Monodisperse emulsions from a microfluidic device, characterised by diffusion NMR

A microfluidic device has been used to create novel monodisperse polymeric oil-in-water emulsions of diameter 15-100 µm, stabilised by surfactants and polymers. The pulse field gradient nuclear magnetic resonance (PFG-NMR) signal attenuation function showed minima that allow a simple calculation of the droplet size and polydispersity. The presence of the minima is due to the restricted diffusion of molecules within the droplets, which can be analysed using standard solutions of the diffusion equation with a spherical boundary condition. However, even when a small population of polymer is unrestricted, the deep troughs in the attenuation function are obscured. The simultaneous water NMR attenuation function gives structural information about the continuous-phase matrix. The NMR size measurements were compared with those obtained by optical and confocal microscopy, and laser diffraction analysis.

Trial fitting of a removable partial denture framework made using computer-aided design and rapid prototyping techniques

Previous studies of CAD/CAM-produced sacrificial patterns for removable partial denture frameworks have been documented but to date, no such restorations have been test-fitted to a patient. This paper provides details of the first trial fitting to a patient of an RPD framework, the sacrificial pattern of which was produced by CAD/CAM and RP technologies. A cast of the patient was scanned and the normal procedures of dental surveying and pattern build were undertaken with reference to the scanned model using computer-aided design. A sacrificial pattern of the design was produced by rapid prototyping technology. After spruing the pattern, investment-casting and finishing techniques were carried out according to conventional principles. The framework was successfully trial-fitted to the patient and clinically judged to be acceptable for the next stage of denture fabrication, that of adding acrylic bases and artificial teeth.

The natural history of chronic painful peripheral neuropathy in a community diabetes population

AIMS

To examine the natural history of chronic painful diabetic neuropathy (CPDN).

METHODS

A cross-sectional study of 350 people with diabetes was performed during 1998-1999 to assess the prevalence of CPDN in the community. Fifty-six patients with CPDN were identified and were followed up an average of 5 years later.

RESULTS

From the original cohort, 12 patients had died and 14 had moved away or were unable to participate in the follow-up study. Thus 30 patients with CPDN [21 male, mean (SD) age 68.6 years (9.4), mean (SD) duration of diabetes 15.4 years (8.7)] were re-assessed. Seven (23%) had been pain free for at least 12 months and 23 continued to report neuropathic pain of similar quality and severity [total McGill Pain Questionnaire Score median (interquartile range) at follow-up 22 (16-39) vs. 20 (16-33) at baseline, P = 0.3; mean (SD) visual analogue scale (VAS) score for pain over the preceding 24 h 5.3 cm (2.9) vs. 4.6 cm (2.5) at baseline, P = 0.1]. Only 65% had ever received treatment for CPDN despite 96% (22/23) reporting pain to their physician; 43.5% had received antidepressants, 17.4% anticonvulsants, 39% opiates and 30% had tried complementary therapies.

CONCLUSIONS

The neuropathic pain of CPDN can resolve completely over time in a minority (23%). In those in whom painful neuropathic symptoms had persisted over 5 years, no significant improvement in pain intensity was observed. Despite the improvement in treatment modalities for chronic pain in recent years, patients with CPDN continue to be inadequately treated.

Successful cardiovascular risk reduction in Type 2 diabetes by nurse-led care using an open clinical algorithm

AIM

To implement a protocol-driven, nurse-led cardiovascular risk reduction clinic using an open clinical algorithm. The primary aim of the clinic was to optimize blood pressure (BP) control; secondary aims were to reduce modifiable cardiovascular risk factors.

METHODS

We studied 110 people with Type 2 diabetes attending a diabetes out-patient centre at University Hospital Aintree, Liverpool. Patients taking one or more antihypertensive drugs were selected for referral to the nurse-led clinic if BP was > 140/85 mmHg; there was no age threshold. An open clinical algorithm was designed to direct the nurse on the use of antihypertensive, statin and aspirin therapy plus lifestyle advice and concordance.

