-term improvement in the resting procoagulant and hypofibrinolytic state. This may translate into a reduction in morbidity and mortality from thrombotic vascular events in this group of patients.

Prospective randomised study of urgent haemorrhoidectomy compared with non-operative treatment in the management of prolapsed thrombosed internal haemorrhoids

OBJECTIVE

To compare the outcome of urgent haemorrhoidectomy with conservative treatment for prolapsed thrombosed internal haemorrhoids.

METHODS

A prospective randomised study of 50 patients with prolapsed thrombosed internal haemorrhoids was carried out using clinical and ultrasonic outcome measures. Peri-operative bed occupancy and the presence of symptoms at 6 and 24 months were compared. Endoanal ultrasonic scanning was carried out to investigate anal sphincter integrity in those patients willing to be studied.

RESULTS

The median length of hospital stay for the group treated conservatively; 2 nights (range 1-9 nights) was significantly shorter than for the group treated by urgent haemorrhoidectomy; 4 nights (range 1-12 nights, P < 0.01). There was no difference between treatment groups in the number of patients with symptoms at six or 24 months. Urgent haemorrhoidectomy was associated with a significantly higher incidence of endosonographically detected anal sphincter damage in 18 patients: 66%vs 0% (P = 0.009).

CONCLUSION

Conservative treatment for prolapsed thrombosed internal haemorrhoids is associated with shorter in patient stay and less anal sphincter damage compared with operative treatment.

Retinopathy of prematurity: an optimum screening strategy

OBJECTIVE

We sought to find out whether birth weight of less than 1251 g or gestational age less than 30 weeks could provide a safe and efficient screening criteria of detecting treatable retinopathy of prematurity (ROP).

METHODS

Infants either with a birth weight less than 1500 g or gestational age less than 32 weeks were screened for ROP during an 8-year period.

RESULTS

In our study, the incidence of ROP was 36 of 187 (19.3%) infants. Although there was a slight increase in the number of infants screened over the years, the incidence of ROP of any stage remained stable. The maximum stage of ROP reached was stage 1 in 10 of 187 (5.3%), stage 2 in 8 of 187 (4.3%), and stage 3 in 18 of 187 (9.6%) infants. Among those with stage 3 disease, threshold ROP was present in 16 of 18 (88.9%). All infants with threshold ROP had a BW less than 1100 g and gestational age less than or equal to 28 weeks. Significantly fewer babies (105/187, or 56%) would have been examined had inclusion criteria of a birth weight of less than 1251 g and gestational age less than 30 weeks been applied. In addition, 31% (134/437) of screening examinations could have been avoided.

CONCLUSIONS

Our study suggests that a birth weight of less than 1251 g and gestational age less than 30 weeks can be safely and efficiently used to screen infants without missing a diagnosis of sight-threatening ROP in our catchment population.

Factors influencing clinicians' decisions to prescribe medication to prevent coronary heart disease

BACKGROUND AND OBJECTIVE

There are variations between individual clinicians as to the thresholds at which preventive treatment for coronary heart disease (CHD) should commence. Patients' decisions may be influenced by clinicians' recommendations. Free text comments added by respondents to closed questionnaires may identify areas which are of real concern to them about the topic being studied. The study aimed to identify issues voluntarily raised by clinicians surrounding the decision to prescribe preventive treatment for CHD.

METHODS

An analysis was undertaken of the free text comments made by cardiologists, general practitioners and practice nurses who responded to a closed question postal questionnaire in which they were asked to identify at which level of pretreatment risk they would offer treatment.

RESULTS AND DISCUSSION

A similar percentage of respondents in each professional group provided free text comments. Clinicians' concerns centred on five main themes around prescribing decisions: the risks and benefits of treatment, the patient's role in treatment decisions, patient characteristics, costs to patients, and costs to the health services. Different issues may be of more concern to some professional groups than others.

CONCLUSION

In addition to the use of risk assessment tools and guidelines, clinicians' actual prescribing behaviour may be influenced by more subjective factors. Patients at similar risk may receive different advice depending on the individual clinician they consult.

Measurement of dijet azimuthal decorrelations at central rapidities in pp collisions at sqrt s =1.96 TeV

Correlations in the azimuthal angle between the two largest transverse momentum jets have been measured using the D0 detector in p (-)p collisions at a center-of-mass energy sqrt[s]=1.96 TeV. The analysis is based on an inclusive dijet event sample in the central rapidity region corresponding to an integrated luminosity of 150 pb(-1). Azimuthal correlations are stronger at larger transverse momenta. These are well described in perturbative QCD at next-to-leading order in the strong coupling constant, except at large azimuthal differences where contributions with low transverse momentum are significant.