RESULTS

Thirty-one percent of patients attending for a first visit to the nurse-led clinic had BP within target when measured to British Hypertension Society standards out of the consultant clinic. Mean BP was 150/76 mmHg compared with 178/88 mmHg (P < 0.001). Subsequently, BP was reduced to 130/68 mmHg (P < 0.001), this reduction being sustained at review 9 months later (mean BP 133/67 mmHg), with 87 (79%) achieving BP <or= 140/85 mmHg. Treatment modalities were adjusted to reduce cardiovascular risk, including antihypertensive medication, lipid-lowering therapy and antiplatelet therapy. High-density lipoprotein-cholesterol improved from 1.2 +/- 0.5 mmol/l to 1.4 +/- 0.5 mmol/l (P = 0.004). The number of patients with microalbuminuria decreased from 41 (47%) to 25 (28%) (P = 0.02), with a fall in urinary albumin:creatinine ratio from 3.0 (1.3-7.9) to 1.8 (1.0-5.0) mg/mmol (P = 0.01). The number of smokers decreased from 22 (20%) to 14 (13%) (P = 0.01). Although not included as an intervention in the protocol, HbA1c improved to 8.1 +/- 1.6% from 8.7 +/- 1.6% (P < 0.001).

CONCLUSION

A protocol-driven, nurse-led clinic using an open clinical algorithm can be used effectively to manage cardiovascular risk reduction in Type 2 diabetes.

Validation of short term recall of mobile phone use for the Interphone study

AIM

To validate short term recall of mobile phone use within Interphone, an international collaborative case control study of tumours of the brain, acoustic nerve, and salivary glands related to mobile telephone use.

METHODS

Mobile phone use of 672 volunteers in 11 countries was recorded by operators or through the use of software modified phones, and compared to use recalled six months later using the Interphone study questionnaire. Agreement between recalled and actual phone use was analysed using both categorical and continuous measures of number and duration of phone calls.

RESULTS

Correlations between recalled and actual phone use were moderate to high (ranging from 0.5 to 0.8 across countries) and of the same order for number and duration of calls. The kappa statistic demonstrated fair to moderate agreement for both number and duration of calls (weighted kappa ranging from 0.20 to 0.60 across countries). On average, subjects underestimated the number of calls per month (geometric mean ratio of recalled to actual = 0.92, 95% CI 0.85 to 0.99), whereas duration of calls was overestimated (geometric mean ratio = 1.42, 95% CI 1.29 to 1.56). The ratio of recalled to actual use increased with level of use, showing underestimation in light users and overestimation in heavy users. There was substantial heterogeneity in this ratio between countries. Inter-individual variation was also large, and increased with level of use.

CONCLUSIONS

Volunteer subjects recalled their recent phone use with moderate systematic error and substantial random error. This large random error can be expected to reduce the power of the Interphone study to detect an increase in risk of brain, acoustic nerve, and parotid gland tumours with increasing mobile phone use, if one exists.

Defining the position of deep inguinal ring in patients with indirect inguinal hernias

A preliminary survey of surgeons of all grades in our hospital revealed confusion about the position of the deep inguinal ring. Standard teaching is that the deep inguinal ring is lateral to the femoral artery. The aim of this study was to define the position of the deep ring in patients undergoing elective inguinal hernia repair. Thirty consecutive male patients undergoing indirect inguinal hernia repair under local anaesthesia were studied. The following landmarks were marked on the patient with a felt pen: anterior superior iliac spine (ASIS), femoral artery (FA), deep inguinal ring (DR), pubic tubercle (PT) and pubic symphysis (PS). The distance of each point from the ASIS was measured in centimetres. The relation of the femoral artery to the deep inguinal ring was confirmed by palpation through the deep ring during surgery. The femoral artery was consistently identified midway between the anterior superior iliac spine and pubic symphysis (mid-inguinal point). The deep inguinal ring was located medial (22/30) or above (8/30) the femoral artery, but never lateral. The mean distances from the anterior superior iliac spine to the deep ring and femoral artery were 8.8 and 7.7 cm, respectively. Contrary to standard teaching, this study demonstrates that the deep inguinal ring lies medial, not lateral, to the femoral artery. This may clarify some of the variations in textbook anatomy, and explain the difficulty in distinguishing direct and indirect inguinal hernias pre-operatively.

Inguinal hernia repair: are ASA grades 3 and 4 patients suitable for day case hernia repair?

The American Society of Anaesthesiologists (ASA) 3 and 4 patients are generally considered unsuitable for day case hernia repair. There are minimal data regarding the acceptability of day case repair in these patients. This study analysed day case hernia rates with special emphasis on ASA grades. A retrospective review of all adult inguinal hernia repairs, under the care of one surgeon over a 9-year period, was performed. The data collected included demographics, ASA grades, the mode of anaesthesia and early complications. 577 patients underwent inguinal hernia repair during the study period. 204 (35%) patients were ASA grade 1, 214 (37%) ASA grade 2, 132 (23%) ASA grade 3 and 29 (5%) ASA grade 4. Day case rates for ASA grades 1-4 under LA were 86, 83, 77 and 76% and under GA, 59, 36, 32 and 0%, respectively (P<0.05). There was no significant difference in the wound complication rates for different ASA grades under GA and LA. ASA grades 3 and 4 patients can undergo day case inguinal hernia repair, with similar complication rates to ASA grades 1 and 2 patients, when surgery is performed under local anaesthesia. ASA grades 3 and 4 patients need not be excluded from day case hernia repair.

Complications and mortality following stoma formation

INTRODUCTION

As stoma formation is thought to be declining, we performed a study to evaluate the rate of stoma formation and the impact on stoma complication rates, together with risk factors for complications.

PATIENTS AND METHODS

Stoma incidence, individual complications and mortality rates were retrieved from a stoma nurse database of 345 stomas created over an 8-year period.

RESULTS

Stoma formation increased over the study period, although the incidence of complications declined. Stoma complications were more frequently seen in emergency surgery. A significant association between stoma complications and mortality was identified.

CONCLUSIONS

Age of patient, urgency of surgery and diagnosis were associated with high levels of morbidity and mortality. Stomas are often formed in frail patients unsuitable for anastomosis formation, which may explain the high mortality in ostomy patients.

Comparison of buffered and unbuffered local anaesthesia for inguinal hernia repair: a prospective study

Bicarbonate buffered local anaesthetic solutions are known to reduce the pain of infiltration. However, its efficacy in reducing the pain of infiltration in patients undergoing inguinal hernia repair has never been tested. This study aims to test the efficacy of bicarbonate buffered solution in reducing the pain of infiltration and pain for the total surgical procedure in a series of patients undergoing elective inguinal hernia repair. Forty consecutive male patients with unilateral, reducible inguinal hernias were studied prospectively. All patients underwent surgery under local anaesthesia, the first 20 with unbuffered solution and the next 20 using buffered solution. Pain scores were obtained for the infiltration in the anaesthetic room and for the total surgical procedure. In addition, satisfaction scores were obtained at the end of the procedure. The mean pain score for the initial infiltration of unbuffered anaesthetic was 3.00 (range 0-5), and for the buffered anaesthetic it was 1.45 (range 0-4), P=0.02. The mean pain score for the entire procedure for the unbuffered group was 3.05 (range 0-6), and for the buffered group it was 1.45 (range 0-5), P=0.02. The patient satisfaction rate was higher with the buffered solution compared to unbuffered solution (P<0.05). There were no complications reported with either solution. Buffered local anaesthetic solution significantly reduces the perceived pain of inguinal hernia repair, both during the infiltration and during the procedure itself. It is safe to administer and it results in a high rate of patient satisfaction.

Improved glycaemic control--an unintended benefit of a nurse-led cardiovascular risk reduction clinic

AIMS

One hundred and ten patients with Type 2 diabetes were referred into a nurse-led cardiovascular risk reduction clinic. The primary aim of the clinic was to optimize blood pressure (BP) control and address cardiovascular risk factors.

METHODS

Those attending outpatient clinics were referred into a nurse-led cardiovascular risk reduction clinic if BP was above 140/85 mmHg. There was no intervention strategy designed in the nurse clinic protocol to improve glycaemic control.

RESULTS

Following attendance at the clinic, there was a significant improvement in HbA1c noted when patients were reviewed 9 months later. HbA1c improved from 8.7 +/- 1.6 to 8.1% +/- 1.6% (P < 0.001) in the whole cohort. Further analysis showed that, after excluding those who had received intervention to improve glycaemic control from another source, during the same period there remained a significant improvement in the non-intervention group of patients.

CONCLUSION

Frequent regular contact and health education in a nurse-led clinic to reduce cardiovascular risk may improve HbA1c in the absence of any specific intervention to improve glycaemic control.

Gastric epithelioid haemangioendothelioma: a rare cause of upper gastrointestinal bleeding

Vascular tumours of the stomach are rare, representing 0.9%-3.3% of all gastric neoplasms. A 58 year old man was admitted as an emergency with a one day history of haematemesis and melaena. He underwent an emergency laparotomy for a tumour in the lesser curve of the stomach. The tumour showed the characteristic histological and immunohistochemical features of epithelioid haemangioendothelioma. Surgery in the form of wide excision seems to be the treatment of choice for this rare neoplasm. This case highlights the difficulty in diagnosing this rare tumour preoperatively and emphasises the need for long term follow up in view of its uncertain metastatic potential.

Retrofitting houses with insulation to reduce health inequalities: aims and methods of a clustered, randomised community-based trial

This paper describes the purpose and methods of a single-blinded, clustered and randomised trial of the health impacts of insulating existing houses. The key research question was whether this intervention increased the indoor temperature and lowered the relative humidity, energy consumption and mould growth in the houses, as well as improved the health and well-being of the occupants and thereby lowered their utilisation of health care. Households in which at least one person had symptoms of respiratory disease were recruited from seven predominantly low-income communities in New Zealand. These households were then randomised within communities to receive retrofitted insulation either during or after the study. Measures at baseline (2001) and follow-up (2002) included subjective measures of health, comfort and well-being and objective measures of house condition, temperature, relative humidity, mould (speciation and mass), endotoxin, beta glucans, house dust mite allergens, general practitioner and hospital visits, and energy or fuel usage. All measurements referred to the three coldest winter months, June, July and August. From the 1352 households that were initially recruited, baseline information was obtained from 1310 households and 4413 people. At follow-up, 3312 people and 1110 households remained, an 84% household retention rate and a 75% individual retention rate. Final outcome results will be reported in a subsequent paper. The study showed that large trials of complex environmental interventions can be conducted in a robust manner with high participation rates. Critical success factors are effective community involvement and an intervention that is valued by the participants.

Retrospective comparison of mesh and sutured repair for adult umbilical hernias

Adult umbilical and paraumbilical hernia repair is associated with a high recurrence rate of 10-30%. Mesh repair has been reported to be associated with low recurrence rates. This study aims to compare sutured repair with prosthetic mesh repair to evaluate recurrence and infection rates. A retrospective study was conducted over an 8-year period including all the umbilical and paraumbilical hernia repairs performed by one consultant surgeon. The hernias were repaired using interrupted suture, Mayo overlap, flat mesh and mesh plug techniques. The study was based on case-note review, telephone and postal questionnaire survey. A total of 100 patients were studied, of which 70 had paraumbilical hernias, 28 had umbilical hernias and 2 had both types of hernia. Median age was 56 years (range 19-90 years). A total of 61 patients had suture repair (50 interrupted suture repair, 11 Mayo) and 39 had prosthetic mesh repair (33 mesh plug, 6 flat mesh). The median body mass index (BMI) was 31.2 (range 23.4-44.5) in the suture repair group and 33.3 (range 24.1-59.1) in the mesh group, with no significant statistical difference in BMI between the two groups (P>0.05). Median follow-up was 4.5 years (range 1-8 years). Recurrence rates for the suture and mesh repair groups were 11.5 and 0%, respectively (P=0.007). Infection rates for the suture and mesh repair groups were 11.5 and 0%, respectively (P=0.007). Our data suggest that prosthetic mesh repair is ideal for managing primary and recurrent umbilical hernias in both obese and non-obese patients.

Chronic painful peripheral neuropathy in an urban community: a controlled comparison of people with and without diabetes

AIMS

A cross-sectional study has been performed in order to estimate the prevalence, severity, and current treatment of chronic painful peripheral neuropathy (CPPN) in people with diabetes in the community.

METHODS

Using a structured questionnaire and examination we have assessed these factors in a community sample of people with diabetes (n=350) and compared them with 344 age- and sex-matched people without diabetes from the same locality.

RESULTS

The prevalence of CPPN was estimated to be 16.2%[95% confidence interval (CI): 6.8-16%] in people with diabetes compared with 4.9% (95% CI: 2.6-7.2%) in the control sample (P < 0.0001). Diabetic subjects with and without CPPN did not differ in age, sex, type and duration of diabetes, body mass index, smoking status and glycaemic control. However, CPPN diabetic subjects had significantly higher Visual Analogue Scale (VAS) scores for pain over the preceding 24 h [median (interquartile range) 3.5 (1.5-6.7) cm vs. 0.7 (0-3.9) cm, P < 0.0001]. Also, the total McGill Pain Questionnaire Score (a measure of pain quality and severity) was 18 (13-31.5) vs. 10 (4-16) (P < 0.0001). Of patients with diabetes and CPPN, 12.5% (7/56) had never reported their symptoms to their treating physician and 39.3% (22/56) had never received any treatment for their painful symptoms.

CONCLUSIONS

CPPN is common, often severe but frequently unreported and inadequately treated.

Mortality and cancer incidence in New Zealand meat workers

AIMS

To ascertain whether there is an increased risk of cancers of the lung and lymphohaematopoietic tissue in workers employed in the New Zealand meat processing industry, and to identify exposures associated with any increased risks.

METHODS

A cohort of 6647 individuals assembled from personnel records from three plants was followed from 1988 until 2000. The observed number of deaths and cancer registrations was compared with expected numbers using five year age and gender specific rates for the New Zealand population. Subgroup analyses evaluated the effect of duration of exposure to selected agents, based on job titles and departments.

RESULTS

Vital status was determined for 84% of the cohort, and 92% of the total possible person-years. Mortality from all causes and all cancers was increased, and there was a significant excess of lung cancer. There were significant trends of increasing risk of lung and lymphohaematopoietic cancer with increasing duration of exposure to biological material.

CONCLUSIONS

Excess risks were observed for mortality from all causes, all cancers, and lung cancer. Although the increased risk of lung cancer may be partly due to confounding by smoking, it is unlikely to be entirely due to this cause. Furthermore, the dose-response relation observed for lung cancer suggests the effect is related to exposure to biological material contained in animal urine, faeces, and blood. Although numbers were small, the risk of lymphohaematopoietic cancer was also associated with increasing duration and level of exposure to biological material.

Intensified treatment of type 2 diabetes--positive effects on blood pressure, but not glycaemic control

BACKGROUND

Since publication of the UK Prospective Diabetes Study (UKPDS) in 1998, there has been a clear evidence base for tight glycaemic (HBA(1c) < 7.0%) and blood pressure (BP < 140/85 mmHg) control.

AIM

To determine the effect of UKPDS-based intensified glycaemic and BP targets on the care of type 2 diabetic patients attending a routine diabetes clinic.

DESIGN

Two surveys, each of 500 consecutively attending type 2 diabetic patients.

METHODS

The first survey was in a 3-month period in 1999, shortly after publication of the UKPDS study. The second was identical, but 2 years later. Glycaemic control (by DCCT-aligned HBA(1c)), BP and treatment details were recorded in both.

RESULTS

BP control was significantly improved in the second survey (mean +/- SD systolic BP from 151 +/- 25 to 146 +/- 26 mmHg, p = 0.001; diastolic from 77 +/- 13 to 72 +/- 12 mmHg, p < 0.0001) and the proportion of patients on anti-hypertensive treatment increased from 33% to 60% (p < 0.0001). Mean HbA(1c) however remained unchanged (8.7 +/- 1.8% in 1999 vs. 8.5 +/- 1.8% in 2001), although there was evidence of more intensive treatment patterns, with declining numbers on diet alone and more on oral agents and/or insulin.

DISCUSSION

Intensified BP control may be achievable within the confines of routine diabetes care, but achievement of optimal glycaemic targets remains problematic.

Passive smoking, as measured by hair nicotine, and severity of acute lower respiratory illnesses among children

The aim of this study was to describe the association between passive smoking and the severity of acute lower respiratory illnesses (ALRI) among 351 children aged 3–27 months admitted to hospital. A total of 297 children provided hair samples, which were analysed for hair nicotine levels as an indicator of passive smoking. A severity of illness grading system was developed by using clinical and management criteria used by the medical staff at hospital. The OR for children with more severe illness being exposed to higher nicotine levels was 1.2, 95% CI: 0.57–2.58 when using dichotomised respiratory severity levels and upper versus lower nicotine quartile levels. In an ordinal logistic regression model, the OR of more severe illness being associated with higher nicotine levels was 1.07 (95% CI: 0.92–1.25). When analysis was limited to the more severe cases, the OR of the least severe category compared to the most severe category, in relation to nicotine levels in hair, was 1.79 (95% CI: 0.5–6.30). The ordinal logistic regression of this group of severely-ill children (OR 1.1 (95% CI: 0.94–1.29) was not substantially different from the overall study subjects.

In general, children with more severe illness tended to have higher levels of nicotine in their hair, although the results were within the limit of chance. Possible explanations of our results include environmental tobacco smoke (ETS) being an initiator of ALRI rather than a risk to severity, exposure levels of ETS were too low to demonstrate an effect on severity, or the power of this study was not high enough to detect an association.

The implications of subspecialisation on the management and outcome of surgery for rectal carcinoma

BACKGROUND

The management of rectal carcinoma has changed significantly over the last decade. We studied the changing trends in the management of rectal carcinoma over a 7-year period in a district general hospital.

METHODS

A retrospective analysis of all patients with histologically proven rectal adenocarcinoma who underwent operative treatment between January 1991 and December 1997 was performed. The type of operative procedure, local recurrence rate and completeness of pathology reporting was documented.

RESULTS

There were 200 operative procedures: 102 anterior resections (AR), and 98 abdominoperineal resections (APR). This included 17 palliative resections because of metastatic disease (n = 8) or extensive local invasion (n = 7) or both (n = 2). The APR rate steadily declined from 72% in 1991 to 19% in 1997 (p < 0.005). Subspecialist 'colorectal' surgeons performed only 24% of the operations in 1991 but the figure for 1997 was 85% (p < 0.01). No circumferential resection margin was reported in 1991 but was reported in 85% of the cases in 1997 (p < 0.001). There was a steady increase in stapled anastomoses from 43% in 1991 to 93% in 1997 (p < 0.03). There were 15 local recurrences following 'curative' resection; 7 following APR and 8 following AR (n.s.).

CONCLUSION

There was a significant increase in the rate of restorative resection of rectal cancer with a concomitant reduction in permanent stoma formation; this may be attributed to an increase in subspecialisation. Despite this, a low rate of local recurrence was maintained throughout the study period.

Passive smoking, as measured by hair nicotine, and severity of acute lower respiratory illnesses among children

The aim of this study was to describe the association between passive smoking and the severity of acute lower respiratory illnesses (ALRI) among 351 children aged 3–27 months admitted to hospital. A total of 297 children provided hair samples, which were analysed for hair nicotine levels as an indicator of passive smoking. A severity of illness grading system was developed by using clinical and management criteria used by the medical staff at hospital. The OR for children with more severe illness being exposed to higher nicotine levels was 1.2, 95% CI: 0.57–2.58 when using dichotomised respiratory severity levels and upper versus lower nicotine quartile levels. In an ordinal logistic regression model, the OR of more severe illness being associated with higher nicotine levels was 1.07 (95% CI: 0.92–1.25). When analysis was limited to the more severe cases, the OR of the least severe category compared to the most severe category, in relation to nicotine levels in hair, was 1.79 (95% CI: 0.5–6.30). The ordinal logistic regression of this group of severely-ill children (OR 1.1 (95% CI: 0.94–1.29) was not substantially different from the overall study subjects.

In general, children with more severe illness tended to have higher levels of nicotine in their hair, although the results were within the limit of chance. Possible explanations of our results include environmental tobacco smoke (ETS) being an initiator of ALRI rather than a risk to severity, exposure levels of ETS were too low to demonstrate an effect on severity, or the power of this study was not high enough to detect an association.

Risk assessment for people with mental health problems: a pilot study of reliability in working practice

INTRODUCTION

This paper describes a pilot study of reliability in the risk assessment of people with mental health problems. Specifically, we explore the evidence for professional and gender bias in ratings, in addition to the general level of agreement between raters.

METHOD

Six professional groups (psychiatrists, junior psychiatric doctors, nurses, community psychiatric nurses, social workers and occupational therapists) participated in the study and rated 159 patients on a nine-item scale which assessed different components of risk.

RESULTS

Contrary to some earlier work, we found no clear evidence that any one group consistently rated more extremely than any other group. Women were more cautious than men in their ratings, and this concurs with previous studies. Finally, a reliability study of randomly selected pairs of raters showed only moderate levels of agreement and, in some instances, the levels of disagreement were high enough to warrant concern.

CONCLUSION

These findings are discussed in the context of current risk assessment practice and the problems associated with investigating reliability in naturalistic settings and designing appropriate rating tools for risk. (Int J Psych Clin Pract 2002; 6: 73-81).